The male partners of adolescent girls and young women in eSwatini (Swaziland) and South Africa report substantial HIV risk behaviours, but the data also challenge the stereotypical image of a ‘sugar daddy’. The men were only a few years older than their partners and many described challenging life circumstances such as unemployment, homelessness and violence.
A parallel, qualitative study from Uganda describes a somewhat different situation, with men often acting as economic providers in relationships of a relatively long duration. These three studies have recently been published in PLOS ONE and presented at this summer’s International AIDS Conference (AIDS 2018) in Amsterdam.
In many African countries, rates of new HIV infections among females aged 15 to 24 are much higher than among their male peers. Unequal power dynamics in sexual relationships with male partners, especially older partners, contribute to this vulnerability. However, older male partners have often been seen as a ‘hidden’ or ‘hard to reach’ population. Until now, most researchers have asked women about their partners, rather than conducting research directly with men.
The US President’s Emergency Plan for AIDS Relief (PEPFAR) therefore created the DREAMS partnership. It aims to reduce HIV infections among adolescent girls and young women in ten sub-Saharan African countries with interventions that go beyond the health sector, addressing structural factors such as poverty, education and gender inequality.
The partnership includes research to better understand the characteristics of older male partners and identify settings in which they can be reached. DREAMS will try to improve these men’s engagement with HIV services. A higher uptake of HIV testing in men, and antiretroviral therapy for the HIV positive, may lower their risk of passing HIV on to young women.
eSwatini is a landlocked country in Southern Africa, formerly known as Swaziland, in which 15% of adolescent girls and young women are living with HIV. DREAMS’ study in eSwatini took a quantitative approach. In 19 rural, peri-urban and urban districts across the country, the researchers worked with community informants to identify 182 venues where men meet and socialise with adolescent girls and young women. These were predominantly drinking spots, kiosks, stores, bars and clubs, although other sites such as parks and churches were also included. Only men aged 20 to 34 were surveyed, on the basis of other work that suggests they are the age group most likely to have younger female partners and to be involved in HIV transmission.
The researchers interviewed 843 men in order to identify 568 men who reported having at least one female partner aged 15-24 in the past year. Over half of this group reported having two or more sexual partners in the past year. Relatively few men told interviewers that they were living with HIV (6%), but men who had at least three partners aged 15 to 24 in the past year were more likely to be HIV positive (adjusted odds ratio 3.2).
The vast majority (88%) of the men described their marital status as single and their average age was 25.7 years. The majority of men (71%) had female partners no more than four years younger than them. In 14%, their partners' average age was 5 to 9 years younger but only 1% reported having partner ten years younger than them or more. Even for men aged 30 to 34, only 3% reported an age gap of ten years or more.
Only 36% had consistently used a condom with their current partner and 57% had talked about HIV status with this partner. Men whose current partner was under the age of 20 were less likely to talk about HIV status than men who had older partners (adjusted odds ratio 0.6).
Only half of the men were currently employed. They were engaged in a wide range of occupations, including industry, transport and government.
A substantial minority reported precarious living conditions –15% had slept outside due to homelessness in the past year, 13% had been jailed in the past year and 8% had experienced a lack of food in the last month. “Challenging life circumstances suggest structural factors may underlie some risk behaviours,” comment the authors.
A similar survey was done in two informal settlements in Durban, South Africa. Here, recruitment took place both in venues where men meet younger women (such as drinking establishments and taxi ranks) and in HIV services.
The demographic profile of the 962 respondents was comparable to that in Swaziland, in terms of age, marital status and employment. Seventy-one per cent reported having multiple partners in the past year (of any age); 24% had five or more partners; 75% had at least one female partner aged 15 to 24 in the past year; and 54% had both younger and older partners.
Just under half the relationships could be described as ‘transactional’ – the men had given money, goods or services mainly to start or stay in the relationship. Such gifts could include drinks, meals and make-up, but for 12% of the men it was something much more substantial, such as paying their partner’s rent or school fees.
Men who were employed (p < 0.01), small business owners (p < 0.01) or educated to technical college or university level (p < 0.05) were more likely to have multiple partners, in accordance with the idea that more economically powerful men have more partners.
Men's vulnerabilities, as well as their power, also emerged as a theme, however. There was a link between traumatic events in childhood or adulthood and sexual risk behaviour.
- In childhood, 77% had been beaten and 21% had seen or heard their mother being beaten. These experiences were associated with less consistent condom use (p < 0.05) and having multiple partners (p < 0.05).
- 42% were not raised by a biological parent and 37% had experienced a parent’s death during childhood. These experiences were associated with less consistent condom use (p < 0.01) and more age-disparate relationships (p < 0.05).
- As adults, 59% had witnessed an armed attack, 39% had been robbed at gunpoint or knifepoint and 41% had felt close to death. These experiences were associated with multiple sexual partnerships (p = 0.001).
The third DREAMS study took a qualitative approach, using in-depth interviews with 94 men in Uganda. The study was done in a mix of rural and urban sites in three geographically and culturally diverse districts. As well as recruiting at community venues where men and younger women met, adolescent girls and young women were asked to refer their male partners to the study. The latter approach was expected to identify men in more stable partnerships.
The respondents had a different profile to the other two studies. While the mean age was 28, interviewees were up to 45 years of age, 80% of respondents were married or cohabiting, and 94% were employed.
Multiple sexual partnerships were seen as a very common practice, as one man described:
“These days most men have more than one woman, most men say that you can’t keep eating one type of food all the time. In fact you can’t find a man with only one woman, it isn’t there.”
Men often sought to develop ‘side’ relationships. They were seen as additional long-term partners whom the man would provide for economically. Many men referred to them as ‘wives’.
“She is not at my home she is in a rental but it’s me who pays her rent, it’s me who is taking care of her in everything even though she is not at my place she still is like my wife now.”
When men did not have an additional partner, it was often because of the cost of doing so. They might however have short-term casual partners who they would meet at drinking establishments. These relationships were nearly always transactional in nature, usually starting with the man buying the girl or woman drinks, a meal or low-cost items like mobile phone credit.
Some interviewees explicitly described a preference for younger partners. As this 31 year old described, they could be more easily controlled:
“If you get a woman who is your age mate, somehow these women tend not to be submissive… yet for a young girl, because of the age difference, she will find it very easy to listen to you, she will treat you with respect because she knows you are older than her and perhaps more experienced.”
Men described a pattern of establishing relationships with younger females. Most men had married in their early twenties, usually to a woman three to five years younger than themselves, and generally saw marriage as an important life event. Within a few years after marrying, however, many men described taking on one or more side partners. This might occur during a period of separation from the first wife due to a conflict or residential relocation.
As men got older, they might also have a series of short-term casual partnerships, almost always with adolescent girls and young women. A few of these might develop into longer term ‘side’ relationships.
The researchers comment that these complex and fluid patterns – including temporary separations of long-term partnerships, ‘side’ partnerships being initiated and casual partnerships sometimes becoming more formalised – will complicate public health strategies to reach these men.
Reynolds Z et al. Who are the male partners of adolescent girls and young women in Swaziland? Analysis of survey data from community venues across 19 DREAMS districts. PLOS ONE 13(9): e0203208, 2018. (Full text freely available.)
Gottert A et al. Male partners of adolescent girls and young women in Durban, South Africa: How high is their HIV risk and what groups are most at risk? 22nd International AIDS Conference, Amsterdam, abstract TUPEC260, 2018. (Abstract.)
Gottert A et al. Men's vulnerabilities are compromising their own health and well-being, and are strongly linked to HIV risk in Durban, South Africa. 22nd International AIDS Conference, Amsterdam, abstract WEPED394, 2018. (Abstract.)
Gottert A et al. Male partners of young women in Uganda: Understanding their relationships and use of HIV testing. PLOS ONE 13(8): e0200920, 2018. (Full text freely available.)