Looking to the future: South African men and women negotiating HIV risk and relationship intimacy

This paper examines the approaches heterosexual men and women in South Africa use to engage their partners in discussions of HIV and risk factors in their relationships. These strategies entail balancing the risks of infection while managing the challenges of maintaining a relationship. In a context in which there is a great deal of insecurity in relationships it is especially challenging to discuss HIV risks with partners. Our findings reveal that concerns about children or the desire to have children provided a legitimate basis for discussing HIV risk with partners. The focus of these discussions is on the future for their children. Research in South Africa should attend to men's and women's desires to have and to raise children. HIV prevention and treatment programmes can capitalise on concerns regarding children, and the future of the family, to engage men and women in discussing mutually acceptable strategies for preventing infection and ensuring safe conception.     

Substance use,gender inequity,violence and sexual risk among couples in Cape Town

Alcohol and other drug use, gender power inequities and violence are key contributors to sexual risks for HIV among South African men and women. Little is known about the intersection between these sex-risk behaviours among couples in established heterosexual relationships. We conducted 10 focus-group discussions with men and women in relationships of 1 year or longer recruited from shebeens (informal taverns) in Cape Town, South Africa. Participants described: high levels of alcohol consumption at shebeens; low levels of condom use with main and casual sex partners; gender roles disfavouring women's condom negotiating power that also promoted economic dependency on male partners; men often spending a portion of the household income on alcohol and other drugs and sex with others in shebeens; loss of household income driving women to trade sex to provide for their families; and sexual violence and the exploitation of women occurring in shebeens. Findings highlight how the social contexts of alcohol and other drug use, gender inequitable norms and gender violence promote HIV risk within established heterosexual relationships in South African communities. Evidence of this kind should inform the design of HIV-risk-reduction interventions tailored to heterosexual couples who drink alcohol in shebeens.     

Traditional male circumcision for reducing the risk of HIV infection: perspectives of young people in South Africa

Increasing evidence suggests that medical male circumcision is associated with a reduced risk of HIV infection for men in sub-Saharan Africa. The aim of this study was to understand the importance of male circumcision as a risk-reducing strategy by exploring perceptions of young men and women. The study draws on focus-group discussions conducted with both men and women in South Africa. The findings suggest that there is widespread support for traditional male circumcision. Traditional circumcision is viewed as a key part of the initiation process. However, a number of concerns were raised about the traditional initiation process, which may lead to risky sexual behaviours, including early sexual debut and multiple sexual partners. In addition, the risky sexual behaviour of men puts women at risk of HIV infection.     

Men’s moralising discourses on gender and HIV risk in rural KwaZulu-Natal,South Africa

Various interventions have resulted in increased rates of HIV testing. However, encouraging men to acknowledge their risk for HIV, to test and link to treatment remains a challenge. In this study, we examine men’s perspectives on navigating HIV risk in rural KwaZulu-Natal, South Africa. Qualitative interviews were conducted at four intervals over a three-year time period with a baseline cohort of 126 men and women. We found that men navigated HIV risk in their sexual relationships mainly by monitoring their partner’s behaviour. Men expressed concerns about female respectability, invoking discourses on hlonipha rooted in Zulu cultural ideals and Christian ideals about women staying close to home. In the post-apartheid era, these concerns were inflected by anxieties over changing gender norms and the high rates and risks of infection in the region. HIV prevention discourses on behaviour intersected with men’s efforts to assert their masculinity through the monitoring and controlling of women’s behaviour. The potential negative impacts of this should be addressed. Prevention efforts need to focus on men’s vulnerability to infection in terms of their own behaviour as well as the contexts in which they live.     

Patterns of Exchange Sex and HIV Infection in High-Risk Heterosexual Men and Women

Heterosexual partnerships involving the trade of money or goods for sex are a well-described HIV risk factor in Africa and Southeast Asia, but less research has been conducted on exchange partnerships and their impact on HIV infection in the United States. In our study, men and women were recruited from high-risk risk neighborhoods in New York City through respondent-driven sampling in 2006–2007. We examined the factors associated with having an exchange partner in the past year, the relationship between exchange partnerships and HIV infection, and the risk characteristics of those with exchange partners by the directionality of payment. Overall, 28% of men and 41% of women had a past-year exchange partner. For men, factors independently associated with exchange partnerships were older age, more total sexual partners, male partners, and frequent non-injection drug use. For women, factors were homelessness, more total sexual partners, more unprotected sex partners, and frequent non-injection drug use. Exchange partnerships were associated with HIV infection for both men and women, although the relationships were substantially confounded by other behavioral risks. Those who both bought and sold sex exhibited the highest levels of risk with their exchange and non-exchange partners. Exchange partnerships may be an HIV risk both directly and indirectly, given the overlap of this phenomenon with other risk factors that occur with both exchange and non-exchange partners.     

Family planning and sexual behavior in the era of HIV/AIDS: the case of Nakuru District, Kenya

Recently, the prevalence of contraceptive use has increased in Kenya. The twin risks of unwanted pregnancy and HIV/AIDS infection remain central concerns of reproductive health programs. However, we do not know how sexually active men and women perceive these risks, nor the strategies they consider appropriate to cope with these risks, nor the difficulties they face in trying to adopt appropriate sexual behaviors to minimize them. This study seeks to provide insights into perceptions, coping strategies, and constraints in the changing behavior of sexually active people in Nakuru District, Kenya. Twelve focus-group discussions were conducted, the results of which show that people in the study area consider the two risks to be serious problems, but that they neither use condoms within marriage nor refuse their partners sex even if they perceive a risk of acquiring HIV. These findings call for serious efforts toward fostering behavioral change in this area.     

Perceptions of sexual risk compensation following posttrial HIV vaccine uptake among young South Africans

Concerns about the impact of risk compensation on advances in biomedical human immunodeficiency virus (HIV) prevention technologies have been documented. We conducted an exploratory qualitative study using focus group discussions with young South African men and women (aged 18 to 24 years) to explore perceptions of risk compensation with regard to a hypothetical posttrial HIV vaccine. During the discussions, participants expressed their disquiet about the potential for risk compensation and the manner in which this might manifest among young people. Discussions specifically focused on reductions in condom use, an increase in multiple partners, and increased frequency of sex. The discussions also revealed contradictory feelings about HIV vaccines: appreciation for their development tempered by concerns about loss of control and undermining morality. Women were particularly concerned with the possibility of increased partner concurrency and infidelity. We suggest that concerns in HIV vaccine target populations about the impact of possible risk compensation be incorporated into strategies for vaccine introduction once vaccines move from the hypothetical to reality.     

Young People's Sexual Partnerships in KwaZulu‐Natal,South Africa: Patterns,Contextual Influences,and HIV Risk

Certain sexual partnering practices, such as multiple, concurrent, or age‐discrepant partnerships, are known to increase HIV risk. Yet the underlying dynamics of young people's relationships are less clearly understood. Using household survey and qualitative data, this study examines partnership dynamics and characteristics in the context of HIV risk, including number of partners, age differences, partnership duration and concurrency, and frequency of contact among young people aged 15–24 in rural KwaZulu‐Natal, South Africa. One‐third of the men surveyed reported multiple and/or concurrent partnering, and one‐fourth of the women had partners who were five years older than they were. Nonparticipation in civic organizations or school was correlated with higher‐risk partnerships for women but not for men. On average, relationships lasted more than a year for the women and men surveyed, and were frequently characterized as “serious.” Qualitative findings pointed to the sequential and overlapping nature of relationships, however, with distance and mobility being important influences. These fluid partnership patterns are an important feature of young people's sexual risk in the context of South Africa's severe HIV epidemic.     

Managing men: women's dilemmas about overt and covert use of barrier methods for HIV prevention

Women in sub-Saharan Africa are at high risk of HIV infection and may struggle to negotiate condom use. This has led to a focus on the development of female-controlled barrier methods such as the female condom, microbicides and the diaphragm. One of the advantages of such products is their contribution to female empowerment through attributes that make covert use possible. We used focus groups to discuss covert use of barrier methods with a sample of South African women aged 18–50 years from Eastern Johannesburg. Women's attitudes towards covert use of HIV prevention methods were influenced by the overarching themes of male dislike of HIV and pregnancy prevention methods, the perceived untrustworthiness of men and social interpretations of female faithfulness. Women's discussions ranged widely from overt to covert use of barrier methods for HIV prevention and were influenced by partner characteristics and previous experience with contraception and HIV prevention. The discussions indicate that challenging gender norms for HIV prevention can be achieved in quite subtle ways, in a manner that suits individual women's relationships and previous experiences with negotiation of either HIV or pregnancy prevention.     

Concern and practice among men about HIV/AIDS in low socioeconomic income areas of Lilongwe, Malawi

The HIV prevalence rate in Malawi, currently estimated to be 15%, is among the highest in the world. There is a growing realization that in order to understand the underlying causes and devise more effective prevention strategies focus should be placed on economic, political, social, and cultural forces as well as perceptions of individual risk to HIV/AIDS. During 2003 we conducted field work in Lilongwe, the capital city of Malawi, to examine perceptions of individuals as to their risk to HIV infection using the structured interviews and the focus group discussions with men from five areas of Lilongwe. The discussion in this paper focuses on the perception of risk to HIV infection among men in low socioeconomic income areas that we interviewed. Our findings indicate that while knowledge about HIV/AIDS and the best ways in which one can protect oneself from getting HIV is very high, people continue to engage in at-risk behaviors without using the necessary protection. Many of the men in our sample indicated that they were indeed at risk of getting infected with HIV. In spite of this, some of the respondents in both the structured interviews and the focus group discussions pointed out that some people had began taking measures to protect themselves, such as using condoms with nonregular partners, women leaving their husbands where cheating was obvious, and, for men, reducing the number of extra-marital sexual relations.     

The relational dynamics of hegemonic masculinity among South African men and women in the context of HIV

In South Africa, the frequent positioning of men's sexual behaviours as a prime driver of the HIV epidemic has generated much interest in men's sexuality. However, the relational nature of dominant male norms that exacerbate the risk of HIV transmission is inadequately understood. This study used sexual biographies to explore how men and women negotiate gendered norms and how this affects their sexual and reproductive health (SRH). A total of 50 sexual-history interviews and 10 focus group discussions were conducted with men, and 25 sexual-history interviews with women, with participants sampled from three age categories (ages 18–24, 25–55 and 55+years), a range of cultural and racial backgrounds and urban and rural sites across five provinces in South Africa. The narratives illustrate that men and women's SRH is largely dependent on the type and quality of their relationships. Men's sexuality was regularly depicted as being detached from intimacy and uncontrollable, which was premised as being opposite from and/or superior to women's sexuality and could justify men's high-risk sexual behaviours. Yet many participants also supported gender equitable relationships and endorsed accountable and healthy SRH behaviours. The narratives reveal that HIV-risky dominant male norms should be addressed relationally for the sake of better SRH outcomes.     

Alcohol Use and Sexual Risks for HIV/AIDS in Sub-Saharan Africa: Systematic Review of Empirical Findings

Alcohol consumption is associated with risks for sexually transmitted infections (STI), including HIV/AIDS. In this paper, we systematically review the literature on alcohol use and sexual risk behavior in southern Africa, the region of the world with the greatest HIV/AIDS burden. Studies show a consistent association between alcohol use and sexual risks for HIV infection. Among people who drink, greater quantities of alcohol consumption predict greater sexual risks than does frequency of drinking. In addition, there are clear gender differences in alcohol use and sexual risks; men are more likely to drink and engage in higher risk behavior whereas women's risks are often associated with their male sex partners' drinking. Factors that are most closely related to alcohol and sexual risks include drinking venues and alcohol serving establishments, sexual coercion, and poverty. Research conducted in southern Africa therefore confirms an association between alcohol use and sexual risks for HIV. Sexual risk reduction interventions are needed for men and women who drink and interventions should be targeted to alcohol serving establishments.     

HIV Infection,Stressful Life Events,and Intimate Relationship Power: The Moderating Role of Community Resources for Black South African Women

Background: Black women in South Africa are vulnerable with limited power in intimate relationships. This study explored whether stressful life events and/or HIV infection were associated with relationship power and whether the impact was moderated by community resources.

Method: One hundred four women living with HIV and 152 women not living with HIV participated in individual interviews.

Results: Undesirable life changes were negatively associated with relationship control. HIV infection and women's knowledge of community resources were associated with mutual decision-making, while frequency of family use of community resources was negatively related to female dominated decisions. Women living with HIV perceived their male partners as less dominant when they perceived their community resources to be more helpful.

Conclusions: Power in intimate relationships may enhance the quality and length of life for black South African women living with HIV. Knowledge of and perceived helpfulness of community resources are avenues for promoting relationship power.     

Use of Dual Protection in Botswana

High rates of unintended pregnancy and of HIV and other sexually transmitted infections prompt calls for use of “dual‐protection” strategies, including consistent condom use or dual‐method use. This study examines the use of dual‐protection strategies in a sample of 15–49‐year‐old men and women in Botswana in 2003. Half of sexually active respondents reported consistent condom use in the past year; 2.5 percent reported dual‐method use. Multiple logistic regression analyses showed that urban residence, less than a ten‐year age difference between partners, discussing HIV and contraception with one's partner, not intending to have a child in the next year, having no children, being in a relationship where one or both partners have additional concurrent partners, and supportive condom norms were associated with dual protection—that is, with consistent condom or dual‐method use. In the context of high HIV prevalence, concerns about disease prevention likely influence contraception, and interventions should address childbearing desires and sexual risk simultaneously.     

HIV/AIDS Risks among Men and Women Who Drink at Informal Alcohol Serving Establishments (Shebeens) in Cape Town,South Africa

HIV/AIDS is devastating southern Africa and the spread of HIV is fueled in some populations by alcohol use. Alcohol serving establishments, such as informal drinking places or shebeens, often serve as high-risk venues for HIV transmission. The current study examined the HIV risks of men (N = 91) and women (N = 248) recruited from four shebeens in a racially integrating township in Cape Town South Africa. Participants completed confidential measures of demographic characteristics, HIV risk history, alcohol and drug use, and HIV risk behaviors. Comparisons of 94 (28%) participants who reported meeting sex partners at shebeens to the remaining sample of shebeen goers, controlling for potential confounds, demonstrated a pattern of higher risk for HIV infection among persons who met sex partners at shebeens. Few differences, however, were observed between men (N = 47) and women (N = 47) who had met sex partners at shebeens, suggesting greater gender similarities than gender differences in this important subpopulation. These results indicate an urgent need for multi-level HIV prevention interventions targeting shebeens and the men and women who drink in these settings. National Institute of Alcohol Abuse and Alcoholism Grant R21-AA014820 supported this research.     

HIV transmission risks of females and males in paired partner relationships

As the HIV/AIDS epidemic has evolved, heterosexual behaviors have come to be an increasingly important mode of transmission and rates of infection have increased faster among women generally and minority women in particular. Most of what we known about heterosexual risk taking is based on survey data collected from either women or men. These data have been useful for helping to understand different levels and types of risk taking by women and men. However, they provide little information about the levels of risk taking that exist for paired partners in main partner relationships, the types of risks each partner brings to the relationship and how the contribution of partner risks varies. Using data from the pretest of a pilot project designed to test a behavioral intervention to reduce HIV/AIDS transmission among main sex partners, the authors developed four subscales of sexual risk taking for each partner. The association between subscales within and between genders are examined and the subscales are combined to obtain measures of couple risks. Particular attention is given to the gender contribution of partners to couple risk and the differential contribution of types of risk to total risk. The data suggest that, even though men bring relatively higher risks to their main partner relationship than women, this varies inversely with the level of couple risk.     

Acceptability of a microbicide among women and their partners in a 4-country phase I trial

OBJECTIVES: We analyzed qualitative and quantitative data for 98 HIV-negative, low-risk women in Malawi, Zimbabwe, India, and Thailand who participated in a safety and acceptability study of BufferGel, a vaginal microbicide to determine the across-country acceptability of vaginal microbicides among women and their partners. METHODS: Quantitative survey data were collected at 7 and 14 days after use among enrolled women, and exit interviews were conducted with women and their partners in separate focus group discussions. RESULTS: Acceptability was high in all sites (73% of women approved of the microbicide). Women in Africa, where HIV infection rates are highest, were virtually unanimous in their desire for such a product, suggesting that an individual's perception of being at risk for HIV will outweigh concerns about side effects, problems applying a product, or other factors, when products are shown to be efficacious. But men and women reported that use, which was kept secret from an intimate partner, would be difficult and might "break the trust" of a relationship. CONCLUSIONS: Acceptability research across diverse settings through all stages of microbicide research, development, and post-licensure dissemination can help maximize acceptability and use.     

Health care-seeking behaviour of HIV-infected mothers and male partners in Nairobi,Kenya

Health care-seeking behaviours of HIV-infected mothers in sub-Saharan Africa are poorly characterised and typically focus on individual health conditions rather than overall health. We conducted a qualitative study to understand how HIV-infected mothers, their male partners and their HIV-exposed infants seek medical services. We performed 32 in-depth interviews (17 female, 15 male) and four focus group discussions among HIV-infected post-partum women and their male partners in Nairobi, Kenya. We used a grounded theory approach to explore the paths followed for health-related concerns. Female participants reported that willingness to be tested for HIV influences whether women sought antenatal care and the type of facility they preferred for childbirth. The need for medical care outside regular clinic hours and securing safe transportation at night were also significant barriers to seeking care. Most men sought services from traditional healers and chemists before HIV diagnosis, and at governmental facilities afterwards. Both men and women sent infants to traditional healers for non-medical conditions such as bewitching and massage but rarely for medical conditions. Strategies to reduce HIV-related stigma and fears in antenatal and maternity settings, increase access to care after-hours and improve linkage to HIV care for men early in their infection are needed.     

‘If I buy the Kellogg's then he should [buy] the milk’: young women's perspectives on relationship dynamics,gender power and HIV risk in Johannesburg,South Africa

Ideals of masculinity and femininity may limit South African women's decision making power in relationships and increase their risk of HIV infection. We conducted 30 in-depth interviews with 18–24-year-old women in inner-city Johannesburg with the aim of understanding young women's expectations of intimate relationships with men, their perceptions of gender and power and how this influences HIV risk. We found that the majority of young women reported expectations of power in relationships that conform to a model of femininity marked by financial independence, freedom to make decisions, including over sexuality, and equality (resistant femininity). The majority of young women, however, were in relationships marked by intimate partner violence, infidelity or lack of condom use. In spite of this, more young women who subscribed to a resistant model of femininity were in less risky relationships than young women who subscribed to acquiescent models, in which power was vested in their male partners. Further, young women who subscribed to resistant femininity had more education than women who subscribed to an acquiescent model. The disconnect between expectations of relationships and young women's lived realities emphasises the need for structural changes that afford women greater economic and thus decision making power.