Jennifer A. Smit

In search of sexual pleasure and fidelity: vaginal practices in KwaZulu-Natal, South Africa

Vaginal practices, such as intra‐vaginal cleansing, drying and tightening, are suspected of placing women at higher risk of acquiring HIV and STIs. Yet, there is limited understanding of what these practices entail, what motivates women to undertake them and what their socio‐cultural and historical meanings are. This paper explores the range of vaginal practices used by women in KwaZulu‐Natal, South Africa and locates these within the context of local patterns of migration and understandings of sexual health and pleasure. Study activities took place at an urban and rural site employing qualitative research techniques: semi‐structured interviewing and an additional ethnographic component in the rural site. Vaginal practices were believed to be ubiquitous and a wide range of substances and procedures were described. Strong motivations for vaginal practices included womens desire to enhance mens sexual pleasure, ensure mens fidelity and exercise agency and control in their relationships. The common use of traditional medicines in this quest to maintain stable relationships and affect the course of love, suggests a complexity that cannot be captured by simple terms like ‘dry sex’. We argue instead that any interventions to change womens reliance on vaginal practices must recognise and attend to the broader social contexts in which they are embedded.

Antiretrovirals and safer conception for HIV-serodiscordant couples

Purpose of reviewMany men and women living with HIV and their uninfected partners attempt to conceive children. HIV-prevention science can be applied to reduce sexual transmission risk while respecting couples’ reproductive goals. Here we discuss antiretrovirals as prevention in the context of safer conception for HIV-serodiscordant couples. Recent findingsAntiretroviral therapy (ART) for the infected partner and pre-exposure prophylaxis (PrEP) for the uninfected partner reduce the risk of heterosexual HIV transmission. Several demonstration projects suggest the feasibility and acceptability of antiretroviral (ARV)s as periconception HIV-prevention for HIV-serodiscordant couples. The application of ARVs to periconception risk reduction may be limited by adherence. SummaryFor male-infected (M+F−) couples who cannot access sperm processing and female-infected (F+M−) couples unwilling to carry out insemination without intercourse, ART for the infected partner, PrEP for the uninfected partner, combined with treatment for sexually transmitted infections, sex limited to peak fertility, and medical male circumcision (for F+M couples) provide excellent, well tolerated options for reducing the risk of periconception HIV sexual transmission.

Progress and challenges to male and female condom use in South Africa

South Africa has responded to the sexually transmissible infection and HIV epidemic with a rapid expansion of its national-level public sector condom program. Male condoms are available widely at no cost in the public sector, with expanded access via social marketing and the private sector. The female condom program is one of the largest and best established globally. National surveys show progressive increases in rates of condom use at last sex. However, inconsistent and incorrect condom use and the likelihood that condoms are discontinued in longer-term partnerships are some of the challenges impeding the condom programs successes in the fight against sexually transmissible infections and HIV. This article reviews the current condom program, related guidelines and policies, and the existing data on male and female condom use, including distribution and uptake. We discuss the main challenges to condom use, including both user and service-related issues and finally how these challenges could be addressed.

Knowledge and use of emergency contraception among women in the Western Cape province of South Africa: a cross-sectional study

BackgroundEmergency contraception (EC) is widely available free of charge at public sector clinics in South Africa. At the same time, rates of teenage and unintended pregnancy in South Africa remain high, and there are few data on knowledge of EC in the general population in South Africa, as in other resource-limited settings.MethodsWe conducted a cross-sectional, interviewer-administered survey among 831 sexually active women at 26 randomly selected public sector clinics in the Western Cape province.ResultsOverall, 30% of the women had ever heard of EC when asked directly, after the method was described to them. Only 15% mentioned EC by name or description spontaneously. Knowledge of EC was independently associated with higher education, being married, and living in an urban setting. Four percent of women had ever used EC.DiscussionThese data suggest that knowledge of EC in this setting is more common among women of higher socioeconomic status living in urban areas. For EC to play a role in decreasing unintended pregnancy in South Africa, specific interventions are necessary to increase knowledge of the method, where to get it, and the appropriate time interval for its use before the need for EC arises. Future health promotion campaigns should target rural and low socioeconomic status communities.

Emergency contraception in South Africa: knowledge, attitudes, and use among public sector primary healthcare clients☆

To determine knowledge of, attitudes toward, and use of emergency contraception (EC), interviews were held with 1068 clients of 89 public sector primary healthcare facilities in two urban and two rural areas of South Africa. Only 22.8% of the clients had heard of EC. Awareness was significantly lower in the most rural area and among older, less educated women. Knowledge of EC was superficial, with 47.1% unsure of the appropriate interval between unprotected intercourse and starting EC and 56.6% not knowing whether it was available at the clinic. Few (9.1%) of those who knew of EC had used it. After explaining EC, attitudes toward its use were found to be positive, with 90.3% indicating that they would use it if needed. Awareness was lower than in developed countries, but higher than in other developing countries. Findings indicate that if women know of EC, where to get it, and how soon to take it, they would use it if needed.

Gender norms in South Africa: implications for HIV and pregnancy prevention among African and Indian women students at a South African tertiary institution.

In post‐Apartheid South Africa, women are constitutionally guaranteed protections and freedoms that were previously unknown to them. These freedoms may have positive implications for womens ability to negotiate sexual protection with partners and hence prevent unintended pregnancy and decrease their risk of HIV. Among tertiary institution students, who are a relatively ‘privileged’ group, there is little information on gender norms that might shape responses to HIV‐prevention programmes. To elicit gender norms regarding womens and mens roles, condom and contraceptive use, sexual communication and sexual pleasure, we conducted 10 semi‐structured focus group discussions with African and Indian female tertiary institution students in order to understand how norms might be used to buttress HIV‐ and pregnancy‐prevention. Participants reported dramatic changes in the structure of gender norms and relations with the formal recognition of womens rights in the post‐Apartheid context. These generational shifts in norms are supported by other research in South Africa. At the same time, women recognized the co‐existence of traditional constructions of gender that operate to constrain womens freedom. The perceived changes that have taken place provide an entry point for intervention, particularly for reinforcing emerging gender norms that promote womens protection against unintended pregnancy and HIV/STIs.

Prevalence, motivations, and adverse effects of vaginal practices in Africa and Asia: Findings from a multicountry household survey

BACKGROUND Women worldwide use various vaginal practices to clean or modify their vulva and vagina. Additional population-level information is needed on prevalence and motivations for these practices, characteristics of users, and their adverse effects. METHODS This was a household survey using multistage cluster sampling in Tete, Mozambique; KwaZulu-Natal, South Africa; Yogyakarta, Indonesia; and Chonburi, Thailand. In 2006-2007, vaginal practices and their motivations were examined using structured interviews with women 18-60 years of age (n=3610). RESULTS Prevalence, frequency, and motivations varied markedly. Two thirds of women in Yogyakarta and Chonburi reported one or more practices. In Yogyakarta, nearly half ingest substances with vaginal effects, and in Chonburi, external washing and application predominate. In Tete, half reported three or four current practices, and a quarter reported five or more practices. Labial elongation was near universal, and 92% of those surveyed cleanse internally. Two thirds in KwaZulu-Natal practiced internal cleansing. Insertion of traditional solid products was rare in Chonburi and Yogyakarta, but one tenth of women in KwaZulu-Natal and nearly two thirds of women in Tete do so. Multivariate analysis of the most common practice in each site showed these were more common among less educated women in Africa and young urban women in Asia. Explicit sexual motivations were frequent in KwaZulu-Natal and Tete, intended for pleasure and maintaining partner commitment. Practices in Chonburi and Yogyakarta were largely motivated by femininity and health. Genital irritation was common at African sites. CONCLUSIONS Vaginal practices are not as rare, exotic, or benign as sometimes assumed. Limited evidence of their biomedical consequences remains a concern; further investigation of their safety and sexual health implications is warranted.

The right to choose parenthood among HIV-infected women and men

As life expectancy for HIV-infected persons improves, studies in sub-Saharan Africa show that a considerable proportion of HIV-positive women and men desire to have children. Integrating sexual and reproductive health care into HIV services has until now emphasized the right of women to make informed choices about their reproductive lives and the right of self-determination to reproduce, but this is often equated with avoidance of pregnancy. Here, we explore guidance and attention to safer conception for HIV-infected women and men. We find this right lacking. Current sexual and reproductive health guidelines are not proactive in supporting HIV-positive people desiring children, and are particularly silent about the fertility needs of HIV-infected men and uninfected men in discordant partnerships. Public health policymakers and providers need to engage the HIV-infected and uninfected to determine both the demand for and how best to address the need for safer conception services.

The Mpondombili Project: Preventing HIV/AIDS and Unintended Pregnancy among Rural South African School-Going Adolescents

Unintended pregnancy, HIV and other sexually transmitted infections are major threats to the health of South African youth. Gendered social norms make it difficult for young women to negotiate safer sex, and sexual coercion and violence are prevalent. Sexual activity among adolescents is influenced strongly by conservative social norms, which favour abstinence. In reality, most young people are sexually active by the end of the teen years. Girls’ decision to have sex is often a passive one, influenced by partners. The Mpondombili Project is a school-based intervention in rural KwaZulu-Natal that aims to promote delay in the onset of sexual activity and condom use as complementary strategies for both sexually experienced and inexperienced youth. Interactive training was carried out with peer educators, teachers and nurses over a 15-month period, and a manual developed. The intervention was implemented in late 2003 with 670 adolescents in two schools. Issues covered included HIV/STI transmission, risk behaviours, HIV testing, pregnancy and contraception, gender inequality, sexual communication and negotiation, managing abusive situations, fear of AIDS, stigma and discrimination and sexual rights. The diversity of young people’s relationships and vulnerability to sexual risk call for the promotion of both risk avoidance (delay in sexual initiation) and risk reduction (condom use) together, regardless of ideology, especially where HIV is well-established, to protect their health. Résumé Les grossesses non désirées, le VIH et d’autres IST sont les principales menaces pour la santé des jeunes Sud-Africains. Les normes sociales différentes selon les sexes rendent difficile aux jeunes femmes de négocier des relations sexuelles protégées, et la coercition et la violence sexuelles sont fréquentes. Des normes sociales conservatrices recommandent l’abstinence aux adolescents. En réalité, la plupart des jeunes sont sexuellement actifs à la fin de l’adolescence. La décision des filles de passer à l’acte est souvent passive, influencée par leurs partenaires. Le projet Mpondombili, mené dans le KwaZulu-Natal rural, conseille comme stratégies complémentaires de retarder le premier rapport et d’utiliser des préservatifs aux jeunes sexuellement expérimentés ou non. En 2003, des jeunes, des enseignants et des infirmières ont dispensé une formation interactive sur 15 mois à 670 adolescents de deux écoles et ont préparé un manuel. La formation a abordé la transmission du VIH/des IST, les comportements à risque, le dépistage du VIH, la grossesse et la contraception, les inégalités sexuelles, la communication et la négociation sexuelles, la gestion des situations d’abus, la peur du SIDA, la stigmatisation, la discrimination et les droits génésiques. La diversité des relations entre jeunes et leur vulnérabilité exigent de promouvoir conjointement des stratégies destinées à éviter le risque (retard de l’initiation sexuelle) et le réduire (utilisation de préservatifs), sans souci d’idéologie, particulièrement là où le VIH a une forte prévalence. Resumen El embarazo imprevisto, el VIH y otras infecciones de transmisión sexual ponen en alto riesgo la salud de la juventud de Sudáfrica, donde las normas sociales basadas en género dificultan que las jóvenes negocien el sexo más seguro, y donde cunden la coerción y la violencia sexual. La actividad sexual de la adolescencia es muy influenciada por las normas sociales conservadoras, que favorecen la abstinencia. En realidad, la mayoría de la juventud es sexualmente activa antes de cumplir los 20 años. La decisión de las jóvenes de tener relaciones sexuales suele ser pasiva, influenciada por sus parejas. El proyecto de Mpondombili es una intervención escolar en la zona rural de KwaZulu-Natal, cuyo objetivo es postergar el inicio de la actividad sexual y promover el uso del condón como estrategias complementarias tanto para la juventud con experiencia sexual como para la inexperimentada. Se realizó capacitación interactiva con educadores de pares, profesores y enfermeras durante 15 meses, y se elaboró un manual. La intervención fue ejecutada en 2003 con 670 adolescentes en dos colegios. Los temas abarcados fueron: la transmisión del VIH/ITS, comportamientos de riesgo, pruebas de VIH, embarazo y anticoncepción, desigualdad de género, comunicación y negociación sexual, manejo de situaciones abusivas, temor del SIDA, estigma y discriminación y derechos sexuales. Debido a las diversas relaciones de la juventud y su vulnerabilidad al riesgo sexual, se debe promover tanto la prevención del riesgo (postergar el inicio de la actividad sexual) como su disminución (uso del condón), independientemente de ideologías, especialmente donde el VIH está bien establecido, a fin de proteger su salud.

Key informant perspectives on policy- and service-level challenges and opportunities for delivering integrated sexual and reproductive health and HIV care in South Africa

BackgroundIntegration of sexual and reproductive health (SRH) and HIV services is a policy priority, both globally and in South Africa. Recent studies examining SRH/HIV integration in South Africa have focused primarily on the SRH needs of HIV patients, and less on the policy and service-delivery environment in which these programs operate. To fill this gap we undertook a qualitative study to elicit the views of key informants on policy-and service-level challenges and opportunities for improving integrated SRH and HIV care in South Africa. This study comprised formative research for the development of an integrated service delivery model in KwaZulu-Natal (KZN) Province.MethodsSemi-structured in-depth interviews were conducted with 21 expert key informants from the South African Department of Health, and local and international NGOs and universities. Thematic codes were generated from a subset of the transcripts, and these were modified, refined and organized during coding and analysis.ResultsWhile there was consensus among key informants on the need for more integrated systems of SRH and HIV care in South Africa, a range of inter-related systems factors at policy and service-delivery levels were identified as challenges to delivering integrated care. At the policy level these included vertical programming, lack of policy guidance on integrated care, under-funding of SRH, program territorialism, and weak referral systems; at the service level, factors included high client load, staff shortages and insufficient training and skills in SRH, resistance to change, and inadequate monitoring systems related to integration. Informants had varying views on the best way to achieve integration: while some favored a one-stop shop approach, others preferred retaining sub-specialisms while strengthening referral systems. The introduction of task-shifting policies and decentralization of HIV treatment to primary care provide opportunities for integrating services.ConclusionNow that HIV treatment programs have been scaled up, actions are needed at both policy and service-delivery levels to develop an integrated approach to the provision of SRH and HIV services in South Africa. Concurrent national policies to deliver HIV treatment within a primary care context can be used to promote more integrated approaches.