Loraine Townsend

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.

The Relationship between Bullying Behaviours and High School Dropout in Cape Town, South Africa

Bullying is generally defined as largely unprovoked, negative physical or psychological actions perpetrated repeatedly over time between bully/ies and victims. Bullying can lead to fear of school, absenteeism, and stunted academic progress, which in turn are precursors to dropping out of school. This papers aim is to report rates of bullying behaviour, and to investigate whether bullying behaviour predicts high school dropout in Cape Town, South Africa. Stratified, proportional sampling yielded 39 from a total of 214 schools, from which 40 learners were randomly selected from the combined class list of two, randomly chosen, Grade 8 classes in each of the 39 participating schools. Thus 1 470 learners (from a total of 181 018) completed a self-report questionnaire in 1997, and were followed-up in 2001. This report focuses on those learners who had dropped out of school between 1997 and 2001 (n = 776; 55.2%). Univariate and multiple logistic regression models were used to investigate the relationship between bullying behaviours and dropout, controlling for factors known to be strongly related to high school dropout, namely age, socioeconomic status, race, or ethnicity, being raised by a single parent, repeating a grade, and substance use. Odds ratios and 95 per cent confidence intervals were calculated, taking the clustering of schools into account. In 1997, 52% of the boys and 37% of the girls had been involved in bullying behaviours. Of the three bullying categories (bully, victim, and bully—victim), girls but not boys in the ‘bully—victim’ category were significantly more likely to drop out of school (OR 1.82; CI 1.09–3.04, and when controlling for confounders OR 2.60; CI 1.32–5.10). The pervasiveness of both high school dropout and bullying behaviour points to an urgent need for future research, and intervention in these areas.

The associations of voluntary counseling and testing acceptance and the perceived likelihood of being HIV-infected among men with multiple sex partners in a South African township.

This paper examines the socio-demographic factors and sexual risk behaviors (condom use, number of sexual partners, STI symptoms) associated with voluntary counselling and testing (VCT) acceptance and self-perceived risk of being HIV-infected among black men with multiple and younger sex partners in a South African township outside of Cape Town. Using respondent driven sampling, we interviewed 421 men, of whom 409 (97.3%) consented to provide a dried blood spot, 12.3% were HIVinfected (95% confidence intervals [CI.] 8.3, 16.9) and 47.2% (CI. 41.1, 53.6) accepted on site VCT. Twenty six percent (CI. 20.2, 30.7) reported having an HIV test in the past year. Few men perceived themselves as very likely to be infected with HIV (15.6%; CI. 10.4, 20.5). VCT acceptance was significantly associated with being older, married or living with a partner, having higher education, having four to six partners in the past three months and testing HIV positive. Self-perceived likelihood of being HIV infected was significantly associated with low condom use and having seven or more partners in the past three months, and testing HIV positive. These findings indicate that men correctly understand that engaging in certain HIV risk behaviors increases the likelihood of HIV-infection. However, those who perceive themselves at high risk of having HIV do not seek testing. Further investigation into the psychological and cultural barriers to reducing risky sexual behaviors and accessing VCT and other HIV services is recommended.

Estimating HIV Prevalence and Risk Behaviors Among High-Risk Heterosexual Men With Multiple Sex Partners: Use of Respondent-Driven Sampling

Objectives:To collect HIV data from high-risk men who have multiple, younger, female sex partners in a periurban township in South Africa. Design:Unlinked anonymous cross-sectional survey using respondent-driven sampling. Methods:Survey conducted among men aged 18 years or older who reported having had sex with more than 1 female partner in the previous 3 months (one of whom was either 3 or more years younger than the participant or below the age of 24) and lived in the area of recruitment. Results:The median age of the 421 recruited men was 28 years (range: 18-62 years). They reported a median of 6 sexual partners (range: 2-39) during the past 3 months, and 51% (confidence interval: 45.0 to 59.6) reported inconsistent condom use with their casual partners. During the 3 months before the survey, 98% of men reported having concurrent sexual relationships. HIV prevalence was 12.3% (confidence interval: 8.3% to 16.9%). Being older than 24 years and not using a condom during the last sexual intercourse with a 1-time sexual partner were significantly associated with HIV infection. Conclusions:This group of heterosexual urban men practice high levels of risky sexual behavior and are an important group that require more targeted HIV surveillance and prevention interventions.

Money talks, bullshit walks interrogating notions of consumption and survival sex among young women engaging in transactional sex in post-apartheid South Africa: a qualitative enquiry

BackgroundTransactional sex is believed to be a significant driver of the HIV epidemic among young women in South Africa. This sexual risk behaviour is commonly associated with age mixing, concurrency and unsafe sex. It is often described as a survival- or consumption-driven behaviour. South Africa’s history of political oppression as well as the globalization-related economic policies adopted post-apartheid, are suggested as the underlying contexts within which high risk behaviours occur among Black populations. What remains unclear is how these factors combine to affect the particular ways in which transactional sex is used to negotiate life among young Black women in the country.In this paper we explore the drivers of transactional sex among young women aged 16–24, who reside in a peri-urban community in South Africa. We also interrogate prevailing constructions of the risk behaviour in the context of modernity, widespread availability of commodities, and wealth inequalities in the country.MethodsData were collected through 5 focus group discussions and 6 individual interviews amongst young women, men, and community members of various age groups in a township in the Western Cape, South Africa.FindingsYoung women engaged in transactional sex to meet various needs: some related to survival and others to consumption. In this poverty-stricken community, factors that created a high demand for transactional sex among young women included the pursuit of fashionable images, popular culture, the increased availability of commodities, widespread use of global technologies, poverty and wealth inequalities. Transactional sex encounters were characterized by sexual risk, a casual attitude towards HIV, and male dominance. However, the risk behaviour also allowed women opportunities to adopt new social roles as benefactors in sexual relationships with younger men.ConclusionTransactional sex allows poor, young women to access what young people in many parts of the world also prioritize: fashionable clothing and opportunities for inclusion in popular youth culture. In the context of high HIV prevalence in South Africa, strategies are needed that present young women with safer economic gateways to create and consume alternative symbols of modernity and social inclusion.

Social networks and concurrent sexual relationships – a qualitative study among men in an urban South African community

Abstract The aim was to explore and describe characteristics of males’ social and sexual networks in a South African peri-urban community. Twenty in-depth interviews were conducted with men participating in a larger quantitative study where the median age of the men was 28.7 years and almost 56% had some high-school education, 17.2% were unemployed and 94.7% were not married. A Thematic Question Guide with open-ended questions was used for the interviews. A thematic content analysis was conducted to explore the characteristics and dynamics of social and sexual relationships among these men. A high number of temporary and stable concurrent female sexual partners, geographic mobility and high levels of unprotected sex were common. Increased status as a man and lack of trust in womens fidelity were given as important reasons for concurrent female sexual relationships. Strong social networks within male core groups provided economic and social support for the pursuit and maintenance of this behaviour. Concurrent sexual relationships in combination with high viral loads among newly infected individuals unaware of their HIV status create an extremely high-risk environment for the spread of HIV in this population. Interventions targeting men at high risk of HIV need to challenge current societal norms of masculinity to help promote individual sexual risk reduction strategies. Such strategies should go beyond increasing condom use, to include a reduction in the number of concurrent sexual partners.

“Taking Care of Business”: Alcohol as Currency in Transactional Sexual Relationships Among Players in Cape Town, South Africa

In this article we examine the dynamics of social relationships in which alcohol use and risky sexual behaviors cooccur. As part of a larger biological and behavioral HIV surveillance survey, 20 men who lived in an urban, informal settlement on the outskirts of Cape Town, South Africa participated in in-depth interviews. Interview transcripts were analyzed according to a latent content analysis. Findings highlight the latent association between alcohol and transactional sex, and enable an in-depth examination of the normative role that alcohol plays in the formation of casual sexual partnerships characterized by exchange. We build on an existing conceptual model that traces the potential pathways by which alcohol use and transactional sex are linked to sexual risk behaviors. The study findings point to the need for multilevel HIV risk-reduction interventions among men to reduce excessive alcohol use, risky sexual behaviors, and underlying perceptions of ideal masculinity.

A Systematic Review of Behavioral Interventions to Prevent HIV Infection and Transmission among Heterosexual, Adult Men in Low-and Middle-Income Countries

Prevention of new HIV infections needs to move to the forefront in the fight against HIV and AIDS. In the current economic crisis, low- and middle-income countries (LMICs) should invest limited resources to amass reliable evidence-based information about behavioral prevention efforts, and on behaviors that are driving the epidemic among people who are engaging in those behaviors. This paper aims to provide a systematic review and synthesis of behavioral interventions among a group of people in high HIV-burden countries: heterosexual men in LMICs. The review includes articles published between January 2001 and May 2010 that evaluated behavioral prevention interventions among heterosexual males aged 18+ years in LMICs. The studies were evaluated using the quality assessment tool for quantitative studies developed by the Effective Public Health Practice Project. The review identified 19 articles that met the reviews inclusion criteria. Most studies were conducted in South Africa (n=6); two each in Uganda and Thailand; and one in each of Angola, Brazil, Bulgaria, India, Nigeria, the Philippines, Russia, Ukraine and Zimbabwe. Eight of 19 interventions increased condom use among their respective populations. Those interventions that sought to reduce the number of sexual partners had little effect, and those that addressed alcohol consumption and intimate partner violence had mixed effects. There was no evidence for any specific format of intervention that impacted best on any of the targeted risk behaviors. The paucity of evaluated interventions for heterosexual men in LMICs suggests that adult men in these countries remain underrepresented in HIV prevention efforts.

Associations between alcohol misuse and risks for HIV infection among men who have multiple female sexual partners in Cape Town, South Africa

Abstract The occurrence of high rates of alcohol consumption in a context of high HIV prevalence in South Africa poses a significant health challenge for this country. This paper aims to answer three questions that could further our knowledge regarding the links between alcohol use and HIV infection: (a) “Are problem drinkers more likely to have multiple concurrent partners than those who are not?”; (b) “Are condoms applied less effectively and less consistently by problem drinkers compared to those who are not?”; (c) “Are the female sexual partners of problem drinkers different from those who are not?” Two cross-sectional HIV bio-behavioural surveillance surveys using Respondent-Driven Sampling were conducted in two peri-urban settings on the outskirts of Cape Town, South Africa. Eight hundred and forty-eight men aged 25–55 years who have multiple, concurrent female sexual partners were recruited. Problem drinkers had a score of ≥3 on the CAGE questionnaire. Questions enquired about partner numbers, condom use and partner traits. Multivariate logistic regression models were developed to determine significant associations between outcome variables and problem drinking. Fifty-eight percent of men were problem drinkers. Compared to non-problem drinkers, problem drinkers were significantly more likely to report having any symptom of a STI; not using condoms due to drinking; inconsistent condom use with all partner types; that their most recent once-off partner was unemployed; having met their most recent partner at an alcohol-serving venue; and having had a once-off sexual relationship. Alcohol may fuel once-off sexual encounters, often characterised by transactional sex and womens limited authority to negotiate sex and condom use; factors that can facilitate transmission of HIV. HIV prevention interventions specifically targeting drinkers, the contexts in which problem drinking occurs and multiple sexual partnering are urgently needed.

The construction of an idealised urban masculinity among men with concurrent sexual partners in a South African township

Background : The perspectives of heterosexual males who have large sexual networks comprising concurrent sexual partners and who engage in high-risk sexual behaviours are scarcely documented. Yet these perspectives are crucial to understanding the high HIV prevalence in South Africa where domestic violence, sexual assault and rape are alarmingly high, suggesting problematic gender dynamics. Objective : To explore the construction of masculinities and mens perceptions of women and their sexual relationships, among men with large sexual networks and concurrent partners. Design : This qualitative study was conducted in conjunction with a larger quantitative survey among men at high risk of HIV, using respondent-driven sampling to recruit participants, where long referral chains allowed us to reach far into social networks. Twenty in-depth, open-ended interviews with South African men who had multiple and concurrent sexual partners were conducted. A latent content analysis was used to explore the characteristics and dynamics of social and sexual relationships. Results : We found dominant masculine ideals characterised by overt economic power and multiple sexual partners. Reasons for large concurrent sexual networks were the perception that women were too empowered, could not be trusted, and lack of control over women. Existing masculine norms encourage concurrent sexual networks, ignoring the high risk of HIV transmission. Biological explanations and determinism further reinforced strong and negative perceptions of women and female sexuality, which helped polarise mens interpretation of gender constructions. Conclusions : Our results highlight the need to address sexuality and gender dynamics among men in growing, informal urban areas where HIV prevalence is strikingly high. Traditional structures that could work as focal entry points should be explored for effective HIV prevention aimed at normative change among hard-to-reach men in high-risk urban and largely informal contexts.