Abstract
Background: Structural drivers of the HIV epidemic are increasingly recognised, and cross-sectional research has shown an association between transactional sex and HIV prevalence, but evidence on the impact of transactional sex on HIV incidence in young women remains limited. Methods: We tested hypotheses that transactional sex predicted incident HIV infections in a dataset of 1077 HIV negative women aged 15-26 enrolled in a cluster randomised controlled trial. Incidence rate ratios were derived from multivariable Poisson models which included terms for age, HSV2, relationship power, condom use, intimate partner violence (IPV) exposure, treatment, stratum and person years of exposure to HIV. Results: 127 sexually active women acquired HIV during the study. HIV incidence was greater among women having transactional sex with a once off partner (IRR 3.29 95% CI 1.02, 10.55, p=0.046) and those having transactional sex with an on-going, concurrent partner (IRR 2.05 95% CI 1.20, 3.52, p=0.009). An analysis was performed to distinguish between the effects of a transactional sexual encounter or relationship and having a higher number of sexual partners or older partners, which are usually entailed in transactional sex. Women having transactional sex with a casual partner (on-going or once off) and two or more partners during follow up had an elevated risk of HIV acquisition (IRR 2.23 95% CI 1.28, 3.88, p=0.005), where as those just having two or more partners did not (IRR 1.20 95% CI 0.81, 1.77, p=0.368). Women with partners 5 or more years older did not have an elevated risk of HIV. Conclusions: Transactional sex with an on-going or once off partner elevates young women’s risk of HIV infection. This finding is independent of partner number or age. These findings support the need for structural interventions in HIV prevention, with a stronger focus on reducing transactional sex.
Highlights
Women who engage in sex motivated by economic gain, whether in prostitution or more informal transactional sex, are very vulnerable to sexually transmitted infections, including HIV, as well as rape and intimate partner violence (IPV) [1,2,3,4,5,6,7]
The high HIV prevalence found in women in prostitution, compared to women in the general population has been recognised since the early days of the HIV epidemic and pertains globally
The potential for mismatch between perceptions of motivation is clearly shown in South Africa where men much more often report perceiving themselves to be in transactional relationships than women describe their own relationships or sex was predicated on material gain, at least in research [3,9,12]
Summary
Women who engage in sex motivated by economic gain, whether in prostitution or more informal transactional sex, are very vulnerable to sexually transmitted infections, including HIV, as well as rape and intimate partner violence (IPV) [1,2,3,4,5,6,7]. In South Africa these are generally called khwapheni or nyatsi (in the Nguni or Sotho group languages and kept secret), and it may be a primary motivation for relationships with main partners [2,12,16]. In the latter case it can be very hard to distinguish transactional relationships from other relationships where there is a predominant expectation of both the man and the woman is that the man will fulfil a provider role, especially as the roles of romantic love, habit, social expedience etc in sustaining relationships are complex, and love may be expressed in gifts [16]. Structural drivers of the HIV epidemic are increasingly recognised, and cross-sectional research has shown an association between transactional sex and HIV prevalence, but evidence on the impact of transactional sex on HIV incidence in young women remains limited
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