Photo: Stephen Gitau, Pexels
Adolescent girls and young women in South Africa have long borne a disproportionate risk of HIV, driven mainly by the prevalence of age-disparate transactional and transient relationships with multiple partners. Although the HIV incidence has declined slightly in this cohort, young girls remain at significantly higher risk than boys the same age.
In rural KwaZulu-Natal, the rate of infections among boys is rising. This might reflect earlier testing among boys than in the past or, as the HSRC’s Phiwokazi Qoza and colleagues write, it might indicate that relationships between young men and older women are becoming more common, alongside concurrent relationships with peers. Understanding why high rates of new infections persist in this age group, despite increasing preventative measures, is critical for designing effective behavioural interventions.
A team of HSRC researchers conducted a study involving 17 young men and women aged 19–24 who reported having partners five or more years older than themselves. They wanted to know how young people navigate and perceive sexual risk in this social environment. The study took place in the uMgungundlovu district of KwaZulu-Natal, where approximately 20% to 30% of adults above 16 years of age live with HIV.
Locally trained female data collectors conducted interviews to solicit participants’ narratives, opinions, and experiences of decision making around HIV testing, condom use, contraceptive use, pregnancy, and related topics. It emerged from these conversations that participants used condoms inconsistently with primary and even side partners – a finding that aligns with national statistics. In the 2017 HIV national household survey (SABSSM V), a quarter of respondents aged 15–24 years had never used a condom with their most recent sexual partner.
Worryingly, in the current study, young men reported making assessments of HIV status based on physical appearance, a practice that the authors refer to as ‘sero-guessing’. Adjectives such as ‘fresh’ or ‘fit’ to describe a body shape or figure were ‘linguistically framed as markers of an HIV negative status’, according to Qoza and colleagues. For instance, one 23-year-old male participant stated, “I can judge a person by her physical appearance, then I can make conclusion that she is fresh, has nothing and everything is all right with her.”
Sero-guessing took place in an environment where the social significance of condoms resulted in their use as a tool for navigating and shaping relationship hierarchies. Many participants indicated that they understood the importance of condoms in protecting against STIs. However, sero-guessing might override existing knowledge about sexual and reproductive health, the authors suggest. In some instances, the practice arguably provided a means for young people to rationalise risky sexual behaviour that offered social/relational benefits.
“For many participants, HIV and AIDS is something that is happening ‘out there’ to ‘other people’ but they are precluded from its occurrence because they have unprotected sex with people they think they trust,” says Qoza. “Trust is informed by aesthetic/physical attributes. But, most importantly, if condoms were not involved when the relationship was initially ‘consummated’, they will rarely be introduced – irrespective of how many people enter the sexual network.”
She and her colleagues argue that these findings indicate the need for educational and behavioural programmes targeting young adults. Although sexual and reproductive health is taught in high school, many people do not have access to information about risk assessment into adulthood – when navigating sexual risk becomes more complex.
Condoms, trust, and commitment
Participants reported that condomless sex signalled trust and commitment; engaging in it became a way to build social capital and maintain a relationship. Conversely, participants reported that insisting on a condom with a ‘straight-main’ – primary partner – may indicate mistrust or infidelity and could cause conflict. It followed that most participants reported not using condoms with their straight-main, even though none of the young men or women were in monogamous relationships. Sero-guessing provided a way to avoid ‘fighting’ about condoms, testing, and HIV status, the authors write.
Given the expectation that condoms were used in casual sexual encounters or side partnerships, the decision not to use them in this context was also socially significant.
Here, too, sero-guessing emerged as a means for young men to rationalise sexual encounters even when they did not have condoms with them. One participant (18 years old) said, ‘I am dating several partners … one is 24 years old. She is fit. I mean physically well-built … so we do not use a condom.’
“Both parties in the condomless sex encounter benefit,” explained Qoza. “The man gains prestige from his peers because he successfully convinced a beautiful woman to forgo all the information they have been taught about sexual risk and trust that they are the desired serostatus. At the same time, the woman agrees to forgo this information because that one act creates a consortium between them that is usually reserved for straight-main partnerships.”
In a larger study of motivations for condom use among young people in six districts across South Africa, conducted by researchers from the South African Medical Research Council (SAMRC), a similar finding emerged. In the qualitative component, involving 237 adolescent girls and young women and 38 male peers, the men reported that impregnating a woman was a way of laying claim to her and proving their masculinity. Young men’s motivations to have condomless sex included ‘increased sexual pleasure, proof of their masculinity and power, and prestige amongst peers,’ the authors write.
It was common for participants to be in primary relationships with people closer to their age and to engage in relationships with older people on the side. The authors note that although relationships between young men and older women lack cultural legitimacy, the lower expectations of commitment that characterise such relationships are attractive for some young men.
In the study, men and women reported similar motivations for dating older partners. Participants said that while straight-mains took care of their emotional needs, older partners took care of their financial and material needs. Dating an older person was also seen to elevate social status.
‘[My friends] would say, “Take him friend and chow his money; these old men have diabetes anyway, so he won’t have sex with you.”,’ a 23-year-old woman said. Another participant, an 18-year-old man, said, “You see the gifts he gets from his date. And the date will come in her car, and they will park somewhere, then you feel the pressure of also wishing to date an older person.”
Although they actively pursued older partners, the participants disapproved of older people engaging in these kinds of relationships. Men and women expressed the view that ‘blessers’ took advantage of young girls: “… Especially older people in most cases will want to have sex without using a condom and this will force you to do things that are against your will. The older partner – when you suggest that they get tested for HIV and such – are quick to say that they are older and they will do no such thing.”
One young woman pointed to a distinction between a large age gap and relationships with people only a few years older (even if the latter was still transactional). Despite this shifting dynamic away from much older partners, the authors note that young women in these networks remain vulnerable to HIV through relationships with younger men who regularly engage in multiple sexual relations. Age-disparate relationships between young men and older women are also likely to increase the HIV risk in these sexual networks.
Qoza and her team underscore the need for increasing awareness that HIV testing is the only way to determine HIV status and should be part of a health routine, rather than viewed as a last resort to confirm a positive status. Education programmes should also emphasise the value of alternative preventative measures such as pre-exposure prophylaxis.
This research provides a snapshot of how young people are making decisions in their sexual relationships, says Qoza. “Whereas these decisions might be individual, they help us understand collective risk behaviours potentially exacerbating the HIV and AIDS epidemic in South Africa. We were able to uncover that young people are not only in age-disparate relationships with older men and women, but they also have concurrent relationships with their peers or people who are closer to their age. Within the multi-party sexual relationships that often emerge, young women are unable to negotiate condom use because of both patriarchy and the desire to develop the social capital associated with serious relationships. Young men are uninterested in negotiating condom use because they rely on sero-guessing to ascertain the desired serostatus and continue to sero-guess in order to avoid conflicts within the relationship.”
The findings of this research can be used to motivate young people not to “test with their eyes”, but rather to engage in consistent condom use, start testing for sexual and reproductive health earlier and continue to rely on healthcare facilities to ascertain their serostatus and the status of sexual partners.
Phiwokazi Qoza, PhD research trainee in the HSRC’s Public Health, Societies and Belonging division