The Cape Town boyfriend and the Joburg boyfriend: women's sexual partnerships and social networks in Khayelitsha, Cape Town

High HIV incidence among young women in South Africa: Data from a large prospective study

Introduction

South Africa has the highest national burden of HIV globally. Understanding drivers of HIV acquisition in recently completed, prospective studies in which HIV was an endpoint may help inform the strategy and investments in national HIV prevention efforts and guide the design of future HIV prevention trials. We assessed HIV incidence and correlates of incidence among women enrolled in ECHO (Evidence for Contraceptive Options and HIV Outcomes), a large, open-label randomized clinical trial that compared three highly effective. reversible methods of contraception and rates of HIV acquisition.

Methods

During December 2015 to October 2018, ECHO followed sexually active, HIV-seronegative women, aged 16–35 years, seeking contraceptive services and willing to be randomized to one of three contraceptive methods (intramuscular depot medroxyprogesterone acetate, copper intrauterine device, or levonorgestrel implant) for 12–18 months at nine sites in South Africa. HIV incidence based on prospectively observed HIV seroconversion events. Cox proportional hazards regression models were used to define baseline cofactors related to incident HIV infection.

Results

5768 women were enrolled and contributed 7647 woman-years of follow-up. The median age was 23 years and 62.5% were ≤24 years. A total of 345 incident HIV infections occurred, an incidence of 4.51 per 100 woman-years (95%CI 4.05–5.01). Incidence was >3 per 100 woman-years at all sites. Age ≤24 years, baseline infection with sexually transmitted infections, BMI≤30, and having new or multiple partners in the three months prior to enrollment were associated with incident HIV.

Conclusions

HIV incidence was high among South African women seeking contraceptive services. Integration of diagnostic management of sexually transmitted infections alongside delivery of HIV prevention options in health facilities providing contraception services are needed to mitigate ongoing risks of HIV acquisition for this vulnerable population.

Clinical trial registration

ClinicalTrials.gov, number NCT02550067 was the main Clinical Trial from which this secondary, non-randomized / observational analysis was derived with data limited to just South African sites.

"An Unchanging God in a Changing World": Sexual Practice and Decision-Making among Christian Women in South Africa

This study explored the relationship between sexual health and religion among young, Pentecostal Christian women navigating the transition to adulthood in Khayelitsha township, in the City of Capetown, South Africa. Between February and August 2019, eleven semi-structured interviews and three focus group discussions were conducted. Thematic analysis and discourse analysis were used to analyse the data collected. The study found that the relationship between sexual health and religion was complex and multifaceted, shaped by the religious dichotomisation of "right" and "wrong", socio-economic constraints and culture. Despite the perceived decline of religious influence on the sexual and social lives of youth, religion continues to play an instrumental role in shaping the dreams, aspirations and lifestyles of young people, especially as they transition to adulthood. We argue therefore, that religion is a significant spiritual and cultural resource that young women use to develop their sexual and social identities, although it cannot always be equated with their sexual practice or decision-making related to sexual health. In the light of this, churches should still be seen as key partners in the fight against HIV as their involvement can act as a stabilising force for young people dealing with poverty and uncertainty. Church engagement with young people should offer programmes that include but are not limited to sexual health.

Making sense of fidelity: young Africans' cross-national and longitudinal representations of fidelity and infidelity in their HIV-related creative narratives, 1997-2014

Mutual fidelity and partner reduction have been identified as key behavioural strategies to prevent HIV transmission in sub-Saharan Africa, particularly following recognition of the role that multiple concurrent sexual partnerships play in driving generalised HIV epidemics. We analysed social representations of fidelity and infidelity in a sample of 1,343 narratives about HIV written by young Africans between 1997 and 2014. The narratives were written at four different time points (1997, 2005, 2008, 2014) by authors aged 10-24 in urban and rural areas of Senegal, Burkina Faso, South-east Nigeria, Kenya and Eswatini. We combined three analytical approaches: descriptive statistics of quantifiable characteristics of the narratives, thematic data analysis and a narrative-based approach. In the sample, fidelity is often promoted as the ideal by narrators, peers and romantic partners, in line with broader discourses around HIV prevention, romantic relationships, familial obligations, and religious and moral imperatives. However, mutual fidelity is rarely modelled in the narratives and representations of combining methods to prevent HIV from entering relationships via infidelity are uncommon. Representations of fidelity reflect loss-framed fear arousal techniques that perpetuate HIV-related stigma. Narrative-based approaches that facilitate skills-building, critical reflection and address stigma can better address fidelity and partner reduction.

Exploring discrepant knowledge of partner sexual behaviour to inform self-risk assessment in a high HIV burdened district in rural KwaZulu-Natal

Understanding the sexual relationships of young women is critical for preventing HIV infections. This study aimed to describe the sexual behaviour of partners, comparing the accuracy of sexual health knowledge between partners. The study took place in 2017 in KwaZulu-Natal, South Africa. Purposive sampling was used to select 18-27-year-old sexually active women. Consenting female participants completed a structured and semi-structured interview, while consenting male sexual partners identified through the female participant completed a structured questionnaire on sexual health information. Using a reflexive inductive approach and thematic analysis, we identified key discrepancies in the assumptions partners make about each other's sexual health information. Twenty-three sexual dyads were identified and four key discrepancies were identified: Age: partners either over or underestimated the age of their partners, HIV status: where partners were unaware of, or incorrectly assumed their partner's status, Lack of awareness of partner's concurrent relationships and more general knowledge of the partner's sexual health behaviours. Discussions about sexual health are mediated by relationship length, type of partner, power and perceived fidelity. While it is possible to undertake dyadic level research, ethical tensions remain. Sex-positive and egalitarian sexual health interventions that target the individual, as well as the sexual relationship, are needed.

Unpacking the practice of ukujola in contemporary South Africa: understanding informal/casual sexual relations of young African adults in the context of HIV and AIDS

HIV and AIDS continue to pose a global health and development challenge, particularly in sub-Saharan Africa. South Africa has the largest number of people living with HIV (PLHIV) in the world. In spite of the accelerated efforts to combat the HIV and AIDS epidemic, there still remains an unabated challenge, i.e. continuing new infections, particularly among young African adults. HIV is largely transmitted through unprotected vaginal and anal sexual intercourse. This study sought to unpack the meaning of ukujola (casual or informal sexual relationships) as socially constructed by Zulu people, and to identify underlying socio-economic factors for ukujola. This study uses a generic qualitative study approach in which 32 qualitative interviews (4 focus groups, 20 in-depth interviews and 8 key-informant interviews) were conducted with isiZulu-speaking participants (aged 21-34) from Umgungundlovu district, KwaZulu-Natal province. The study found that ukujola relationships are a relatively new phenomenon in Zulu society. Ukujola relationships encompass all "illegitimate" relationships, i.e. in which there has never been involvement of the families. The involvement of families in negotiating ilobolo (bride wealth) is a pre-requisite for legitimate relationships, particularly marriage. Multiple concurrent sexual partnerships typically exist in ukujola relationships, and unprotected sex is common. There is a need for a national dialogue on ilobolo in the context of HIV and AIDS.

"It Was Not My Aim to Sleep There": The Impact of Timing and Location of Sex on Adherence to Coitally-Dependent HIV Pre-exposure Prophylaxis

The FACTS 001 trial found that vaginal pre- and post-coital application of 1% tenofovir gel did not prevent HIV-1 infection amongst young South African women. The trial included a multi-faceted approach to adherence support and collected objective and self-reported adherence measures. Using qualitative data collected from a random sub-set of FACTS 001 participants (135 in-depth interviews at product discontinuation and 13 focus group discussions at dissemination of trial results), we explore the importance of 'place' and 'timing' in shaping acts of sexual intimacy and product adherence. Demographically, this qualitative sub-sample is similar to the trial cohort of predominantly young, unemployed women living with parents or other family members. Sexual intimacy was largely unpredictable and happened across multiple locations in which women had limited privacy, autonomy, or control over the timing of sex. This made adherence to the dosing strategy challenging. Findings may inform the development of future event-driven pre-exposure prophylaxis regimens or products.

Personal support and expressions of care for pregnant women in Soweto, South Africa

Background: Pregnancy is life changing, making great demands on women to adapt physically, psychologically, and socially. Social relationships and the support that flow from these provide a critical role in managing health problems in pregnancy. Isolation and lack of care, in contrast, may lead women to experience increased distress during this time.

Objective: This study aimed to explore South African women's perception and experience of care and support in pregnancy.

Methods: A life history approach was employed to explore women’s experiences of pregnancy and sexual behaviour, with each participant encouraged to narrate important life events from her own perspective. We drew on narrative interviews with 15 pregnant women, conducted between July and October 2015, in which we explored questions regarding pregnancy planning and the provision and receipt of care. A thematic approach was employed to code and analyse the data.

Results: Themes that emerged from the interviews showed that participants gained a sense of stability in their lives when they had support in their pregnancy, especially when dealing with challenging situations. This support came variously from family, friends, and social networks. Overall, those participants who mentioned the most support, and its diversity across different groups, reported a better experience of pregnancy.

Conclusions: Women emphasised the importance of social and emotional support in pregnancy. Understanding women’s experiences can assist in making pregnancy less overwhelming, and can add to a woman’s ability to deal with different challenges before and after the arrival of the new baby.

Ecological correlates of multiple sexual partnerships among adolescents and young adults in urban Cape Town: a cumulative risk factor approach

Studies in South Africa have reported unsafe levels of risky sexual behvaiours among adolescents and young adults, with the country reporting the highest burden of HIV/AIDS globally, as well as a high rate of teenage pregnancy. While determinants of risky sexual behaviours have been investigated for factors occurring at the individual and household levels, not fully explored in the literature is the effect of community level factors. Furthermore, it is unclear whether risk factors occurring within the ecology of adolescents and young adults act cumulatively to influence their sexual practices. This article aims to address this knowledge gap using a case study of the Cape Area Panel Study of adolescents and young adults in urban Cape Town, South Africa. The ecological framework was adopted to guide the selection of risk factors at the individual, household, and community levels. Multivariate linear discriminant function analyses were used to select significant risk factors for multiple sexual partnerships and used to produce risk indices for the respondents. The cumulative risk approach was applied to test whether significant risk factors acted cumulatively. Findings point to the importance of ecological factors in influencing outcomes of multiple sexual partnerships among respondents and further demonstrate that ecological risk factors may act cumulatively. These findings are important for South Africa that is grappling with teenage pregnancy and disproportionate HIV epidemic among the youth.