Sexual risk taking and HIV vulnerability among young women in post-apartheid South Africa

Abstract: Background: Young women face the highest risk of HIV infection than any other group in South Africa. Within the broad population of young women, those who have multiple sexual partners are thought to have a heightened risk of contracting HIV. Qualitative evidence suggests transactional sex, age mixing, inconsistent condom use and intimate partner violence as the leading risk factors that contribute to the risk of HIV among young women in the country. However little is known about the extent and organization of these risk behaviours among women who have multiple sexual partners. Historical and post-apartheid structural arrangements are suggested as the contextual antecedents of young women’s vulnerability to HIV in the country. However, the evidence on how these risk and vulnerability factors combine to heighten HIV risk and the particular ways in which young women use their sexual behaviour to negotiate life in the country remains sparse. Main aim: This dissertation analyses and explores HIV, sexual risk taking, intimate partner violence and relationship power inequity among young women aged 16-24 who have multiple sexual partners in a peri-urban setting in the Western Cape, South Africa. Methods: The research employed a mixed methods approach that made use of quantitative and qualitative methods. In the quantitative study, Respondent Driven Sampling was used to recruit and manage the enrolment of 259 young women reporting more than one sexual partner in the past three months. In the qualitative study, young women aged 16-24, men aged 23-32, community leaders and parents were recruited using purposive sampling methods and enrolled in focus group discussions, individual interviews and key informant interviews. Estimates of population proportions and 95% confidence intervals (CIs) were calculated using the Respondent-Driven Sampling Analysis Tool 5.6 (RDSAT). Focus group discussions, individual interviews and key informant interviews were analysed using content analysis methods. Findings: Extremely high rates of sexual risk taking were established among the largely adolescent, school going and poor subpopulation of young women. Nearly all of them had engaged in transactional sex with their most recent sexual partner (91%), 87% and 77% reported concurrency and inconsistent condom use respectively, in the past 3 months. Eight out of ten reported experiences of violence and 70% reported sexual coercion at sexual debut. Having high numbers of partners (≥ 7) in a short space of time increased the likelihood of inconsistent condom use with main and causal partners. Transactional sex and age mixing were strong predictors of experiences of sexual intimate partner violence. The qualitative findings confirmed the high levels of sexual risk taking among the young women, and suggested a combination of relational, social, economic and household arrangements as the main drivers of their risk behaviours. Parenting young women in this context was experienced as extremely challenging as parents grappled with new and poorly understood post-apartheid legislation on children’s rights, and local, community deficits. Conclusions: The young women featured in this dissertation presented with a constellation of high-risk sexual behaviours that clustered to form a risk syndrome. Multiple concurrent sexual partnering, transactional sex and age mixing were shown to hold important economic and existential meanings for the young women. The young women used these sexual risk behaviours to pursue social inclusion and avoid exclusion in a local context marked by new and sudden exposure to commodities, social and economic inequalities, global technologies, and a strong and punitive popular youth culture. Importantly, the nature of these risk behaviours was inherently structured to undermine women’s power and exacerbate vulnerability to male dominance, extremely high levels of violence, and ultimately HIV. A combination of macro-level and bottom up strategies that address social, economic and gender inequalities and the negative impact of global technologies and popular youth culture on young women are urgently needed in South Africa.