Abstract
Background: HIV is transmitted more effectively during anal intercourse (AI) than vaginal intercourse (VI). However, patterns of heterosexual AI practice and its contribution to South Africa’s generalized epidemic remain unclear. We aimed to determine how common and frequent heterosexual AI is in South Africa. Methods: We searched for studies reporting the proportion practising heterosexual AI (prevalence) and/or the number of AI and unprotected AI (UAI) acts (frequency) in South Africa from 1990 to 2015. Stratified random-effects meta-analysis by sub-groups was used to produce pooled estimates and assess the influence of participant and study characteristics on AI prevalence. We also estimated the fraction of all sex acts which were AI or UAI and compared condom use during VI and AI. Results: Of 41 included studies, 31 reported on AI prevalence and 14 on frequency, over various recall periods. AI prevalence was high across different recall periods for sexually active general-risk populations (e.g. lifetime = 18.4% [95%CI:9.4–27.5%], three-month = 20.3% [6.1–34.7%]), but tended to be even higher in higher-risk populations such as STI patients and female sex workers (e.g. lifetime = 23.2% [0.0–47.4%], recall period not stated = 40.1% [36.2–44.0%]). Prevalence was higher in studies using more confidential interview methods. Among general and higher-risk populations, 1.2–40.0% and 0.7–21.0% of all unprotected sex acts were UAI, respectively. AI acts were as likely to be condom protected as vaginal acts. Discussion: Reported heterosexual AI is common but variable among South Africans. Nationally and regionally representative sexual behaviour studies that use standardized recall periods and confidential interview methods, to aid comparison across studies and minimize reporting bias, are needed. Such data could be used to estimate the extent to which AI contributes to South Africa’s HIV epidemic.
Highlights
The increased risk of HIV transmission during receptive anal intercourse (AI) compared to receptive vaginal intercourse (VI) is long established, yet its role as a determinant of epidemics driven by sex between men and women in different settings remains uncertain [1,2,3,4,5,6]
This paper presents our systematic review of evidence from published literature on self-reported sexual behaviour to determine how common and how frequent heterosexual AI and unprotected AI (UAI) is practised in South Africa
Our findings suggest that heterosexual AI is commonly practised by both men and women in South Africa
Summary
The increased risk of HIV transmission during receptive anal intercourse (AI) compared to receptive vaginal intercourse (VI) is long established, yet its role as a determinant of epidemics driven by sex between men and women (heterosexual sex) in different settings remains uncertain [1,2,3,4,5,6]. The risks of AI have often been omitted from sexual health messaging targeted at people who have heterosexual sex This has potentially led to the misconception that UAI is safe and may have driven lower condom use during AI among heterosexuals [9,10,11]. Methods: We searched for studies reporting the proportion practising heterosexual AI (prevalence) and/or the number of AI and unprotected AI (UAI) acts (frequency) in South Africa from 1990 to 2015. And regionally representative sexual behaviour studies that use standardized recall periods and confidential interview methods, to aid comparison across studies and minimize reporting bias, are needed. Such data could be used to estimate the extent to which AI contributes to South Africa’s HIV epidemic
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