In order to clarify the links between gender issues and HIV
infection, Rachel Jewkes of the South African Medical Research Council examined
data from the cohort of young women recruited to evaluate the impact of a
behavioural intervention known as Stepping Stones.
Women from both the intervention and control groups are included in this
analysis, as long as they were HIV negative at the beginning of the study, had sex
whilst in the cohort and completed follow-up after 12 and 24 months.
The researchers examined the behaviour and experiences that
the women reported at the beginning of the study and whether they subsequently acquired HIV. The study
design is therefore more robust than a one-off cross-sectional survey, as it
can suggest whether a link between one factor and HIV infection is causal or
Included in the analysis are 1077 women aged 15 to 26 years,
with an average age of 18 at baseline (the beginning of the study). The
majority were very poor, still in school, unmarried and already sexually active.
The cohort was recruited in primarily rural parts of the Eastern Cape province.
During the two years of follow-up, 127 women acquired HIV.
In other words, the incidence of new infections was extremely high, but not
unusual in this setting, at 6.2% a year.
Data from this cohort, published
two years ago in The Lancet,
showed that women who reported having relatively little power in sexual
relationships at baseline (for example, feeling obliged to sleep over when a
boyfriend wanted her to) were more likely to subsequently acquire HIV. In women
with medium or high relationship power equity, incidence was 5.5% a year; in
those with low relationship power equity, it was 8.5% a year.
Similarly, women who reported at baseline that sexual
partners had been either physically or sexually violent were also more likely
to go on to acquire HIV. Women reporting either one or no incidents of intimate
partner violence had an incidence of 5.2% a year, but women reporting two or
more incidents had an HIV incidence of 9.6% a year.
Both these differences in incidence were statistically
significant after adjustment for confounding factors.
Rachel Jewkes suggests that certain ideals of masculinity
which are widely accepted in some South African communities legitimise unequal and often violent
relationships. Men are expected to dominate and control women, and violence may
be justified to enforce and demonstrate this. This may place women at increased
risk of HIV infection by creating psychological distress, encouraging women to
be more acquiescent, preventing women from influencing the circumstances of sex
(including condom use and the frequency of sex) and allowing men to have
multiple and concurrent partners (and therefore more likely to themselves have
HIV and sexually transmitted infections).
In their new study, the researchers turn to the issue of
‘transactional’ sex – in other words, when a woman reported that part of her
motivation for having a sexual relationship was that she expected her partner
to provide cash, food, cosmetics, clothes, transport, a bed for the night or to
do some handyman work. These relationships are seen in terms of men fulfilling
a traditional provider role, rather than as being akin to prostitution.
Transactional sex was asked about, at the beginning of the
study, in relation to different types of partners. A total of 143 women
reported it in relation to main partners, 59 women reported it with ongoing and
usually secret second partners (known as makhwapheni
in the Zulu and Xhosa languages), and seven women reported it with one-off
In relation to main partners, there were no statistically
significant differences in HIV incidence between those women reporting and not
reporting transactional relationships.
However, when looking at makhwapheni
and one-off partners, women who did not report transactional relationships
had an HIV incidence of 5.7% a year, but women who did have a transactional
relationship had an incidence of 14.5% a year.
The researchers then adjusted their figures for other
factors which are known to influence HIV incidence (including condom use, age, herpes
infection, relationship inequity and intimate partner violence). They
calculated that having transactional relationships with makhwapheni or one-off partners doubled the risk of acquiring HIV
(incident rate ratio 2.06, 95% confidence interval 1.22 – 3.48).
Although it could be hypothesised that transactional
relationships are risky because male partners are more likely to be older (for
example a ‘sugar daddy’) or because they are associated with women having more
sexual partners, neither of these factors were associated with statistically
significant increases in the risk of HIV infection.
The authors suggest financial and material vulnerabilities
may introduce a particular type of vulnerability into sexual relations. “When
there is an absence of explicit negotiation and a bolstered sense of male
entitlement, men perceive that gifts of cash result in a woman accepting sex on
his terms, which are often without condoms and without space to assert
preferences for monogamy and so forth.”