"Taking care of business": alcohol as currency in transactional sexual relationships among players in Cape Town, South Africa

Transactional sex and risky sexual practices in Jamaica

BACKGROUND

Transactional sex relationships (TSRs) create financial and emotional support for men and women, as well as an increased sexual risk. Studies have reported high HIV and STI transmission rates among young women in transactional sex relationships. However, little is known about TSR prevalence in Jamaica and risky sexual practices among participants. This study investigates the sexual behaviour of Jamaicans in TSR.

METHODS

Secondary data analysis of a national survey revealed that 586 participants (38%) self-reported being in at least one TSR in the last 12 months. We also identified a third category called "Benefluids", who play both roles of benefactor and beneficiary in transactional sex relationships.

RESULTS

59 percent of male Benefluids had two to five transactional sex relationship partners in the last 12 months, compared to 40% of female Benefluids. Twenty-eight percent of female Benefluids reported sexually transmitted infection symptoms in the last 12 months compared to 13.5% of male Benefluids. While females reported more sexually transmitted infection symptoms, young men had the highest sexual risk precursors.

CONCLUSIONS

People in transactional sex relationships often play the role of beneficiaries and benefactors to meet material and sexual needs but this increases the risk of STI symptoms.

Pathways to transactional sex among peri-urban South African women: the role of relationship control, food insecurity and alcohol misuse

Transactional sex increases sub-Saharan African women's risk of HIV acquisition. We quantitatively explored the pathways contributing towards women's future engagement in transactional sex with casual partners and khwapheni (secret concurrent sex partners). We conducted secondary data analysis from a cluster randomised controlled trial in urban informal settlements in eThekwini Municipality., South Africa. Data were collected at enrolment (t0) and 24 months' later (t2) using self-completed questionnaires. Structural equation modelling (SEM) assessed pathways leading to transactional sex over two years. 677 women 18-35 years were enrolled and 80.5% (n = 545) were followed up. At t2, 44.6% of respondents reported transactional sex with a casual partner or khwapheni. The SEM demonstrated a small effect (d = 0.23) between transactional sex at t0 and at t2. Controlling for past transactional sex, main partner relationship control had a large effect size on future transactional sex (d = 0.60). Hazardous drinking had a medium effect size (d = 0.45) and food insecurity a small effect (d = 0.24), (RMSEA 0.03, 90%CI 0.02-0.04; CFI 0.97; TLI 0.96). HIV prevention programming should highlight current transactional sex but also address structural issues predicting future transactional sex, including food insecurity and alcohol misuse. Gender transformative interventions to reduce controlling behaviours in main relationships are worth investigating.

"Something we can all share": Exploring the social significance of food insecurity for young people in KwaZulu-Natal, South Africa

Food insecurity remains a pressing global issue and South Africa continues to face socioeconomic inequalities that make securing food a challenge for many young people. To address this challenge, we need better understanding of the social context of food and its importance in driving perceptions and behaviours about food and its scarcity. In this study, we examine the meaning of food for young people living in urban informal settlements and rural villages in KwaZulu-Natal, and investigate how they exert agency in the face of food insecurity. We use qualitative data from 17 photo/video elicitation interviews conducted from December 2020-January 2021 with young people experiencing food insecurity. The sample consisted of 9 women and 8 men who were part of the Siyaphambili Youth ("Youth Moving Forward") project. Data were analysed using thematic analysis. Themes included the challenges young people face in securing food and money for food. However, in exploring young people's agency, food also plays a critical role in shaping their identities and social networks. Relevant themes included the use of food as a means of bonding with others; solidifying relationships; and as a signifier of social status and gender roles. Despite the challenges of food insecurity, young people demonstrated resilience and agency, utilising social and gendered coping strategies to secure food and to maintain their social networks. Our study contributes to the understanding of food insecurity amongst young people in South Africa and highlights the need for a comprehensive and culturally sensitive approach to addressing this issue. We argue that interventions aimed at addressing food insecurity should prioritise the empowerment of local communities and consider the sociocultural and gendered context of food in their design and implementation.

South African male university students' perspectives on gender norms concerning alcohol and related harmful behaviours towards female drinkers

High rates of gender violence in South Africa, including those in higher education institutions, have prompted considerable research into understanding its causes. Studies focusing on gender and sexual risk at universities have found alcohol to be a significant contributor to gender violence. In this study, I analyse alcohol-related gender violence against female drinkers from the perspectives of male students. In-depth individual interviews were conducted with ten undergraduate male students at a university residence. Findings reveal that alcohol is seen as a masculine privilege. Male students explain that men use alcohol to give them the courage to enact hegemonic heterosexual masculinities. While they see alcohol as a tool to enhance men's capacity to control women, they simultaneously attribute blame to alcohol for men's loss of control over their behaviour. Alcohol is also exploited as currency to coerce women into submission to sexual favours. When male students blame alcohol for any deviant behaviour, men's culpability in the violation of female students remains hidden. Violence prevention efforts in educational contexts must address the ways in which alcohol shapes students' experience of gender, sexuality and violence.

From Survival to Glamour: Motivations for Engaging in Transactional Sex and Relationships Among Adolescent Girls and Young Women in South Africa

We explored transactional sex and relationships (TSR) among South African adolescent girls and young women (AGYW) using (1) survey data from 4,399 AGYW aged 15–24 years, and (2) qualitative data from 237 AGYW and 38 male peers. Ten percent of sexually active AGYW reported having ever had transactional sex; 14% reported having stayed in a relationship for money or material items. Factors associated with higher reporting of TSR included HIV positivity, higher food insecurity, and alcohol use. Those AGYW who were between the ages of 20–24 years (OR: 1.0; 95% CI: 0.81–1.24), had a sexual partner older than her by 5 years or more (OR: 1.89; 95% CI: 1.58–2.26), and had a transactional relationship in the past (OR: 61.1; 95% CI: 47.37–78.76) were more likely to report having transactional sex. AGYW qualitative narratives included both assertions of agency in choosing to engage in TSR, and power inequities resulting in condomless sex. Our findings can inform interventions to addressing transactional sex and relationships, critical to South Africa’s HIV response.

Transactional Sex, Alcohol Use and Intimate Partner Violence Against Women in the Rakai Region of Uganda

Transactional sex (TS) is prevalent in sub-Saharan Africa. Women's engagement in TS is linked with HIV infection; little is known about the relationship between TS, intimate partner violence (IPV) and alcohol use-established HIV risk behaviors. Using modified Poisson regression, we assessed associations between TS and physical, verbal and sexual IPV among 8248 women (15-49 years) who participated in the Rakai Community Cohort Study across forty communities in Uganda. An interaction term assessed moderation between alcohol use and TS and no significant interaction effects were found. In adjusted analysis, alcohol use and TS were significantly associated with all forms of IPV. In stratified analysis, TS was only associated with IPV in agrarian communities; alcohol use was not associated with physical IPV in trade communities or sexual IPV in trade and fishing communities. Identifying differences in IPV risk factors by community type is critical for the development of tailored interventions.

Gendered syndemic of intimate partner violence, alcohol misuse, and HIV risk among peri-urban, heterosexual men in South Africa

Men whose sexual behaviors place them at risk of HIV often exhibit a "cluster" of behaviors, including alcohol misuse and violence against women. Called the "Substance Abuse, Violence and AIDS (SAVA) syndemic," this intersecting set of issues is poorly understood among heterosexual men in sub-Saharan Africa. We aim to determine cross-sectional associations between men's use of alcohol, violence, and HIV risk behaviors using a gendered syndemics lens. We conducted a baseline survey with men in an informal, peri-urban settlement near Johannesburg (Jan-Aug 2016). Audio-assisted, self-completed questionnaires measured an index of risky sex (inconsistent condom use, multiple partnerships, transactional sex), recent violence against women (Multicountry Study instrument), alcohol misuse (Alcohol Use Disorders Tool), and gender attitudes (Gender Equitable Men's Scale). We used logistic regression to test for syndemic interaction on multiplicative and additive scales and structural equation modeling to test assumptions around serially causal epidemics. Of 2454 men, 91.8% reported one or more types of risky sex. A majority of participants reported one or more SAVA conditions (1783, 71.6%). After controlling for socio-demographics, higher scores on the risky sex index were independently predicted by men's recent violence use, problem drinking, and inequitable gender views. Those men reporting all three SAVA conditions had more than 12-fold greater odds of risky sex compared to counterparts reporting no syndemic conditions. Each two-way interaction of alcohol use, gender inequitable views, and IPV perpetration was associated with a relative increase in risky sex on either a multiplicative or additive scale. A structural equation model illustrated that gender norms predict violence, which in turn predict alcohol misuse, increasing both IPV perpetration and risky sex. These data are consistent with a syndemic model of HIV risk among heterosexual men. Targeting intersections between syndemic conditions may help prevent HIV among heterosexual men in peri-urban African settings.

The theory of masculinity in studies on HIV. A systematic review

This study aimed to describe the methodological characteristics of publications on HIV and masculinity, to identify possible information gaps and determine the main thematic areas. A systematic review was conducted of gender, masculinity, HIV infection and other sexually-transmitted infections in original articles published between 1992 and 2015. Original studies published from Pubmed and Scopus were included. A total of 303 articles were identified, of which 187 were selected. Most of the studies were qualitative and the most widely used technique was the interview. Twenty-nine-point five percent of studies were performed in South Africa, 20.8% in the USA, and 3.2% in Europe. Fifteen percent of the studies were performed in heterosexuals, 12.8% in men who have sex with men, and 60% did not specify the sexual orientation of the population. Eight thematic areas were defined, the most frequent being sexuality and risk behaviours, defined by men's need to demonstrate they were sexually active and a breadwinner. Most studies on HIV and masculinity show a gender bias by not specifying the sexual identity of the population. Studies should consider diversity in sexual and cultural identity in different contexts, including in Europe, to carry out more effective HIV interventions from a masculinity perspective.

HIV/AIDS mortality attributable to alcohol use in South Africa: a comparative risk assessment by socioeconomic status

OBJECTIVES

To quantify HIV/AIDS mortality attributable to alcohol use in the adult general population of South Africa in 2012 by socioeconomic status (SES).

DESIGN

Comparative risk assessment based on secondary individual data, aggregate data and risk relations reported in the literature.

SETTING

South African adult general population.

PARTICIPANTS

For metrics of alcohol use by SES, sex and age: 27 070 adults that participated in a nationally representative survey in 2012. For HRs of dying from HIV/AIDS by SES: 87 029 adults that participated in a cohort study (years 2000 to 2014) based out of the Umkhanyakude district, KwaZulu-Natal.

MAIN OUTCOME MEASURES

Alcohol-attributable fractions for HIV/AIDS mortality by SES, age and sex were calculated based on the risk of engaging in condom-unprotected sex under the influence of alcohol and interactions between SES and alcohol use. Age-standardised HIV/AIDS mortality rates attributable to alcohol by SES and sex were estimated using alcohol-attributable fractions and SES-specific and sex-specific death counts. Rate ratios were calculated comparing age-standardised rates in low versus high SES by sex.

RESULTS

The age-standardised HIV/AIDS mortality rate attributable to alcohol was 31.0 (95% uncertainty interval (UI) 21.6 to 41.3) and 229.6 (95% UI 108.8 to 351.6) deaths per 100 000 adults for men of high and low SES, respectively. For women the respective rates were 10.8 (95% UI 5.5 to 16.1) and 75.5 (95% UI 31.2 to 144.9). The rate ratio was 7.4 (95% UI 3.4 to 13.2) for men and 7.0 (95% UI 2.8 to 18.2) for women. Sensitivity analyses corroborated marked differences in alcohol-attributable HIV/AIDS mortality, with rate ratios between 2.7 (95% UI 0.8 to 7.6; women) and 15.1 (95% UI 6.8 to 27.7; men).

CONCLUSIONS

The present study showed that alcohol use contributed considerably to the socioeconomic differences in HIV/AIDS mortality. Targeting HIV infection under the influence of alcohol is a promising strategy for interventions to reduce the HIV/AIDS burden and related socioeconomic differences in South Africa.

HIV Prevention Among Women Who Use Substances And Report Sex Work: Risk Groups Identified Among South African Women

This cross-sectional study presents baseline data from women (n = 641) in a community-based randomized trial in Pretoria, South Africa. Women were eligible if they reported recent alcohol or other drug (AOD) use and condomless sex. Latent class analyses were conducted separately for those who reported sex work and those who did not. Among those who reported sex work, a Risky Sex class (n = 72, 28%) and Low Sexual Risk class (n = 190, 73%) emerged. Those in the Risky Sex class were more likely to report that their last episode of sexual intercourse was with their boyfriend (vs. a client/other partner) compared with the Low Sexual Risk class (p < 0.001). Among participants who did not report sex work, a Drug-Using, Violence-Exposed, and Impaired Sex class (n = 53; 14%) and Risky Sex and Moderate Drinking class (n = 326; 86%) emerged. The findings suggest that interventions for women who engage in sex work should promote safer sexual behavior and empowerment with main partners. Women who use AODs, experience physical or sexual violence, and have impaired sex may be a key population at risk for HIV and should be considered for tailored behavioral interventions in conjunction with South Africa's plan to disseminate HIV prevention methods to vulnerable women.

TRIAL REGISTRATION

ClinicalTrials.gov registration NCT01497405.

Alcohol use and sexual risk behaviour among men and women in inner-city Johannesburg, South Africa

BACKGROUND

Alcohol misuse is a key factor underlying the remarkable vulnerability to HIV infection among men and women in sub-Saharan Africa, especially within urban settings. Its effects, however, vary by type of drinking, population group and are modified by socio-cultural co-factors.

METHODS

We interviewed a random sample of 1465 men living in single-sex hostels and 1008 women in adjacent informal settlements in inner-city, Johannesburg, South Africa. Being drunk in the past week was used as an indicator of heavy episodic drinking, and frequency of drinking and number of alcohol units/week used as measures of volume. Associations between dimensions of alcohol use (current drinking, volume of alcohol consumed and heavy episodic drinking patterns) and sexual behaviours were assessed using multivariate logistic regression.

RESULTS

Most participants were internal migrants from KwaZulu Natal province. About half of men were current drinkers, as were 13% of women. Of current male drinkers, 18% drank daily and 23% were drunk in the past week (women: 14% and 29% respectively). Among men, associations between heavy episodic drinking and sexual behaviour were especially pronounced. Compared with non-drinkers, episodic ones were 2.6 fold more likely to have transactional sex (95%CI = 1.7-4.1) and 2.2 fold more likely to have a concurrent partner (95%CI = 1.5-3.2). Alcohol use in men, regardless of measure, was strongly associated with having used physical force to have sex. Overall effects of alcohol on sexual behaviour were larger in women than men, and associations were detected between all alcohol measures in women, and concurrency, transactional sex and having been forced to have sex.

CONCLUSIONS

Alcohol use and sexual behaviours are strongly linked among male and female migrant populations in inner-city Johannesburg. More rigorous interventions at both local and macro level are needed to alleviate alcohol harms and mitigate the alcohol-HIV nexus, especially among already vulnerable groups. These should target the specific dimensions of alcohol use that are harmful, assist women who drink to do so more safely and address the linkages between alcohol and sexual violence.

Men's Behavior Predicts Women's Risks for HIV/AIDS: Multilevel Analysis of Alcohol-Serving Venues in South Africa

South Africa has among the highest rates of HIV infection in the world, with women disproportionately affected. Alcohol-serving venues, where alcohol use and sexual risk often intersect, play an important role in HIV risk. Previous studies indicate alcohol use and gender inequity as drivers of this epidemic, yet these factors have largely been examined using person-level predictors. We sought to advance upon this literature by examining venue-level predictors, namely men's gender attitudes, alcohol, and sex behavior, to predict women's risks for HIV. We recruited a cohort of 554 women from 12 alcohol venues (6 primarily Black African, and 6 primarily Coloured [i.e., mixed race] venues) in Cape Town, who were followed for 1 year across four time points. In each of these venues, men's (N = 2216) attitudes, alcohol use, and sexual behaviors were also assessed. Men's attitudes and behaviors at the venue level were modeled using multilevel modeling to predict women's unprotected sex over time. We stratified analyses by venue race. As predicted, venue-level characteristics were significantly associated with women's unprotected sex. Stratified results varied between Black and Coloured venues. Among Black venues where men reported drinking alcohol more frequently, and among Coloured venues where men reported meeting sex partners more frequently, women reported more unprotected sex. This study adds to the growing literature on venues, context, and HIV risk. The results demonstrate that men's behavior at alcohol drinking venues relate to women's risks for HIV. This novel finding suggests a need for social-structural interventions that target both men and women to reduce women's risks.

Targeting vulnerable populations: a synthetic review on alcohol use and risky sexual behaviour among migrant populations

Background

Research has demonstrated a link between alcohol use and risky sexual behaviour among different types of migrant populations. Therefore, research investigating risk factors associated with alcohol consumption among them is a public health priority. This review aimed to explore the intersection between migration, alcohol consumption and risky sexual behaviour.

Methods

This article is a synthetic review of empirical studies on the association of alcohol and high-risk sexual behaviour among different types of the migrant populations, focusing on measurable outcomes generated from quantitative data. A descriptive analysis generated from global and situational studies was used to interpret the reviewed research and to discuss critically the factors that drive migrants to engage in alcohol consumption and high-risk behaviour.

Results

This review found out that there is a significant and positive association between global and situational alcohol use and several outcomes of risky sexual behaviour among different types of migrant populations. This association was however mainly observed at high quantities and frequencies of alcohol use, mainly among male migrants, and was often tied to a specific situation or context, for instance the type of sexual partner, the level of mobility and to environmental factors such as living arrangements and entertainment venues.

Conclusions

The study supports previous research that alcohol use is associated with risky sexual behaviour among different types of migrant populations. Therefore, future interventions should target mobile, male migrant heavy drinkers. Additional research is needed using more event-level and longitudinal methodologies that overcome prior methodological limitations.

Gendered sexual uses of alcohol and associated risks: a qualitative study of Nigerian University students

Background

Alcohol misuse among young people is a global phenomenon. In many countries, young people engage in heavy drinking and this exacerbates risky sexual behaviour. In Nigeria, alcohol held multiple roles in the traditional era but was mainly consumed by adult males for pleasure. Adult females and young people were culturally constrained from drinking in most communities. In contemporary Nigeria, young people’s drinking is increasing, and many engage in sexual intercourse under the influence of alcohol.

Methods

This study draws on the traditional gender and social sexual scripts to explore the factors that motivate young people to use alcohol for sexual purposes. In-depth interviews were conducted with 19 to 23-year old male and female undergraduate students from a Nigerian university. Thematic analysis was conducted with the aid of NVivo 10 software.

Results

Men drink to become confident to initiate sexual relationships, stimulate sexual urges, prolong erection, increase sexual satisfaction and become more aggressive during sexual intercourse. Women also drink to be bold in initiating sexual relationships, for sexual arousal and to increase satisfaction. Relatedly, not every brand of alcohol is used for sexual purposes. For example, while men use ‘herbal’ alcoholic beverages and a mixture of locally-produced gin and marijuana, women use champagne and other flavoured alcoholic beverages. The results also revealed that young people use alcohol or salt in a bid to prevent conception after sexual intercourse.

Conclusions

Adherence to the traditional gender (masculinity) and social sexual scripts amongst men and the enactment of what appears to be a new form of femininity script amongst women contribute to a culturally specific understanding of the motivations to use alcohol for sexual purposes. Evidence-based strategies should be employed to distribute information about the consequences of sexual intercourse under the influence of alcohol.

"Nothing Is Free": A Qualitative Study of Sex Trading Among Methamphetamine Users in Cape Town, South Africa

South Africa is facing an established epidemic of methamphetamine, known locally as "tik." Globally, methamphetamine has been linked to high rates of sexual risk behaviors, including sex trading. The goal of this study was to qualitatively examine the experiences of sex trading among methamphetamine users in Cape Town, South Africa. Individual in-depth interviews were conducted with 30 active methamphetamine users (17 men and 13 women) recruited from the community. Interviews were conducted in local languages using a semi-structured guide that included questions on sex trading experiences and perceptions of sex trading among methamphetamine users. Interviews were audio-recorded, transcribed, and analyzed using analytic memos and coding with constant comparison techniques. The data revealed that in a setting of high levels of addiction and poverty, sex was an important commodity for acquiring methamphetamine. Women were more likely to use sex to acquire methamphetamine, but men reported opportunistic cases of trading sex for methamphetamine. Four models of sex trading emerged: negotiated exchange, implicit exchange, relationships based on resources, and facilitating sex exchange for others. The expectation of sex trading created a context in which sexual violence against female methamphetamine users was common. Multiple sexual partners and inconsistent condom use in acts of sex trading put methamphetamine users at high risk of HIV. Interventions in this setting should address addiction, which is the primary driver of sex trading among methamphetamine users. Harm reduction interventions may include education about HIV and other sexually transmitted infections, availability of condoms and HIV testing, and sexual violence prevention.

Reducing HIV Risks in the Places Where People Drink: Prevention Interventions in Alcohol Venues

Apart from individual alcohol drinking behavior, the context or places where people drink play a significant role in HIV transmission risk. In this paper, we review the research that has been conducted on alcohol venues to identify the social and structural factors (e.g., social norms, sexual behavior) that are associated with HIV risk in these places, to review HIV prevention interventions based in alcohol venues, and to discuss appropriate methodologies for alcohol venue research. Alcohol venues are defined here as places that sell or serve alcohol for onsite consumption, including bars, bottle stores, nightclubs, wine shops, and informal shebeens. Despite the many established HIV risk factors at play in alcohol venues, limited prevention strategies have been implemented in such places. A total of 11 HIV prevention interventions or programs were identified. HIV prevention interventions in alcohol venues may be conducted at the individual, social, or structural level. However, multilevel interventions that target more than one level appear to lead to the most sustainable behavior change. Strategies to incorporate alcohol venues in biomedical prevention strategies including antiretroviral therapy for alcohol users are also discussed.

Alcohol Use and Transactional Sex among Women in South Africa: Results from a Nationally Representative Survey

BACKGROUND

Transactional sex is a risk factor for HIV infection. Alcohol use may increase the risk of transactional sex. No nationally-representative studies have examined the relationship between multiple dimensions of alcohol use and transactional sex in women in South Africa. The aim of the study was to examine the relationship between alcohol dependence, binge drinking and frequency of drinking in the past month and transactional sex in adult women in South Africa.

METHODS

A cross-sectional study using multi-stage, cluster sampling collected data from a nationally representative sample of 5,969 women aged 16-55 years in 2012. The analysis conducted for this paper was restricted to women reporting sexual activity in the past 12 months (n = 3,594). Transactional sex was defined as having received money/gifts in exchange for sex with any sex partner in the past year. Alcohol use measures included: alcohol dependence (≥2 positive responses to the CAGE questionnaire); binge drinking (≥4 drinks for women on one occasion); and drinking frequency in the previous month. Logistic regression models were built to test the hypotheses that each dimension of alcohol use was associated with transactional sex.

RESULTS

About 6.3% (n = 225) of sexually active women reported transactional sex. Almost a third (30.6%) of sexually active women had ever drunk alcohol, and 19.2% were current (past month) drinkers. Among lifetime drinkers, 28.0% were alcohol dependent and 56.6% were binge drinkers. Alcohol dependent women were twice as likely to report transactional sex (AOR 2.0, 95% CI 1.1-4.3, p<0.05) than those not alcohol dependent. Binge drinkers were 3.1 times more likely to have had transactional sex (95% CI 1.5-6.6, p<0.01) than non-binge drinkers. There was no significant relationship between frequency of drinking in the past month and transactional sex.

CONCLUSION

Alcohol dependency and binge drinking are significantly associated with transactional sex in South African women. HIV prevention programmes need to target these women, and address both their alcohol use, as well as the HIV risks associated with transactional sex.

Men (and women) as "sellers" of sex in alcohol-serving venues in Cape Town, South Africa

The relationship between transactional sex, HIV risk, and partner violence has been well documented in South Africa, but research has focused primarily on women and has not been conducted in high-risk social contexts. The aim of this study was to examine associations between transactional sex and HIV risk among women and men in alcohol-serving venues in Cape Town, South Africa. We surveyed 1,989 women and 2,468 men attending alcohol-serving venues in Cape Town, South Africa to assess transactional sex behavior (i.e., receiving money or goods in exchange for sex), alcohol and drug use, history of childhood abuse, current relationship violence, and sexual risk behaviors. Among both women and men, trading sex was related to higher alcohol use, greater likelihood of drug use, substance use in sexual contexts, and a greater likelihood of experiencing physical and sexual violence. Compared to other women, women who traded sex reported a greater proportion of condom-unprotected sex; this relationship was not found for men. Analyses showed that men were almost twice as more likely to report trading sex for items, including money or alcohol, than women (9.7 vs. 5.8 %). Overall, men who traded sex were similar to their female counterparts. Similar associations between trading sex and different risk behaviors were found among women and men with limited economic means and substance use problems. Future research should more closely study transactional sex in high-risk venues as it relates to violence and should examine men who trade sex as a potential bridge population between heterosexual women and men who have sex with men.

Giving or receiving something for sex: a cross-sectional study of transactional sex among Ugandan university students

OBJECTIVE

This study sought to determine the prevalence of transactional sex among university students in Uganda and to assess the possible relationship between transactional sex and sexual coercion, physical violence, mental health, and alcohol use.

METHODS

In 2010, 1954 undergraduate students at a Ugandan university responded to a self-administered questionnaire that assessed mental health, substance use, physical violence and sexual behaviors including sexual coercion and transactional sex. The prevalence of transactional sex was assessed and logistic regression analysis was performed to measure the associations between various risk factors and reporting transactional sex.

RESULTS

Approximately 25% of the study sample reported having taken part in transactional sex, with more women reporting having accepted money, gifts or some compensation for sex, while more men reporting having paid, given a gift or otherwise compensated for sex. Sexual coercion in men and women was significantly associated with having accepted money, gifts or some compensation for sex. Men who were victims of physical violence in the last 12 months had higher probability of having accepted money, gifts or some compensation for sex than other men. Women who were victims of sexual coercion reported greater likelihood of having paid, given a gift or otherwise compensated for sex. Respondents who had been victims of physical violence in last 12 months, engaged in heavy episodic drinking and had poor mental health status were more likely to have paid, given a gift or otherwise compensated for sex.

CONCLUSIONS

University students in Uganda are at high risk of transactional sex. Young men and women may be equally vulnerable to the risks and consequences of transactional sex and should be included in program initiatives to prevent transactional sex. The role of sexual coercion, physical violence, mental health, and alcohol use should be considered when designing interventions for countering transactional sex.

Alcohol use, sexual relationship power, and unprotected sex among patrons in bars and taverns in rural areas of North West province, South Africa

We examined the relative importance of alcohol consumption and sexual relationship power (SRP) in predicting unprotected sex among 406 bar patrons in North West province, South Africa. We assessed participants' demographic characteristics, alcohol consumption, SRP, and number of unprotected sexual episodes in the past 6 months. In correlational analyses, alcohol consumption was significantly associated with frequency of unprotected sex for both males and females. SRP was significantly associated with frequency of unprotected sex for males and marginally associated for females. In multivariate regression analyses, alcohol consumption was significantly associated with frequency of unprotected sex for both males and females. SRP's association was marginally significant for females and not significant for males. Alcohol consumption is more strongly associated with unprotected sex than is SRP among bar patrons. Combination HIV prevention approaches to curb problem drinking and increase condom accessibility, and regular and effective use are needed in tavern settings. SRP needs further examination among tavern populations.

Love, lust and the emotional context of multiple and concurrent sexual partnerships among young Swazi adults

Men and women in Swaziland who are engaged in multiple or concurrent sexual partnerships, or who have sexual partners with concurrent partners, face a very high risk of HIV infection. Ninety-four in-depth interviews were conducted with 28 Swazi men and women (14 of each sex) between the ages of 20 and 39 to explore participants' sexual partnership histories, including motivations for sexual relationships which carried high HIV risk. Concurrency was normative, with most men and women having had at least one concurrent sexual partnership, and all women reporting having had at least one partner who had a concurrent partner. Men distinguished sexual partnerships that were just for sex from those that were considered to be 'real relationships', while women represented most of their relationships, even those which included significant financial support, as being based on love. Besides being motivated by love, concurrent sexual partnerships were described as motivated by a lack of sexual satisfaction, a desire for emotional support and/or as a means to exact revenge against a cheating partner. Social and structural factors were also found to play a role in creating an enabling environment for high-risk sexual partnerships. These factors included social pressure and norms; a lack of social trust; poverty and a desire for material goods; and geographical separation of partners.

Gender-based violence, alcohol use, and sexual risk among female patrons of drinking venues in Cape Town, South Africa

Gender-based violence is a well-recognized risk factor for HIV infection among women. Alcohol use is associated with both gender-based violence and sexual risk behavior, but has not been examined as a correlate of both in a context of both high HIV risk and hazardous drinking. The purpose of this paper is to examine the association between recent abuse by a sex partner with alcohol and sexual risk behavior among female patrons of alcohol serving venues in South Africa. Specifically, the aim of this study is to determine whether sexual risk behaviors are associated with gender-based violence after controlling for levels of alcohol use. We surveyed 1,388 women attending informal drinking establishments in Cape Town, South Africa to assess recent history of gender-based violence, drinking, and sexual risk behaviors. Gender-based violence was associated with both drinking and sexual risk behaviors after controlling for demographics among the women. A hierarchical logistic regression analysis showed that after controlling for alcohol use sexual risk behavior remained significantly associated with gender-based violence, particularly with meeting a new sex partner at the bar, recent STI diagnosis, and engaging in transactional sex, but not protected intercourse or number of partners. In South Africa where heavy drinking is prevalent women may be at particular risk of physical abuse from intimate partners as well as higher sexual risk. Interventions that aim to reduce gender-based violence and sexual risk behaviors must directly work to reduce drinking behavior.

"Because he has bought for her, he wants to sleep with her": alcohol as a currency for sexual exchange in South African drinking venues

Previous research has documented the practice of transactional sex in sub-Saharan Africa and its association with gender-based violence, gender inequalities and HIV risk. At the same time, it has been suggested that women may use transactional sex to obtain a greater sense of control over their lives and their sexualities, and to garner access to resources. The aim of this study was to better understand the practice of exchanging alcohol for sex in alcohol-serving venues in a township in Cape Town, South Africa. Data were collected between June 2009 and October 2010. Six venues were included and observations were conducted in each for four one-week periods over the course of a year. In-depth qualitative interviews included 31 women and 13 men whom interviewers had observed as regular venue customers. Follow-up interviews were conducted with 24 respondents to explore emerging themes. Interviews were recorded and transcribed. Using a grounded theory approach, Atlas.ti was used to code transcripts, field notes, and analytical memos written about each document. Results revealed that alcohol was commonly used as a currency of sexual exchange in this setting, and both women and men understood that accepting alcohol from a man implied consent for sexual favors. Women reported a sense of agency in participating in the transactional sex dynamic, especially when they were able to manipulate it to meet their own ends without fulfilling the men's sexual expectations. At the same time, data revealed that the norm of transactional sex reinforced the undervaluing and commoditization of women. As identified elsewhere, transactional sex put both women and men at greater risk of HIV through multiple partners and inconsistent use of condoms, and the possibility of rape. Interventions are needed to address sexual risk behaviors and substance use within this context to prevent new HIV infections.

Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa

BACKGROUND

Alcohol-serving venues in South Africa provide a location for HIV prevention interventions due to risk factors of patrons in these establishments. Understanding the association between mental health and risk behaviors in these settings may inform interventions that address alcohol use and HIV prevention.

METHODS

Participants (n = 738) were surveyed in 6 alcohol-serving venues in Cape Town to assess post-traumatic stress disorder (PTSD) and depression symptoms, traumatic experiences, sexual behavior, and substance use. Logistic regression models examined whether traumatic experiences predicted PTSD and depression. Generalized linear models examined whether substance use, PTSD, and depressive symptoms predicted unprotected sexual intercourse. Men and women were analyzed separately.

RESULTS

Participants exhibited high rates of traumatic experiences, PTSD, depression, alcohol consumption, and HIV risk behaviors. For men, PTSD was associated with being hit by a sex partner, physical child abuse, sexual child abuse and HIV diagnosis; depression was associated with being hit by a sex partner, forced sex and physical child abuse. For women, both PTSD and depression were associated with being hit by a sex partner, forced sex, and physical child abuse. Unprotected sexual intercourse was associated with age, frequency and quantity of alcohol use, drug use, and PTSD for men and frequency and quantity of alcohol use, depression, and PTSD for women.

CONCLUSION

Mental health in this setting was poor and was associated with sexual risk behavior. Treating mental health and substance-use problems may aid in reducing HIV infection. Sexual assault prevention and treatment after sexual assault may strengthen HIV prevention efforts.

Reasoning and deciding PMTCT-adherence during pregnancy among women living with HIV in Kenya

This study explores type identities among rural and urban slum women on antiretroviral therapies who become pregnant. Narrative structuring was chosen to develop type narratives that illustrate how rural and urban women handle their HIV-infection and how they reason and decide about PMTCT-adherence during pregnancy and childbirth. Women in rural areas described their lives as 'secure and family controlled'. This gave the women security and predictability in life, but also meant that it was difficult to keep secrets about HIV infection. For women in the urban slum area the narratives were a tale of the uncertain and hard to predict reality in the slum, but also about self-reliance and decisiveness. They portrayed themselves as 'vulnerable and striving to survive' thus managing a tough situation without long-term solutions. We conclude that pregnancy poses different social challenges in rural and urban areas affecting how women choose to manage their adherence to PMTCT, which is also affected by HIV stigma and lack of disclosure.

HIV risk behaviours and their relationship to intimate partner violence (IPV) among men who have multiple female sexual partners in Cape Town, South Africa

HIV/AIDS and intimate partner violence (IPV) are growing public health concerns in South Africa. Knowledge about adult men's perpetration of IPV and links between HIV risk behaviours and IPV is limited. Respondent driven sampling was used to recruit men who have multiple concurrent female sexual partners. Forty-one percent of the 428 recruited men had perpetrated IPV. Inconsistent condom use was associated with physical IPV; experiencing a symptom of a sexually transmitted infection and engaging in transactional sex were associated with physical and sexual IPV; problem alcohol use was associated with physical, and any IPV, but not sexual IPV; having five or more partners was associated with sexual IPV; perceptions of partners' infidelity were associated with physical and any IPV. HIV risk reduction interventions among men, especially those with multiple female sex partners, should incorporate strategies to change the underlying construction of masculinity that combines the anti-social and risky behaviours of IPV perpetration, inconsistent condom use, transactional sex and heavy alcohol consumption.