Social Exchange and Sexual Behavior in Young Women's Premarital Relationships in Kenya

Social norms that sustain transactional sex and associations with sexual health outcomes: A mixed-methods study in the Comarca Ngäbe-Buglé, a rural-Indigenous region of Panama

The Comarca Ngäbe-Buglé (CNB), home to >200,000 Indigenous people, is one of the poorest regions in Panama. We describe transactional sex (TS) behaviours, normative beliefs and factors associated with TS among Indigenous adolescents(14-19years) in the CNB. We conducted a mixed-methods study in the CNB between January and November 2018, which included a qualitative study with participant observation and semi-structured interviews that focused on descriptive norms related to TS; and a cross-sectional study among public-school-going adolescents using self-administered questionnaire to report sexual behaviour and injunctive norms related to TS. Participants in the epidemiological study were also asked to submit samples for HIV, syphilis, chlamydia, and gonorrhoea testing. Qualitative thematic analysis was used to organise and analyse field notes and semi-structured interviews. Quantitative analysis included four models: TS experience and acceptance of a TS offer and the associations of these outcome variables with demographic and behavioural variables and HIV/STI infections. In the qualitative study among 20 adolescents, we found that people offering TS were reported to be from within and outside of the community, and included older men and women, and disturbingly, teachers. Participants reported feeling individual and collective agency in the decision to engage in TS and described little social sanctions for participation. In the quantitative study among 700 adolescents(309 girls[45.1%],379 boys[54.9%]), we found that girls(18.8%;58/309) and boys(15.5%;58/379) reported similar levels of having been offered TS, and of acceptance among those offered(girls 81.4% [35/43]; boys 77.8% [35/45]). TS was found to be associated with the reported forced sex and HIV/syphilis seropositivity. Due to widespread acceptance and feelings of agency, interventions would not be effective if they focused on eliminating the transactional component of sexual encounters. Instead, interventions should focus on individual and household economic stability, increasing violence reporting, bringing perpetrators to justice, and adopting condom use during all sexual encounters.

Batswana Adolescents' Attitudes Toward Sex With Older Adults: Psychometric Properties of the Attitudes Toward Transactional Sex Scale

A programmatic series of studies developed and evaluated the Attitudes toward Transactional Sex Scale (ATTS) to measure adolescents' attitudes toward engaging in a sexual encounter initiated by an older adult offering desired objects such as cell phone, clothes, cash, or car rides in exchange for sex. Qualitative interviews informed the initial item generation followed by a series of studies assessing the psychometric properties of the measure. Study 1 evaluated the ATTS in a sample of 186 Batswana adolescents and assessed the factor structure, item-to-whole correlations, internal consistency, and convergent validity. In Study 2, the ATTS was administered to a cross-validation sample (N = 387). Confirmatory factor analysis, convergent validity, and internal consistency were consistent with the findings from the original sample. Discriminant validity was also assessed in Study 2. A subset of the sample (N = 119) completed the measure on two occasions and yielded satisfactory test-retest reliability. The resulting instrument appears to have sound psychometric properties and can be used to measure adolescents' attitudes toward accepting such adult sexual initiation that are implicated in the disproportionate burden of HIV among adolescents and young adults in sub-Saharan Africa. No existing measure with known psychometric properties has previously been available.

Transactional sex among women in Sub-Saharan Africa: A systematic review and meta-analysis

INTRODUCTION

Transactional sex is casual sex between two people to receive material incentives in exchange for sexual favors. Transactional sex is associated with negative consequences, which increase the risk of sexually transmitted diseases, including HIV/AIDS, unintended pregnancy, unsafe abortion, and physiological trauma. In Sub-Saharan Africa, several primary studies have been conducted in various countries to examine the prevalence and associated factors of transactional sex among women. These studies had great discrepancies and inconsistent results. Hence, this systematic review and meta-analysis aimed to synthesize the pooled prevalence of the practice of transactional sex among women and its associated factors in Sub-Saharan Africa.

METHOD

Data source: PubMed, Google Scholar, HINARI, the Cochrane Library, and grey literature were searched from March 6 to April 24, 2022, and included studies conducted from 2000 to 2022. The pooled prevalence of transactional sex and associated factors was estimated using Random Effect Model. Stata (version 16.0) was used to analyze the data. The I-squared statistic, a funnel plot, and Egger's test were used to check for heterogeneity and publication bias, respectively. A subgroup analysis was done based on the study years, source of data, sample sizes, and geographical location.

RESULTS

The pooled prevalence of transactional sex among women in Sub-Saharan Africa was 12.55% (9.59%-15.52%). Early sexual debut (OR = 2.58, 95% CI: 1.56, 4.27), substance abuse (OR = 4.62, 95% CI: 2.62, 8.08), history of sexual experience (OR = 4.87, 95% CI: 2.37, 10.02), physical violence abuse (OR = 6.70, 95% CI: 3.32, 13.53), orphanhood (OR = 2.10, 95% CI: 1.27, 3.47), and sexual violence abuse (OR = 3.76, 95% CI: 1.08, 13.05) were significantly associated with transactional sex.

CONCLUSION

The prevalence of transactional sex among women in sub-Saharan Africa was high. Alcohol consumption, substance abuse, early sex debuts, having a history of sexual experiences, physical violence, and sexual violence increased the practice of transactional sex.

Development of an Index to Measure the Exposure Level of UN Peacekeeper-Perpetrated Sexual Exploitation/Abuse in Women/Girls in the Democratic Republic of Congo

Sexual exploitation and abuse (SEA) of women and girls by United Nations (UN) peacekeepers is an international concern. However, the typical binary measurement of SEA (indicating that it occurred, or it did not) disregards varying exposure levels and the complex circumstances surrounding the interaction. To address this gap, we constructed an index to quantify the degree to which local women and girls were exposed to UN-peacekeeper perpetrated SEA. Using survey data (n = 2867) from the Democratic Republic of Congo (DRC), eight indicators were identified using a combination of qualitative (thematic analysis of narrative data) and quantitative variables. With further development, this index may offer a more comprehensive and nuanced perspective of peacekeeper-perpetrated SEA that can better inform SEA prevention and intervention efforts.

Sugar Dating, Perceptions of Power, and Condom Use: Comparing the Sexual Health Risk Behaviours of Sugar Dating to Non-Sugar Dating Women

Sugar dating is a form of dating typically characterized by wealthier, older men providing financial support to younger, less financially secure women in exchange for companionship and sexual intimacy. The goals of the current study were to (1) quantitatively assess the sexual practices of sugar dating women in their arrangements with sugar daddies, including time spent on sexual activity, average number of current partners, and relative perceptions of relationship power, (2) examine how perceptions of power within arrangements relate to condom use with sugar daddies, and (3) compare samples of sugar dating and non-sugar dating women on both condom use consistency by partner type and rates of STI testing and diagnoses. Overall, condom use for all women was highest with casual sexual partners and lowest with romantic partners, with sugar dating women's condom use with sugar daddies in between. Consistent with social exchange theory, perception of power within sugar dating arrangements predicted condom use with sugar daddies, such that women who felt they held more power reported more consistent condom use. Further, sugar dating women were twice as likely to have been diagnosed with an STI but were more than six times as likely to have been tested for STIs.

Individual and Relationship-Level Correlates of Transactional Sex Among Adolescent Girls and Young Women in Malawi: A Multilevel Analysis

Transactional sex increases HIV risk among adolescent girls and young women (AGYW). Understanding the individual and dyadic nature of transactional sex may provide evidence for risk reduction interventions. Multilevel logistic regression was used to cross-sectionally examine correlates of transactional sex among AGYW in Lilongwe, Malawi. Participants (N = 920) reported 1227 relationships. Individual-level associations were found between being divorced/widowed (AOR 5.07, 95% CI 1.93, 13.25), married (AOR 0.26, 95% CI 0.09, 0.72), or unstably housed (AOR 7.11, 95% CI 2.74, 18.47) and transactional sex. At the relationship-level, transactional sex occurred in relationships with: non-primary primary partners (AOR 4.06, 95% CI 2.37, 6.94), perceived partner concurrency (AOR 1.85, 95% CI 1.11, 3.08), and feared violence with couples HIV testing (AOR 2.81, 95% CI 1.26, 6.29), and less likely to occur in relationships with children (AOR 0.15, 95% CI 0.06, 0.38). Multiple co-occurring social and structural vulnerabilities increase transactional sex engagement warranting the need for social protection and gender transformative approaches.

Adolescent girls' perceived readiness for sex in Central Uganda - liminal transitions and implications for sexual and reproductive health interventions

Young women in Uganda are at risk of negative sexual and reproductive health outcomes, in part because of sex with older men. Theoretically grounded in the concept of liminality, this paper examines perceived markers of adolescent girls' suitability for sexual activity. In 2014, we conducted 19 focus group discussions and 44 in-depth interviews in two communities in Uganda. Interviews were conducted using a semi-structured tool, audio-recorded and transcribed verbatim. Interviews examined markers of transition between childhood, adolescence and adulthood and how these were seen as relating to girls' perceived readiness for sex. Analysis was thematic. Pre-liminal status was most often accorded to childhood. Sex with a child was strongly condemned. Physical changes during puberty and children's increasing responsibility, autonomy and awakening sexuality reflected a liminal stage during which girls and young women were not necessarily seen as children and were increasingly described as suitable for sex. Being over 18, leaving home, and occupying 'adult' spaces reflected post-liminal status and perceived appropriateness for sexual activity including for girls under the age of 18. Interventions that seek to prevent early sexual debut and sexual activity with older men have the potential to reduce sexual and reproductive health risks.

Development and Validation of the Couple Sexual Satisfaction Scale for HIV and Sexual Health Research

Sexual satisfaction is an important dimension of relationship quality with implications for sexual and reproductive health (SRH), and HIV prevention, care, and treatment. We developed and validated the Couple Sexual Satisfaction Scale (CSSS) with heterosexual couples in sub-Saharan Africa. Using data from qualitative interviews with 94 partnered women and men in Swaziland and Malawi, we generated a 22-item scale and administered it to 211 couples with at least one partner living with HIV in Malawi. We performed an exploratory factor analysis (EFA) to identify and confirmatory factor analysis (CFA) to test the factor structure. To assess validity, we tested for associations between the CSSS and relationship quality, consistent condom use, and intimate partner violence (IPV) using generalized estimating equations. The EFA yielded two factors, general sexual satisfaction (13-item CSSS-Gen subscale, e.g., "I am satisfied with the sweetness of sex in our relationship") and HIV-specific sexual satisfaction (4-item CSSS-HIV subscale, e.g., "My appetite for sex has gone down due to HIV"), accounting for 78% of the shared variance. The CFA supported the two-factor solution: χ²(118) = 203.60; CFI = 0.909; SRMR = 0.057; RMSEA = 0.058. Participants with higher CSSS-Gen scores reported higher coital frequency and relationship quality (intimacy, trust, unity, equality, relationship satisfaction, commitment, partner social support), and less consistent condom use, physical IPV, and emotional IPV. Participants with higher CSSS-HIV scores reported higher coital frequency and relationship quality (trust, partner support), and less consistent condom use, and sexual IPV. The CSSS demonstrated good psychometric properties and provides new opportunities to study sexual reproductive health and HIV-related health behaviors among couples in sub-Saharan Africa.

Adolescents' Perceptions About Dating and Sexual Permissiveness in Ebonyi State, Nigeria: What Can Be Done to Enhance Adolescents' Sexual Health and Well-Being

Introduction: Adolescent sexual and reproductive health (SRH) issues constitute key health concerns as some adolescents are directly or indirectly involved in sexual engagements, with increased risks and health consequences. The study aims to explore adolescents' perceptions about dating and permissive sexual behaviors which will contribute to designing sexual and reproductive health interventions. This paper adds to knowledge on adolescents' perceptions about dating, pre-marital, casual, transactional and age-disparate sex in southeastern, Nigeria.

Methods: A qualitative study was undertaken in the three senatorial zones of Ebonyi state, south eastern Nigeria. The study population comprised unmarried in- and out-of-school adolescents aged 13–18 years. Data were collected using a pre-tested focus group discussion (FGD) guide. There were six FGDs for boys and six FGDs for girls. A thematic framework approach was used for data analysis.

Results: Adolescents' views about dating and other sexual behaviors were varied. The dominant view is that hugging, touching and kissing are inappropriate for unmarried adolescents. Similarly, pre-marital, casual, transactional, and age-disparate sex were viewed as unacceptable. However, some adolescents perceived pre-marital abstinence as a hindrance to the attainment of sexual satisfaction and reproductive capacity in marriage. Some boys and girls indicated that casual sex is good, because it enables girls from poor homes to socialize with more privileged boys/men, and that such relationships could lead to marriage. Some considered transactional and age-disparate sex as a means of survival from poverty and unemployment. Boys were more permissive in their views about sexual behaviors compared to the girls.

Conclusion: Adolescents' perceptions of sexual behaviors as acceptable/unacceptable vary and are gendered. This should be considered in designing innovative strategies to improve adolescents' sexual health and well-being.

Precautionary savings and shock-coping behaviors: Effects of promoting mobile bank savings on transactional sex in Kenya

For the vulnerable, even small shocks can have significant short- and long-term impacts. Beneficial shock-coping mechanisms are not widely available in sub-Saharan Africa. We test whether an individual precautionary savings intervention can reduce a shock-coping behavior common in sub-Saharan Africa that has negative spillovers: transactional sex. Among a set of vulnerable women, we randomly assigned an intervention that promoted savings in a mobile banking account labeled for goals and emergency expenses. We find that a majority of individuals adopt the mobile account and the intervention led to reductions in transactional sex as a shock-coping response, and a decrease in symptoms of sexually transmitted infections. Changes are sustained in the medium-term among sex workers, but not among other vulnerable women.

Profiles of HIV Risk, Sexual Power, and Decision-Making among Sexual Minority Men of Color Who Engage in Transactional Sex: A Latent Profile Analysis

Though the transmission of HIV is preventable, there were still 37,968 new documented cases in the United States in 2018. HIV incidence is disproportionate in sexual minority men of color. The purpose of this study was to examine sexual relationship power risk profiles to identify distinct subgroups within the profiles who carry the highest HIV risk. Latent class profile analysis was used to identify subgroups of sexual minority men of color at the highest risk for contracting HIV based on their sexual power profiles. Among 322 sexual minority men, we identified four latent profiles. Profile 1: Low transactional sex and high power (n = 133; 14.3%); Profile 2: Transactional sex, high decision-making in sexual relationships, and low control in sexual relationship (n = 99; 30.7%); Profile 3: Low transactional sex, low decision-making, and moderate control (n = 43; 13.4%); Profile 4: High transactional sex and low power (n = 47; 14.6%). LPA was useful to identify distinct subgroups based on measures of sexual risk and relationship sexual power. Findings carry significant implications for developing tailored strategies to increase HIV knowledge and related HIV prevention and risk reduction services for sexual minority men of color who engage in transactional sex.

High HIV Prevalence and Low HIV-Service Engagement Among Young Women Who Sell Sex: A Pooled Analysis Across 9 Sub-Saharan African Countries

BACKGROUND

Epidemiological data are needed to characterize the age-specific HIV burden and engagement in HIV services among young, marginalized women in sub-Saharan Africa.

SETTING

Women aged ≥18 years who reported selling sex were recruited across 9 countries in Southern, Central, and West Africa through respondent driven sampling (N = 6592).

METHODS

Individual-level data were pooled and age-specific HIV prevalence and antiretroviral therapy (ART) coverage were estimated for each region using generalized linear mixed models. HIV-service engagement outcomes (prior HIV testing, HIV status awareness, and ART use) were compared among women living with HIV across age strata (18-19, 20-24, and ≥25 years) using generalized estimating equations.

RESULTS

By age 18%-19%, 45.4% [95% confidence interval (CI): 37.9 to 53.0], 5.8% (95% CI: 4.3 to 7.8), and 4.0% (95% CI: 2.9 to 5.4) of young women who sell sex were living with HIV in Southern, Central, and West Africa respectively. Prevalence sharply increased during early adulthood in all regions, but ART coverage was suboptimal across age groups. Compared with adult women ≥25, young women aged 18-19 were less likely to have previously tested for HIV [prevalence ratio (PR) 0.76; 95% CI: 0.72 to 0.80], less likely to already be aware of their HIV status (PR 0.48; 95% CI: 0.35 to 0.64), and less likely to be taking ART (PR 0.67; 95% CI: 0.59 to 0.75).

CONCLUSIONS

HIV prevalence was already high by age 18-19 in this pooled analysis, demonstrating the need for prevention efforts that reach women who sell sex early in their adolescence. ART coverage remained low, with women in the youngest age group the least engaged in HIV-related services. Addressing barriers to HIV service delivery among young women who sell sex is central to a comprehensive HIV response.

A Systematic Review of HIV Interventions for Young Women in Sub-Saharan Africa

Adolescent girls and young women (AGYW) ages (15-24 years old) in Southern and Eastern Africa account for nearly 30% of all new HIV infections. We conducted a systematic review of studies examining the effectiveness of behavioral, structural, and combined (behavioral + structural) interventions on HIV incidence and risky sexual behaviors among AGYW. Following PRISMA guidelines, we searched PubMed, CINAHL, Web of Science, and Global Health. Twenty-two studies met inclusion criteria conducted in Eastern and Southern Africa and comprised behavioral, structural, or combined (behavioral and structural) interventions. All findings are based on 22 studies. HIV incidence was significantly reduced by one structural intervention. All three types of interventions improved condom use among AGYW. Evidence suggests that structural interventions can reduce HIV incidence, while behavioral and combined interventions require further investigation.

Multiple sexual partnerships and associated factors among young psychoactive-substance-users in informal settlements in Kampala, Uganda

BACKGROUND

Multiple sexual partnerships increase the risk of transmission of HIV and can be exacerbated by substance abuse. However, the association between psychoactive substance use and multiple sexual partnerships among young people in informal settlements of low-income countries is not well known. This study established the prevalence of multiple sexual partnerships and associated factors among young psychoactive-substance-users in informal settlements in Kampala, Uganda.

METHODS

This was a cross-sectional study involving 744 young (aged 18-24 years), sexually active, psychoactive substance-users selected from 12 of the 57 informal settlements of Kampala City. The prevalence of multiple sexual partnerships and their differential distribution by socio-demographic strata was established. Modified Poisson regression models were run in Stata 14 software to generate prevalence rate ratios for the factors associated with multiple sexual partnerships.

RESULTS

About 40.6% (37.9% of males and 50.0% of females) had engaged in multiple sexual partnerships in the last 30 days. Engaging in multiple sexual partnerships in the last 30 days was positively associated with being female (PR 1.29, 95% CI: 1.03-1.63); staying in the informal settlement for 6-10 years (PR 1.34, 95% CI: 1.02-1.75) and chewing khat in the last 30 days (PR 1.93, 95% CI: 1.10-3.40).

CONCLUSION

Multiple sexual partnerships are highly prevalent among young psychoactive-substance-users, irrespective of the socio-demographic strata. Being female, having lived in the informal settlement for 6-10 years, and chewing khat were significantly associated with having multiple sexual partners in the last 30 days. In tackling this high-risk sexual behaviour, it is recommended that risk-reduction interventions are considered for the different socio-demographic strata identified in this study, i.e. females, those who have lived in the informal settlement for about 6-10 years, and those who chew khat.

Community perspectives on the extent to which transactional sex is viewed as sexual exploitation in Central Uganda

Background

Definitions of child sexual exploitation vary. Sexual exploitation violates children’s rights and exposes them to mental and physical harm. There exist differences in views of behaviour that is considered exploitative, including transactional sex. This paper explores community perspectives on the extent to which transactional sex is considered exploitative.

Methods

In 2014, we conducted 19 focus group discussions and 44 in-depth interviews with young people and adults in two communities in Uganda. Participants were presented with vignettes describing sexual encounters between adolescent girls and young women and men to explore under what conditions participants considered the scenario to be exploitative and why. Interviews were conducted in Luganda using a semi-structured tool, audio recorded and transcribed verbatim. Analysis was thematic and complemented by constant comparison and deviant case analysis techniques.

Results

Definitions by multilateral, bilateral, and non-governmental organisations of the sexual exploitation of children shared similarities with community conceptualisations of wrong or unfair sex. Although in community conceptualisations there was no consensus on what constituted sexual exploitation, transactional sex was condemned to the extent to which it involved sex with a minor or misled a naïve or immature girl; involved lack of consent, particularly in relationships characterised by power differentials; or worsened the pre-existing status of the girl. Also relevant was the extent to which a man’s intentions were considered inappropriate; the adolescent girl or young woman was considered vulnerable; and the adolescent girl or young woman was considered responsible for ‘her situation’.

Conclusions

Existing social norms that condemn sex with a minor or sex that involves deception, sexual coercion or misleading an immature girl, present opportunities to mobilise communities to protect adolescent girls and young women at risk. Any intervention must, however, be designed with full cognisance of the social and structural drivers that underlie transactional sex and limit adolescent girls’ and young women’s opportunities to provide for themselves without recourse to sexual relationships with men. Interventions must also be designed to recognise that girls in transactional sex relationships may not consider themselves as exploited, thus requiring engagement with them based on their own concerns, aspirations, and expectations.

Health Education Training Embedded in a Microfinance Platform Associated with Safer Sexual Behavior in Haitian Women

Sexual health education interventions have generally yielded modest impact, but may be more successful when integrated into programs designed to alleviate poverty and empower women. Between December 2017 and February 2018, we interviewed 304 Haitian female microfinance clients, 75 of whom had received health education training delivered within their regular meetings. Participants reported six key sexual health outcomes. We used log-binomial models to estimate the association between health education training and each outcome, and tested for interaction by age and literacy status. Women with health education training reported more condom use with unfaithful partners [PR (95% CI) 1.78 (1.04, 3.02)], more HIV testing [PR (95% CI) 1.56 (1.28, 1.90)], and fewer STI symptoms [PR (95% CI) 0.37 (0.19, 0.73)], compared to women with no training. Some of the associations were stronger among older women [e.g. HIV testing: PR (95% CI) 2.09 (1.49, 2.82)] and illiterate women [e.g. condom use: PR (95% CI) 3.46 (1.05, 11.38)]. These findings add to the growing body of evidence demonstrating the potential to use microfinance programs as platforms for health education delivery, and provide the first evidence for the association in Haiti.

Is transactional sex exploitative? A social norms perspective, with implications for interventions with adolescent girls and young women in Tanzania

Although transactional sex is common in many sexual relationships, there has been little research into the degree to which the practice is considered exploitative in the settings in which it is practiced. We describe the social norms that influence transactional sex in two sites in Mwanza, Tanzania, and explore local understandings of whether and under what conditions it is considered exploitative. We then compare these "emic" understandings of exploitation to international definitions and norms around sexual exploitation. This study employed a qualitative research design involving 18 focus group discussions and 43 in-depth interviews with young people aged 14-24 years and parents with children aged 14-24 years in a rural area and an urban center within Mwanza, Tanzania. Thematic analysis was conducted with the aid of NVivo 10. The social norms influencing the practice of transactional sex included: reciprocity as a core cultural value that permeates the way exchange in sexual relationships is judged; gendered expectations that men should provide for women's material needs in sexual relationships and that women should reciprocate by means of sex; and peer pressure to be perceived as "fashionable". Adolescent girls and young women (AGYW) are under strong peer pressure to conform to a "modern lifestyle" as reflected in stylish clothing and other items of modernity such as cellphones. The emic conceptualization of exploitation is defined by circumstances surrounding the relationship or a sexual encounter. Important factors that characterize local notions of when transactional relationships are considered exploitative include: when the encounter or relationship involves an imbalance of power (based on age, male economic power and social status); when a man fails to reciprocate; and when sex is coerced. According to community perspectives, young women's behavior should be considered exploitative of men when they take gifts or money yet refuse sex or when they demand large sums of money. Interventions aimed at reducing AGYW's exploitation through transactional sex need to be cognizant of the variations in the understanding of what constitutes sexual exploitation as well as the social and gender norms influencing the practice of transactional sex. Interventions need to involve communities and families in critical thinking that helps them identify positive alternatives to current gendered social norms that shape the involvement of AGYW and men in transactional sex.

The State of Sex Research in MFT and Family Studies Literature: A Seventeen-Year Content Analysis

The ability to conceptualize and treat sexual problems has been widely accepted as a crucial skill to master the MFT training. However, clients' sexual relationships are often ignored by clinicians because of a lack of experience or training, or personal discomfort. In this content analysis, we review sex and sex therapy research within MFT and family studies journals since the turn of the century. Of the 13,919 articles published within the 15 journals, 137 focused on sexuality or sex therapy. The articles were divided into five themes: sexual and relational health, sexual diversity, treatment and contributors of sexual dysfunction, sex therapy practices, and sexual education and development. Implications for clinical practices, sex therapy integration, and future research are discussed.

Agency as a mediator in the pathway from transactional sex to HIV among pregnant women in Swaziland: a multigroup path analysis

Introduction: Transactional sex is a structural driver of HIV for women and girls in sub-Saharan Africa. In transactional relationships, sexual and economic obligations intertwine and may have positive and negative effects on women’s financial standing and social status. We conducted a clinic-based survey with pregnant women in Swaziland using a locally validated transactional sex scale to measure the association between subjective social status, transactional sex, and HIV status, and to assess whether this association differed according to a woman’s agency within her relationship.

Methods: We recruited a convenience sample of 406 pregnant women at one rural and one urban public antenatal clinic in Swaziland and administered a behavioural survey that was linked to participant HIV status using clinic records. We then conducted a multigroup path analysis to test three hypotheses: (1) that more engagement in transactional sex is associated with decreased condom use and increased subjective social status; (2) that subjective social status mediates the relationship between transactional sex and HIV status; and (3) that these relationships are different across groups according to whether or not a woman reported any indicator of constrained agency within her relationship.

Results: The amount and value of material goods received from a sexual partner was significantly and positively associated with higher subjective social status among all participants. As the amount of material goods received from a partner increased, women who reported no indicators of constrained agency were less likely to use condoms. Conversely, there was no relationship between transactional sex and condom use among women who reported any indicator of constrained relationship agency. Among women who reported any indicator of constrained agency, HIV was significantly associated with lower subjective social status.

Conclusions: Relationship agency likely plays a key role in determining which mechanisms create HIV risk for women in transactional relationships. Interventions to mitigate these risks must address social forces that penalize women who engage in sexual relationships as well as structural drivers of gendered economic disparity that reduce women’s agency within their sexual and romantic relationships.

Relationship Power and Sexual Violence Among HIV-Positive Women in Rural Uganda

Gender-based power imbalances place women at significant risk for sexual violence, however, little research has examined this association among women living with HIV/AIDS. We performed a cross-sectional analysis of relationship power and sexual violence among HIV-positive women on anti-retroviral therapy in rural Uganda. Relationship power was measured using the Sexual Relationship Power Scale (SRPS), a validated measure consisting of two subscales: relationship control (RC) and decision-making dominance. We used multivariable logistic regression to test for associations between the SRPS and two dependent variables: recent forced sex and transactional sex. Higher relationship power (full SRPS) was associated with reduced odds of forced sex (AOR = 0.24; 95 % CI 0.07-0.80; p = 0.020). The association between higher relationship power and transactional sex was strong and in the expected direction, but not statistically significant (AOR = 0.47; 95 % CI 0.18-1.22; p = 0.119). Higher RC was associated with reduced odds of both forced sex (AOR = 0.18; 95 % CI 0.06-0.59; p < 0.01) and transactional sex (AOR = 0.38; 95 % CI 0.15-0.99; p = 0.048). Violence prevention interventions with HIV-positive women should consider approaches that increase women's power in their relationships.

Cultural consensus modeling to measure transactional sex in Swaziland: Scale building and validation

Transactional sex is associated with increased risk of HIV and gender based violence in southern Africa and around the world. However the typical quantitative operationalization, "the exchange of gifts or money for sex," can be at odds with a wide array of relationship types and motivations described in qualitative explorations. To build on the strengths of both qualitative and quantitative research streams, we used cultural consensus models to identify distinct models of transactional sex in Swaziland. The process allowed us to build and validate emic scales of transactional sex, while identifying key informants for qualitative interviews within each model to contextualize women's experiences and risk perceptions. We used logistic and multinomial logistic regression models to measure associations with condom use and social status outcomes. Fieldwork was conducted between November 2013 and December 2014 in the Hhohho and Manzini regions. We identified three distinct models of transactional sex in Swaziland based on 124 Swazi women's emic valuation of what they hoped to receive in exchange for sex with their partners. In a clinic-based survey (n = 406), consensus model scales were more sensitive to condom use than the etic definition. Model consonance had distinct effects on social status for the three different models. Transactional sex is better measured as an emic spectrum of expectations within a relationship, rather than an etic binary relationship type. Cultural consensus models allowed us to blend qualitative and quantitative approaches to create an emicly valid quantitative scale grounded in qualitative context.

Sexual Behavior Among Young Carers in the Context of a Kenyan Empowerment Program Combining Cash-Transfer, Psychosocial Support, and Entrepreneurship

This study examined associations between sexual initiation, unprotected sex, and having multiple sex partners in the past year with participation in a three-year empowerment program targeting orphan and vulnerable children (OVC). The Kenya-based program combines community-conditioned cash transfer, psychosocial empowerment, health education, and microenterprise development. Program participants (n = 1,060) were interviewed in a cross-sectional design. Analyses used gender-stratified hierarchical logit models to assess program participation and other potential predictors. Significant predictors of increased female sexual activity included less program exposure, higher age, younger age at most recent parental death, fewer years of schooling, higher food consumption, higher psychological resilience, and lower general self-efficacy. Significant predictors of increased male sexual activity included more program exposure, higher age, better food consumption, not having a living father, and literacy. Findings support a nuanced view of current cash transfer programs, where female sexual activity may be reduced through improved financial status but male sexual activity may increase. Targeting of OVC sexual risk behaviors would likely benefit from being tailored according to associations found in this study. Data suggest involving fathers in sexual education, targeting women who lost a parent at a younger age, and providing social support for female OVC may decrease risk of human immunodeficiency virus (HIV) transmission.

Ideals as Anchors for Relationship Experiences

Research on young-adult sexuality in sub-Saharan Africa typically conceptualizes sex as an individual-level risk behavior. We introduce a new approach that connects the conditions surrounding the initiation of sex with subsequent relationship well-being, examines relationships as sequences of interdependent events, and indexes relationship experiences to individually held ideals. New card-sort data from southern Malawi capture young women's relationship experiences and their ideals in a sequential framework. Using optimal matching, we measure the distance between ideal and experienced relationship sequences to (1) assess the associations between ideological congruence and perceived relationship well-being, (2) compare this ideal-based approach to other experience-based alternatives, and (3) identify individual- and couple-level correlates of congruence between ideals and experiences in the romantic realm. We show that congruence between ideals and experiences conveys relationship well-being along four dimensions: expressions of love and support, robust communication habits, perceived biological safety, and perceived relationship stability. We further show that congruence is patterned by socioeconomic status and supported by shared ideals within romantic dyads. We argue that conceiving of ideals as anchors for how sexual experiences are manifest advances current understandings of romantic relationships, and we suggest that this approach has applications for other domains of life.

The sexual risk context among the FEM-PrEP study population in Bondo, Kenya and Pretoria, South Africa

BACKGROUND

Incidence rates in the FEM-PrEP and VOICE trials demonstrate that women from diverse sub-Saharan African communities continue to be at substantial HIV risk.

OBJECTIVE

To describe and compare the sexual risk context of the study population from two FEM-PrEP trial sites-Bondo, Kenya, and Pretoria, South Africa.

METHODS

At baseline we collected information about demographics, sexual behaviors, and partnership beliefs through quantitative questionnaires with all participants (Bondo, n = 720; Pretoria, n = 750). To explore the sexual risk context, we also conducted qualitative, semi-structured interviews with HIV-negative participants randomly selected at several time points (Bondo, n = 111; Pretoria, n = 69).

RESULTS

Demographics, sexual behavior, and partnership beliefs varied significantly between the sites. Bondo participants were generally older, had fewer years of schooling, and were more likely to be employed and married compared to Pretoria participants. Bondo participants were more likely to report multiple partners and not knowing whether their partner had HIV than Pretoria participants. A significantly higher percentage of Bondo participants reported engaging in sex without a condom with their primary and other partners compared to Pretoria participants. We found a borderline association between participants who reported not using condoms in the 4 weeks prior to baseline and lower risk of HIV infection, and no association between having more than one sexual partner at baseline and HIV infection.

DISCUSSION

Despite significantly different demographics, sexual behaviors, and partnership beliefs, many women in the FEM-PrEP trial were at risk of acquiring HIV as demonstrated by the sites' high HIV incidence. Though gender dynamics differed between the populations, they appear to play a critical role in women's sexual practices. The findings highlight different ways women from diverse contexts may be at-risk for HIV and the importance of providing HIV prevention options that are both effective and feasible given personal and social circumstances.

Communicating about microbicides with women in mind: tailoring messages for specific audiences

Introduction

Current HIV prevention options are unrealistic for most women; however, HIV prevention research has made important strides, including on-going development of antiretroviral-based vaginal microbicide gels. Nevertheless, social-behavioural research suggests that women's ability to access and use new HIV prevention technologies will be strongly influenced by a range of socio-cultural, gender and structural factors which should be addressed by communications and marketing strategies, so that these products can be positioned in ways that women can use them.

Methods

Based on an extensive literature review and in-country policy consultation, consisting of approximately 43 stakeholders, we describe barriers and facilitators to HIV prevention, including potential microbicide use, for four priority audiences of Kenyan women (female sex workers [FSWs], women in stable and discordant relationships, and sexually active single young women). We then describe how messages that position microbicides might be tailored for each audience of women.

Results

We reviewed 103 peer-reviewed articles and reports. In Kenya, structural factors and gender inequality greatly influence HIV prevention for women. HIV risk perception and the ability to consistently use condoms and other prevention products often vary by partner type. Women in stable relationships find condom use challenging because they connote a lack of trust. However, women in other contexts are often able to negotiate condom use, though they may face challenges with consistent use. These women include FSWs who regularly use condoms with their casual clients, young women in the initial stages of a sexual relationship and discordant couples. Thus, we consider two approaches to framing messages aimed at increasing general awareness of microbicides – messages that focus strictly on HIV prevention and ones that focus on other benefits of microbicides such as increased pleasure, intimacy or sexual empowerment, in addition to HIV prevention.

Conclusions

If carefully tailored, microbicide communication materials may facilitate product use by women who do not currently use any HIV prevention method. Conversely, message tailoring for women with high-risk perception will help ensure that microbicides are used as additional protection, together with condoms.

Husbands' Participation in Housework and Child Care in India

The authors tested theories of housework among tea plantation workers in India, where women comprise the main part of the workforce and are breadwinners in their families. Analysis of 49 semistructured interviews and survey data from 3,181 female workers revealed that although women were mainly responsible for domestic labor, more than half of husbands usually or sometimes helped their wives with cooking, fuel wood collection, and child care. The analyses revealed a curvilinear relationship between husbands' earnings share and their participation in each task, supporting theories of bargaining and gender display. The probability of male participation decreased to its lowest level when men earned less than their wives. Husbands rarely helped with clothes washing-considered the most feminine task-and their participation did not respond to changes in relative earnings. These results support the authors' argument that patterns of bargaining and gender display will vary depending on the gendered nature of housework tasks within a particular society.

Gender, power, and intimate partner violence: a study on couples from rural Malawi

Gender-based power imbalances are perhaps the most compelling underlying explanation for intimate partner violence (IPV) among women in sub-Saharan Africa. However, an overemphasis on female victimization results in an incomplete understanding of men's experiences as victims and the broader dyadic context in which violence occurs. This study examines the role of three domains of relationship power (power resources, processes, and outcomes) on sexual and physical IPV victimization in a unique sample of 466 young couples from Malawi. Two power resources were studied, namely, income and education level. Power processes were captured with a measure of couple communication and collaboration called unity. Power outcomes included a measure of relationship dominance (male dominated or female-dominated/egalitarian). Multilevel logistic regression using the Actor Partner Interpersonal Model framework was used to test whether respondent and partner data were predictive of IPV. The findings show that unity and male dominance were salient power factors that influenced young people's risk for sexual IPV. Unity had a stronger protective effect on sexual IPV for women than for men. Involvement in a male-dominated relationship increased the risk of sexual IPV for women, but decreased the risk for men. The findings also showed that education level and unity were protective against physical IPV for both men and women. Contrary to what was expected, partner data did not play a role in the respondent's experience of IPV. The consistency of these findings with the literature, theory, and study limitations are discussed.

Prevalence and risk factors for inter-generational sex: a cross-sectional cluster survey of Barbadian females aged 15-19

Background

The aim of this study was to establish the prevalence and risk factors for intergenerational (IG)-sex in females aged 15–19 residing in Barbados.

Methods

This cross sectional cluster survey was conducted in a 2.6% national sample in the age range (n = 261) recruited from multiple polling districts chosen with a probability proportional to size. Consent was obtained from participants aged ≥18 years or from parents/guardians of participants <18 years, with participant assent. The prevalence of age at first sex was analyzed using a life table approach and risk factors for IG sex (defined as sexual relations with a male 10 or more years older) were analyzed by logistic regression, adjusting for age.

Results

51.0% of adolescent females in the survey reported ever having had sex, among whom prevalence of IG-sex was 13.2% (95% CI: 6.7-19.8) at first sex, 29.0% (22.3-35.7) within the preceding twelve months, and 34.8% (24.3-45.4) ever. Condom use at first sex was positively related to willingness to have sex (F statistic = 9.8, p = 0.001). The strongest determinant for IG-sex was age of sexual debut (age adjusted Odds Ratio [95% CI]: 0.58[0.41-0.83]), followed by money or gifts received from the partner (2.91[1.17-7.23] and self-esteem (0.33[0.11-0.95]).

Conclusions

The survey establishes a high rate of IG-sex in Barbados, a ‘high income’ country. Most insightful is that risk of IG-sex nearly halved for every year at which first sex was delayed. A high proportion of coerced sex was reported at first sexual experience and this was linked to poor condom use. Affirmative prevention approaches are recommended to boost self-acclamation of adolescent women within less coercive relationships, especially during their first sexual encounter.

Considerations regarding antiretroviral chemoprophylaxis and heterosexuals in generalized epidemic settings

PURPOSE OF REVIEW

To discuss the factors pertinent to the use of pre-exposure prophylaxis (PrEP) by at-risk heterosexuals in countries with generalized HIV epidemics.

RECENT FINDINGS

PrEP will have the greatest prevention effect if targeted to those at highest risk, but identifying and engaging such persons is challenging. Serodiscordant couples account for a high proportion of new infections and are an appropriate target for PrEP, but the proportion of people in such relationships is small and outside partnerships are common. Differences in adherence coupled to pharmacology of the drugs may account for differences in efficacy seen in the trials. Mathematical modeling indicates that the benefits of PrEP in highly endemic settings outweigh the risk of induced viral resistance. Behavioral risk compensation was not observed in the trials, but current open-label studies will better determine if disinhibition will be an important problem.

CONCLUSIONS

PrEP is a potentially useful HIV-prevention strategy for generalized heterosexual epidemics. Optimal implementation will require learning more about ways to improve acceptability and adherence and how best to deliver PrEP within the context of limited resource availability.

Migration experience and premarital sexual initiation in urban Kenya: an event history analysis

Migration during the formative adolescent years can affect important life-course transitions, including the initiation of sexual activity. In this study, we use life history calendar data to investigate the relationship between changes in residence and timing of premarital sexual debut among young people in urban Kenya. By age 18, 64 percent of respondents had initiated premarital sex, and 45 percent had moved at least once between the ages of 12 and 18. Results of the event history analysis show that girls and boys who move during early adolescence experience the earliest onset of sexual activity. For adolescent girls, however, other dimensions of migration provide protective effects, with greater numbers of residential changes and residential changes in the last one to three months associated with later sexual initiation. To support young people's ability to navigate the social, economic, and sexual environments that accompany residential change, researchers and policymakers should consider how various dimensions of migration affect sexual activity.