Premarital sex, procreation, and HIV risk in Nigeria

Estimating HIV incidence in the Akwa Ibom AIDS indicator survey (AKAIS), Nigeria using the limiting antigen avidity recency assay

INTRODUCTION

HIV incidence estimates are important to characterize the status of an epidemic, identify locations and populations at high risk and to guide and evaluate HIV prevention interventions. We used the limiting antigen avidity assay (LAg) as part of a recent infection testing algorithm to estimate HIV incidence in the Akwa Ibom AIDS Indicator Survey (AKAIS), Nigeria.

METHODS

In 2017, AKAIS, a cross-sectional population-based study was conducted at the household (HH) level in 31 local government areas (LGAs) of Akwa Ibom state. Of the 8963 participants aged ≥15 years who were administered questionnaires for demographic and behavioural data, 8306 consented to HIV rapid testing. Whole-blood specimens were collected from 394 preliminary HIV-seropositive individuals for CD4+ cell count determination and plasma storage. Samples were shipped to a central quality laboratory for HIV confirmatory testing and viral load determination. A total of 370 HIV-positive specimens were tested for the recent HIV infection using the LAg assay.

RESULTS

Of the 8306 consenting adults, the HIV prevalence was 4.8%. Of the 370 HIV-positive samples tested for HIV recency, the median age was 35 years, 48.8% had CD4+ cell count >500/mm3 and 81.3% was not virally suppressed. Viral suppression was greater among females (21%) than for males (13%). A total of 11 specimens were classified as recent based on the LAg assay and HIV viral load ≥1000 copies/mL. The weighted, adjusted HIV-1 incidence was 0.41/100 person-years (95% CI 0.16 to 0.66); translating to 13,000 new cases of HIV infections annually in Akwa Ibom, a state with a population of 5.5 million. The HIV incidence rate was similar in females and males (0.41% and 0.42% respectively). The incidence rate was the highest among participants aged 15 to 49 years (0.44%, 95% CI 0.15 to 0.74) translating to 11,000 new infections annually, about 85% of all new infections in the state.

CONCLUSIONS

The finding of the high HIV incidence among the 15 to 49-year age group calls for renewed and innovative efforts to prevent HIV infection among young adults in Akwa Ibom state.

Application of Core Processes for Understanding Multiple Concurrent Sexual Partnerships Among Adolescents in Uganda

Introduction: Adolescents in Uganda, as in other sub-Saharan countries, engage in sex with multiple concurrent partners, thus placing them at risk for HIV and unplanned pregnancies, but it is not clear why. This study explored why adolescents in Uganda engage in multiple concurrent sexual partnerships (MCSP). Methods: This study used a Core Processes methodology. We used the processes of brainstorming, and identification of evidence and theoretical support, in various phases/steps of intervention planning, to provide possible explanations for adolescent MCSP. Results: Adolescents were found to have limited knowledge of the risks associated with MCSP and perceived a low risk for HIV. Peer influence to engage in MCSP exacerbated the problem among adolescents. Poor communication with sexual partners and parents and societal indifference to multiple sexual partnerships increased permissive attitudes toward infidelity. The unclear adolescent sexual and reproductive health policies hampered access to services, and transactional sexual relationships with older (polygamous) sexual partners increased the HIV risk. Adolescents were found to be more concerned about unplanned pregnancies than HIV risk. Discussion: From the empirical evidence, adolescent health programs in Uganda should incorporate comprehensive sexual health education on HIV and teenage pregnancy risk-reduction strategies. Programs should strengthen parental and community support through enhanced collaborative training on communication with and for adolescents. Forming strategic partnerships with various stakeholders for concerted efforts to address the MCSP problem among adolescents is critical.

The problem or the solution? Early fertility and parenthood in the transition to adulthood in Khayelitsha, South Africa

In South Africa, early fertility and teenage pregnancy have become a central focus of both political and public health concern. In this article, we explore the ways that young men and women have used their fertility and performance of parenthood to navigate the transition from childhood to adulthood. For these young people, the persistent inequities related to income poverty, inadequate education, lack of employment opportunities and a high burden of disease remain significant barriers to achieving this transition. This article draws on ethnographic data collected between 2014 and early 2016 with young adults (17-25 years) in Town Two, Khayelitsha. Participant observation was the primary data collection method. Narratives and experiences of 15 young people are presented here. We argue that in addition to immediate fertility desires, young people's contraceptive decision-making was significantly shaped by gendered ideals and social norms. Young women's fertility operated as both an aspiration and a threat within partnerships. Some couples partially achieved relationship stability or longevity through having a child. Entering parenthood in the context of a seemingly stable relationship was perceived as a movement towards an accepted, albeit tenuous, form of social adulthood. Although living up to the ideal of good parent was challenging, it was partially achieved by young mothers who provided care and young fathers who provided financially for children. In the absence of other accepted markers of transition to adulthood and within a context of deprivation and exclusion, early fertility, though clearly a public health problem, can become a solution to social circumstances.

HIV-prevention knowledge among illiterate and low-literate women in rural Amhara, Ethiopia

More than 85% of Ethiopia's population lives in rural areas and literacy levels in the country are relatively low. Despite this, little is known about levels of knowledge in regard to HIV/AIDS and condom use among illiterate and low-literate rural individuals. We conducted a cross-sectional study among 200 illiterate to semi-literate women, ages 13 to 24, from two rural communities in the Amhara region of northwestern Ethiopia. Nearly all the women had heard about HIV and AIDS. Among the illiterate individuals (n = 54), 24% did not know that HIV was the cause of AIDS and 48% did not know that HIV could be transmitted by sexual intercourse without a condom with an HIV-infected person. Among the same group, 59% did not know what a condom is. Literacy had a strong positive association with knowledge of HIV transmission and condoms. Thus, due to a generally higher level of literacy (grade 5-8 attainment), very young women (ages 13-20) had better knowledge of HIV transmission and condoms than did women ages 21-24 who by comparison were less literate. Given poor knowledge of HIV transmission and condoms among illiterate and low-literate women in Amhara, targeted HIV-prevention interventions are needed in this region.

Flexible kinship: caring for AIDS orphans in rural Lesotho

HIV/AIDS has devastated families in rural Lesotho, leaving many children orphaned. Families have adapted to the increase in the number of orphans and HIV-positive children in ways that provide children with the best possible care. Though local ideas about kinship and care are firmly rooted in patrilineal social organization, in practice, maternal caregivers, often grandmothers, are increasingly caring for orphaned children. Negotiations between affinal kin capitalize on flexible kinship practices in order to legitimate new patterns of care, which have shifted towards a model that often favours matrilocal practices of care in the context of idealized patrilineality.

HIV, poverty and women

This review examines the interactions of financial status and HIV and its implications for women. MEDLINE and Google scholar were searched using the keywords 'women', 'poverty' and 'HIV' in any field of the article. The search was limited to articles published in English over the last 10 years. The first section of the article tries to establish whether poverty or wealth is a risk factor for HIV. There is credible evidence for both arguments. While wealth shows an increased risk for both sexes, poverty places women at a special disadvantage. The second section explains how the financial status interacts with other 'non biological' factors to put women at increased risk. While discrimination based on these factors disadvantage women, there are some paradoxical observations that do not fit with the traditional line of explanation (e.g. paradoxical impact of wealth and education on HIV). The final section assesses the impact of HIV in driving poverty and the role of women in interventional programmes. The specific impact of poverty on females in families living with HIV is less explored. Though microfinance initiatives to empower women are a good idea in theory, the actual outcome of such a programme is less convincing.

Making sense of HIV in southeastern Nigeria: fictional narratives, cultural meanings, and methodologies in medical anthropology

Fictional narratives have rarely been used in medical anthropological research. This article illustrates the value of such narratives by examining how young people in southeastern Nigeria navigate the cultural resources available to them to make sense of HIV in their creative writing. Using thematic data analysis and narrative-based methodologies, it analyzes a sample (N = 120) from 1,849 narratives submitted by Nigerian youth to the 2005 Scenarios from Africa scriptwriting contest on the theme of HIV. The narratives are characterized by five salient themes: tragedy arising from the incompatibility of sex outside marriage and kinship obligations; female vulnerability and blame; peer pressure and moral ambivalence; conservative Christian sexual morality; and the social and family consequences of HIV. We consider the strengths and limitations of this narrative approach from a theoretical perspective and by juxtaposing our findings with those generated by Daniel Jordan Smith using standard ethnographic research methods with a similar Igbo youth population.

Immuno-virologic outcomes and immuno-virologic discordance among adults alive and on anti-retroviral therapy at 12 months in Nigeria

Background

Predictors of immuno-virologic outcomes and discordance and their associations with clinical, demographic, socio-economic and behavioral risk factors are not well described in Nigeria since HIV viral load testing is not routinely offered in public HIV treatment programs.

Methods

The HACART study was a multi-center observational clinic-based cohort study of 2585 adults who started HAART between April 2008 and February 2009. A total of 628 patients were randomly selected at 12 months for immuno-virologic analyses.

Results

Virologic suppression rate (<400 copies/ml) was 76.7%, immunologic recovery rate (CD4 change from baseline ≥50 cells/mm³) was 77.4% and immuno-virologic discordance rate was 33%. In multivariate logistic regression, virologic failure was associated with age <30 years (OR 1.79; 95% CI: 1.17-2.67, p=0.03), anemia (Hemoglobin < 10 g/dl) (OR 1.71; 95% CI: 1.22-2.61, p=0.03), poor adherence (OR 3.82; 95% CI: 2.17-5.97, p=0.001), and post-secondary education (OR 0.60; 95% CI: 0.30-0.86, p=0.02). Immunologic failure was associated with male gender (OR 1.46; 95% CI: 1.04-2.45, p=0.04), and age <30 years (OR 1.50; 95% CI: 1.11-2.39, p=0.03). Virologic failure with immunologic success (VL^-/CD4⁺) was associated with anemia (OR 1.80; 95% CI: 1.13-2.88, p=0.03), poor adherence (OR 3.90; 95% CI: 1.92-8.24, p=0.001), and post-secondary education (OR 0.40; 95% CI: 0.22-0.68, p=0.005).

Conclusions

Although favorable immuno-virologic outcomes could be achieved in this large ART program, immuno-virologic discordance was observed in a third of the patients. Focusing on intensified treatment preparation and adherence, young patients, males, persons with low educational status and most importantly baseline anemia assessment and management may help address predictors of poor immuno-virologic outcomes, and improve overall HIV program impact. Viral load testing in addition to the CD4 testing should be considered to identify, characterize and address negative immuno-virologic outcomes and discordance.

The evolution of our knowledge of HIV-associated kidney disease in Africa

Human immunodeficiency virus (HIV) infection started in Africa circa 1930. South Africa has the highest prevalence rate in the world. Although reports of HIV-associated nephropathy (HIVAN) appeared in the early 1980s, the earliest report from sub-Saharan Africa (SSA) came in 1994. Geographical, socioeconomic, political, and ethical factors have worked in concert to shape the character of HIV disease as it is seen in SSA. Political leaders within SSA have, through their actions, significantly contributed to the incidence of HIV infection. Black females, who often face cultural suppression and disadvantage, have a higher prevalence of HIV than males. Too few studies and outcomes data have bedeviled the statistics in SSA in relation to HIVAN prevalence and its management. Much of what is written is approximation and anecdotal. The largest reliable biopsy series comes from the University of Cape Town, where a workable classification of HIVAN has been developed to enable standardization of terminology. Histologic and clinical prognostic indicators with outcomes have been evaluated using this classification. Patients with HIV who present with acute kidney injury appear to have mainly acute tubular necrosis due to sepsis, dehydration, and nephrotoxic drugs. Since the rollout of combination antiretroviral therapy, the extent of HIV infection and kidney disease continues to be modified and possibly retarded.

Gender inequities in sexually transmitted infections: implications for HIV infection and control in Lagos State, Nigeria

Beyond the statistics of sex-based differences in infection rates, there are profound differences in the underlying causes and consequences of HIV infections in male and female which need to be examined. The study therefore examines; the gender differences in the STI knowledge and gender-related potential risks of HIV heterosexual transmission. Quantitative and qualitative data were collected. A multistage random sampling procedure was employed in administration of 1358 questionnaires. For qualitative data, four focus group discussions (FGD) were conducted to collect information from stakeholders within the study population, while In-depth interview was employed to collect information from 188 people living with HIV/AIDS through support groups in the State. The data collected were subjected to basic demographic analytical techniques. Combination of univariate, bivariate, and multivariate analysis were employed. Information from focus group discussions and in-depth interviews were transcribed and organized under broad headings that depict different aspects of the discussions. Majority of the respondents interviewed did not inform their partners about their infection in the study area. It was also discovered that stigmatization did not allow some women to disclose their status to their sexual partners. Some of the HIV-positive patients interviewed agreed that they did not attend the health facilities to treat the STI’s before they were finally confirmed positive. The study hypothesis revealed that communication between partners about STI’s was associated with an increase in risk reduction behaviour. The paper concluded that there is need for more information and education on communication about STI’s between the sexual partners; to reduce the spread of sexually transmitted diseases within the nation.

The influence of knowledge and sociodemographics on AIDS perception and sexual practices among secondary school students in Nigeria

BACKGROUND

Recent trends show a disproportionate increase in new incidences of HIV infection among teenagers compared to other population segments.

OBJECTIVES

This study assessed secondary school students' perception of AIDS epidemic, and the influence of sociodemographic variables and AIDS knowledge on their perception and sexual practices.

METHODS

Nigerian teenagers (N=1143) were surveyed using a questionnaire that elicited information on their demographics, AIDS knowledge, perceptions and previous encounter with survivors, and sexual practices.

RESULTS

Although AIDS epidemic was not a serious issue of concern to a substantial number of the students, they were knowledgeable on AIDS, and their perceptions on AIDS epidemics influenced their sexual practices. Female teenagers were more knowledgeable and concerned, and more frequently reported inexperience with sexual intercourse compared to their male counterparts.

CONCLUSION

AIDS education and campaigns that foster the internalization of the seriousness of AIDS epidemics and arouse concern about them could enhance safe sexual practices among the youths.

Internal migration and health: premarital sexual initiation in Nigeria

The high rates of youth migration to urban and economic centers, in the context of persistent poverty and devastating HIV/AIDS burden, have raised intricate social policy challenges in developing countries. Using the 2008 Nigeria Demographic and Health Survey data, descriptive statistics, Kaplan-Meier survival curves and discrete-time hazard regression models, this study examines the patterns of internal migration and sexual initiation among never-married Nigerian youth aged 15-24. We find that migrants generally show stronger association than non-migrants, and urban-rural and rural-rural migrants particularly show the strongest independent association with premarital sexual initiation. Other significant covariates are age, religion, ethnic origin, educational attainment, independent living arrangement, formal employment and exposure to the mass media. The findings highlight the direct importance of youth migration in understanding and addressing the challenges of premarital sexual behavior and the need for behavior change policies and programs to be sensitive to the complex contextual nuances across youth groups in one country.

Antiretroviral therapy and reproductive life projects: mitigating the stigma of AIDS in Nigeria

As millions of people infected with HIV in Africa are increasingly able to live longer and healthier lives because of access to antiretroviral therapy, concerns have emerged that people might eschew protective practices after their health improves. Extending beyond the notion of sexual "disinhibition," researchers have begun to analyze the sexual behavior of people in treatment through the perspective of their marital and childbearing aspirations. This article explores the reproductive life projects of HIV-positive men and women in southeastern Nigeria, showing how actions that contradict medical advice are understandable in the context of patients' socially normative desires for marriage and children. Based on in-depth interviews and observations (June-December 2004; June-July 2006; June-July 2007) of people enrolled in the region's oldest treatment program, we argue that broadly held social expectations with regard to reproduction are experienced even more acutely by HIV-positive people. This is because in Nigeria the stigma associated with AIDS is closely tied to widespread perceptions of social and moral crisis, such that AIDS itself is seen as both a cause and a symptom of anxiety-producing forms of social change. Specifically, in an era of rapid societal transformation, Nigerians see sexual promiscuity and the alienation of young people from traditional obligations to kin and community as indicative of threatened social reproduction. For people who are HIV-positive, marrying and having children offer not only the opportunity to lead normal lives, but also a means to mitigate the stigma associated with the disease. Four ethnographic case studies are provided to exemplify how and why social and personal life projects can trump or complicate medical and public health priorities. These examples suggest that treatment programs must openly address and proactively support the life projects of people on antiretroviral therapy if the full benefits of expanded access to treatment are to be realized.

Promiscuous Girls, Good Wives, and Cheating Husbands: Gender Inequality, Transitions to Marriage, and Infidelity in Southeastern Nigeria

The transition from premarital sexual relationships and courtship to marriage and parenthood in southeastern Nigeria involves particularly dramatic adjustments for young women who have absorbed changing ideas about sexuality, marriage, and gender equality, and who have had active premarital sexual lives. In the eyes of society, these women must transform from being promiscuous girls to good wives. This paper examines these adjustments and, specifically, how young married women's lives are affected by the reality of male infidelity and a persistent gendered double standard regarding the acceptability of extramarital sex.

Looking at Complicating Non-Biological Issues in Women with HIV

INTRODUCTION

The increasing number of women acquiring Human Immunodeficiency Virus (HIV) has resulted in a 'feminization' of the epidemic. In this article we are reviewing whether females are disadvantaged in the epidemic, due to factors independent of the biological differences in sexes.

MATERIALS AND METHODS

We searched MEDLINE and EMBASE for articles with key words 'Women', 'Gender,' and 'HIV' in any field. The search was restricted to articles published in English within the last 10 years (1999-2009). Data were coded independently by two reviewers from 94 selected sources. The coded data were categorized under five commonly encountered concepts; violence, poverty, gender norms, prevention-/treatment-related issues, and Highly Active Anti-Retroviral Treatment (HAART).

RESULTS

The link between inter-partner violence (IPV) and HIV risk for women is observed by many authors. In assessing the link between poverty and HIV, indicators such as food insufficiency and income inequality may be better indicators compared to wealth itself. Although women are disadvantaged with male-dominated gender norms, evidence suggests that the traditional norms are changing in many societies. A positive association between living in urban communities, education, and better HIV knowledge has been observed in females, although it is not always synonymous with reduced risk behavior.

CONCLUSIONS

Women are still disadvantaged in many HIV-related issues such as poverty, violence, and gender norms. At least in Africa, there is evidence of a positive change in spheres of education and gender norms. However, the situation in Asia is largely unexplored.

Limits to modern contraceptive use among young women in developing countries: a systematic review of qualitative research

Background

Improving the reproductive health of young women in developing countries requires access to safe and effective methods of fertility control, but most rely on traditional rather than modern contraceptives such as condoms or oral/injectable hormonal methods. We conducted a systematic review of qualitative research to examine the limits to modern contraceptive use identified by young women in developing countries. Focusing on qualitative research allows the assessment of complex processes often missed in quantitative analyses.

Methods

Literature searches of 23 databases, including Medline, Embase and POPLINE^®, were conducted. Literature from 1970–2006 concerning the 11–24 years age group was included. Studies were critically appraised and meta-ethnography was used to synthesise the data.

Results

Of the 12 studies which met the inclusion criteria, seven met the quality criteria and are included in the synthesis (six from sub-Saharan Africa; one from South-East Asia). Sample sizes ranged from 16 to 149 young women (age range 13–19 years). Four of the studies were urban based, one was rural, one semi-rural, and one mixed (predominantly rural). Use of hormonal methods was limited by lack of knowledge, obstacles to access and concern over side effects, especially fear of infertility. Although often more accessible, and sometimes more attractive than hormonal methods, condom use was limited by association with disease and promiscuity, together with greater male control. As a result young women often relied on traditional methods or abortion. Although the review was limited to five countries and conditions are not homogenous for all young women in all developing countries, the overarching themes were common across different settings and contexts, supporting the potential transferability of interventions to improve reproductive health.

Conclusion

Increasing modern contraceptive method use requires community-wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth-friendly services. Interventions should aim to counter negative perceptions of modern contraceptive methods and the dual role of condoms for contraception and STI prevention should be exploited, despite the challenges involved.

The social context of marital happiness in urban Indian couples: interplay of intimacy and conflict

This research examines the happiness of 182 married, urban Hindu husbands and wives. Prior research emphasizes that the processes mediating well-being diverge across cultures with personal desires not impacting the happiness of non-Western couples. However, with globalization as self needs become important, barometers of happiness such as intimacy and conflict in a relationship assume a critical role in the quality and longevity of marriage, even for non-Western marriages in a contemporary India. Participants were 91 Indian couples, married an average of 11 years, from three socioeconomic classes, three family structures, and arranged and love marriages. Results reveal that happy couples, compared with unhappy couples, reported agreement, empathy, validation, support, and fulfilled expectations. Couples' experience and expression of intimacy, affected by social context, also predicted enhanced levels of happiness in marriage while conflict had a negative effect on marital happiness. This research suggests how personal desires may be transforming cultural practices.

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.

Life projects and therapeutic itineraries: marriage, fertility, and antiretroviral therapy in Nigeria

OBJECTIVE

To examine and understand the marital and fertility aspirations and behaviours of individuals receiving antiretroviral therapy (ART) in Nigeria and evaluate the effects on sexual behaviour, disclosure, and adherence.

DESIGN AND METHODS

The study used ethnographic methods of participant observation and in-depth interviews of individuals receiving ART through a government-supported programme in southeastern Nigeria.

RESULTS

Interviews and observations of individuals on treatment demonstrate that marriage and childbearing are paramount desires for people whose health is restored by ART. The concept of life projects is introduced and combined with the established idea of therapeutic itineraries to show how participation in and adherence to treatment, disclosure of HIV status, and decisions about sexual behaviour cannot be understood in purely biomedical terms. Marital and reproductive aspirations routinely impinge on and often trump clinical and public health priorities. Emblematic case studies are provided to illustrate the social dynamics that motivate and explain behaviour seemingly inimical to individual and public health.

CONCLUSION

Effective antiretroviral programme design and therapy management will require acknowledging and often enabling rather than discouraging the marital and reproductive goals of individuals if issues of disclosure, adherence, and prevention are to be realistically addressed.

Gender, sexuality, and antiretroviral therapy: using social science to enhance outcomes and inform secondary prevention strategies

OBJECTIVES

To explore how, within the context of antiretroviral therapy (ART) uptake and adherence, social science research on gender and sexuality could complement existing epidemiological and behavioral research on uptake, adherence, disinhibition and reproduction.

METHODS

Bibliographical database searches on ART uptake and adherence, the sexual practices of HIV-positive individuals, and fertility management among HIV-positive men and women were conducted over a 6-month period using ISI Web of Science and Medline. Articles were sorted by main topic and then analysed to reveal the unarticulated assumptions that have framed research to date.

RESULTS

The adoption of more social scientific theoretical frameworks would move research on uptake, adherence, disinhibition, and reproduction among HIV-infected and affected individuals beyond the current overemphasis on how cognitive and ideological factors shape behavior and towards an understanding of how culture and inequality shapes the way people engage with ART and craft their sexual and reproductive lives. Research that pays greater attention to the social processes that create differentials in uptake and adherence, rather than just the quantification of those differentials, will open up new possibilities for community-based interventions. Similarly, social science research on gender and sexuality can provide insight into the social factors shaping reproductive and sexual behavior, and thus enhance our ability to manage the potentially competing priorities of limiting marital sexual risk and increasing access to reproductive choice among HIV-affected couples.

CONCLUSION

The ability to produce good clinical outcomes and to develop effective policies for secondary prevention will be enhanced by a deeper understanding of how gender inequality and the social organization of sexuality shape the sexual and reproductive behavior of individuals using ART.

Sex, money, and premarital partnerships in southern Malawi

In this paper, I argue two main points. First, in premarital, sexual partnerships in rural Malawi, the purpose of money exchange extends beyond the alleviation of female partners' economic constraints, and, second, by clarifying this broader purpose, it becomes possible to recognize where women exert control over their own sexual selves. These findings come from field observations and a rich set of in-depth interviews (N=54), bolstered on occasion by survey data, conducted with young women and men, aged 15-24 years, in the Balaka district in the southern region of the country. This research demonstrates that, contrary to typical expectations, money and gift transfers in sexual partnerships are part and parcel of the courting practices of young Malawian women and men. Transfers are as much about the expression of love and commitment as they are about meeting the financial needs of women or the acquisition of sex for men. Using narrative information to shed light on the semiotics of the sex-money link, these findings from Malawi offer a new perspective that broadens usual interpretations of transactional sex, the understanding of which is critical in fighting AIDS.

The changing political economy of sex in South Africa: the significance of unemployment and inequalities to the scale of the AIDS pandemic

Between 1990 and 2005, HIV prevalence rates in South Africa jumped from less than 1% to around 29%. Important scholarship has demonstrated how racialized structures entrenched by colonialism and apartheid set the scene for the rapid unfolding of the AIDS pandemic, like other causes of ill-health before it. Of particular relevance is the legacy of circular male-migration, an institution that for much of the 20th century helped to propel the transmission of sexually transmitted infections among black South Africans denied permanent urban residence. But while the deep-rooted antecedents of AIDS have been noted, less attention has been given to more recent changes in the political economy of sex, including those resulting from the post-apartheid government's adoption of broadly neo-liberal policies. As an unintentional consequence, male migration and apartheid can be seen as almost inevitably resulting in AIDS, a view that can disconnect the pandemic from contemporary social and economic debates. Combining ethnographic, historical, and demographic approaches, and focusing on sexuality in the late apartheid and early post-apartheid periods, this article outlines three interlinked dynamics critical to understanding the scale of the AIDS pandemic: (1) rising unemployment and social inequalities that leave some groups, especially poor women, extremely vulnerable; (2) greatly reduced marital rates and the subsequent increase of one person households; and (3) rising levels of women's migration, especially through circular movements between rural areas and informal settlements/urban areas. As a window into these changes, the article gives primary attention to the country's burgeoning informal settlements--spaces in which HIV rates are reported to be twice the national average--and to connections between poverty and money/sex exchanges.