Elsevier

Social Science & Medicine

Volume 59, Issue 8, October 2004, Pages 1581-1592
Social Science & Medicine

Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection

https://doi.org/10.1016/j.socscimed.2004.02.003Get rights and content

Abstract

Sex workers have long been considered a high-risk group for HIV infection, but to date little quantitative research has explored the association between HIV risk and exchange of sex for material gain by women in the general population. The objective of this study was to estimate the prevalence of such transactional sex among women attending antenatal clinics in Soweto, South Africa, to identify demographic and social variables associated with reporting transactional sex, and to determine the association between transactional sex and HIV serostatus. We conducted a cross-sectional study of women seeking antenatal care in four Soweto health centres who accepted routine antenatal HIV testing. Private face-to-face interviews covered socio-demographics, sexual history and experience of gender-based violence. 21.1% of participants reported having ever had sex with a non-primary male partner in exchange for material goods or money. Women who reported past experience of violence by male intimate partners, problematic substance use, urban residence, ever earning money, or living in substandard housing were more likely to report transactional sex, while women who reported delayed first coitus, were married, or had a post-secondary education were less likely to report transactional sex. Transactional sex was associated with HIV seropositivity after controlling for lifetime number of male sex partners and length of time a woman had been sexually active (OR=1.54, 95% CI: 1.07, 2.21). Women who reported non-primary partners without transactional sex did not have increased odds of being HIV seropositive (OR=1.04, 95% CI: 0.75, 1.43). We conclude that transactional sex may place women at increased risk for HIV, and is associated with gender-based violence, substance use and socio-economic disadvantage. Research, policy and programmatic initiatives should consider the role of transactional sex in women's HIV risk, with attention to the intersecting roles of violence, poverty, and substance use in shaping women's sexual behaviour.

Introduction

Sex work is associated with increased risk of HIV infection in South Africa (Dunkle et al., 2004a; Ramjee, Karim, & Sturm, 1998) and globally (Day & Ward, 1997; D’Costa et al., 1985; Kreiss et al., 1986). It represents, however, only one end of broad spectrum of transactional sexual behaviour. Research in sub-Saharan Africa has suggested that exchange of sex for material gain is common practice, and that few women who engage in such transactions identify as sex workers (Caldwell, Caldwell, & Quiggin, 1989; Hunter, 2002; Jewkes, Vundule, Maforah, & Jordaan, 2001; Kaufman & Stavrou, 2002; Luke (2002), Luke (2003); MacPhail & Campbell, 2001; Mujaya et al., 1998; Nyanzi, Pool, & Kinsman, 2001; Nzyuko et al., 1997; Silberschmidt & Rasch, 2001; Wood, 2002; Wood & Jewkes, 2000). Transactional sex is often motivated by basic survival and subsistence needs (Hunter, 2002; Luke, 2002), but young women whose opportunities for education and employment are severely circumscribed may also use transactional sex to help achieve higher status in youth cultures which prioritise sexual success and conspicuous consumption (Hunter, 2002; Kaufman & Stavrou, 2002; Leclerc-Madlala, 2001; Luke (2002), Luke (2003); Nyanzi et al. (2001); Silberschmidt & Rasch, 2001). Understanding the range of motivation and contexts for transactional sex is thus important for understanding sexual behaviour and disease risk.

Transactional sex occurs in different types of sexual relationships. Studies among South African youth find that young women often receive gifts from primary dating partners (Wood & Jewkes, 2000; Jewkes et al., 2001; Kaufman & Stavrou, 2002; MacPhail & Campbell, 2001). While these gifts are rarely the sole motivation for the relationship (Wood & Jewkes, 2000; Kaufman & Stavrou, 2002; MacPhail & Campbell, 2001), they do provide an incentive for young women to both have sex (Jewkes et al., 2001; Kaufman & Stavrou, 2002) and eschew condom use (Kaufman & Stavrou, 2002; MacPhail & Campbell, 2001). Transactional sex also occurs with non-primary partners. In South Africa, a “roll-on” (seSotho: nyatsi; isiZulu: makwapheni) is a secret sexual partnership which is by definition concurrent with, and hidden from, a primary relationship (Jewkes, Nduna, Jama, Dunkle, & Levin, 2002). A roll-on may be a older man who provides financial resources (a sugar daddy) (Hunter, 2002), the father of one or more of a woman's children with whom she continues having sex to secure financial support (Jewkes, et al., 2002) or any other man who provides some form of on-going emotional and/or financial support. The other important category of non-primary partners are men a woman has sex with only once. Sometimes a woman has sex in the hope of establishing an on-going relationship that never materialises, but “once-off” sex may also be a “thank you” for drinks bought in a shebeen (township bar)(Wojcicki & Malala, 2001), a free lift in a car or truck (Kaufman & Stavrou, 2002), or a bed for the night (Jewkes et al., 2002; Wojcicki & Malala, 2001). Neither type of non-primary partnership is necessarily transactional, but such partnerships are frequently motivated by material or financial considerations.

Several authors have noted associations between transactional sex and gender-based violence. Women who have experienced some forms of gender-based violence, particularly child sexual assault, have been found to be more likely to subsequently trade sex for money or drugs (Beadnell, Baker, Morrison, & Knox, 2000; Cunningham, Stiffman, Dore, & Earls, 1994; Gilbert, El-Bassel, Schilling, Wada, & Bennet, 2000; James & Meyerding, 1977; Kalichman, Williams, Cherry, Belcher, & Nachimson, 1998; Mullings, Marquart, & Brewer, 2000; Zierler et al., 1991). On the other hand, trading sex has been found to be associated with increased risk of rape and physical violence from clients or from men who anticipated that their financial outlay would be reciprocated by sex (Karim, Karim, Soldan, & Zondi, 1995; Wojcicki & Malala, 2001; Nyanzi et al., 2001). It is important, therefore, to consider transactional sex within the context of both gender-based economic disparities and the high prevalence of violence in sexual relationships (Zierler & Krieger, 1997).

This paper describes the prevalence of self-reported transactional sex with non-primary partners among a sample of women seeking routine antenatal care in Soweto, South Africa and describes the socio-demographic and behavioural variables, including experience of gender-based violence, which are correlated with reporting transactional sex. We then assess the association between transactional sex and newly diagnosed HIV infection.

Section snippets

Materials and methods

Data for this analysis were drawn from a larger study of gender-based violence and HIV infection carried out in Soweto, South Africa between November 2001 and April 2002. Details of the study design and the instrument used to assess gender-based violence have been described in more detail elsewhere (Dunkle et al., 2004c). Participants were recruited from antenatal clinics in three community health centres and Soweto's single public hospital. All women presenting for care in these clinics were

Results

Our final sampling frame comprised 3982 pregnant women who attended study clinics between November 2001 and April 200. Of these women, 1790 (45.0%) were sampled and screened for potential eligibility, and 1467 (82.0%) of those were eligible. Of these, 1395 (95.1%) agreed to participate. The women ranged in age from 16 to 44 and were from 6 to 41 weeks pregnant. Overall, 49.8% of women reported ever having non-primary partners, and 21.1% of the overall sample reported ever engaging in

Discussion

In Soweto, South Africa, 21% of women attending antenatal clinics reported engaging in sex for material gain with a man other than a primary partner. Women who reported such transactional sex had significantly increased odds of testing HIV seropositive at the time of the interview. Transactional sex was more likely to be reported by women who also reported lifetime experience of violence by male intimate partners, problematic alcohol or drug use, urban residence, ever earning money, or living

Acknowledgements

We thank all women who participated in the project, as well as the VCT counsellors and nursing sisters working in our study sites. We thank our fieldwork team: Paulina Damane, Thoko Mahlangu, Pumla Mengezeleli, Sonia Mohlakoane, Hellen Nkadimeng, and Susan Ramatsea. Dr. Mieko Yoshihama provided valuable feedback on earlier drafts of this manuscript. The Australian Agency for International Development provided core funding for the work. Dr. Dunkle's participation was supported by fellowships and

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