HIV disproportionately affecting young women in South Africa

Fifteen percent of young South African women, aged between 15 and 24 are HIV-positive, compared to only 5% of South African males in the same age group, according to a study published in the September 23^rd edition of AIDS. The investigators found that older sexual partners, sexually transmitted infections and inconsistent condom use were amongst the risk factors for HIV infection, but they also found that young people who had participated in South Africa’s loveLife HIV prevention activities were less likely to be HIV-infected.

In 2003 investigators conducted a nationally representative survey of young South Africans and collected data on HIV prevalence, HIV-risk factors, and knowledge of and participation in national HIV prevention campaigns. Almost 12,000 young people from across South Africa were interviewed for the study and had a voluntary HIV test.

The majority of individuals participating in the study were black (82%). Just under half (47%) of the total study population were living in townships or in informal rural settlements, a quarter reported living in households without electricity and only 38% of 20 – 24-year-olds had completed high school education.

HIV prevalence was 16% in young females compared to 5% in young males (p

The investigators highlight that nearly one in four women in their early 20s were HIV-infected compared to only one in 14 men in the same age range.

Vaginal or anal sex was reported by 48% of 15 – 19-year-olds, and this increased to 89% of individuals in the 20 to 24 age range. There were no significant differences by gender.

Of the individuals who reported ever having sex, a quarter of men and 45% of women reported having more than one sexual partner. Inconsistent condom use was reported by 61% of sexually active men and 71% of sexually active women.

A third of sexually active females under the age of 19 reported ever having been pregnant and this increased to 59% of sexually active women in their 20s.

There appears to have been a high prevalence of sexually transmitted infections, with 9% of males and 19% of females reporting an unusual genital discharge in the last year and approximately 7% of males and females genital ulcers. Circumcision was reported by a third of men.

Males reported that their sexual partners were an average of one year older than them whereas females reported that their sexual partners were on average four years older. Just under 18% of males reported having penetrative sex for the first time aged under 14, as did 8% of females. Approximately 3% of males and females said that they had engaged in transactional sex, and 2% of young men and 10% of young women said that they had ever been forced to have sex.

There was a high level of knowledge about national HIV prevention campaigns, with 85% reporting having heard of the loveLife campaign and 25% of women and 15% of men reported ever having had an HIV test. The majority (60%) of men and women said that they had changed their behaviour because of HIV.

The investigators looked at their data to see if they could identify factors which were predictive or protective of HIV infection. Amongst men the factors were genital ulcers in the past year (p = 0.04), more than one sexual partner (p = 0.02), and not being circumcised (p = 0.05). Amongst females factors strongly predictive of HIV infection were being aged 15 – 19 and having a partner one to four years older (p

Factors reducing the risk of HIV infection included participation in a loveLife programmes (males, p = 0.01; females, p

“This survey is the largest nationally representative household survey of HIV prevalence and detailed sexual behaviour conducted in young people in South Africa to date”, note the investigators.

The investigators emphasise the gender inequality of HIV, with young South African females being many times more likely to be HIV-infected than young males. “Older male partners have been theorised to place young women at greater risk of HIV infection”, comment the investigators, who note that their study found that 15- to 19-year-old females in their study had sexual partners an average of one to four years older.

Partner reduction is also identified by the investigators as having an important role in controlling HIV as each additional sexual partner significantly increased the risk of HIV infection. Inconsistent condom use, sexually transmitted infections, and long-term, deep-rooted inequalities in South African society are also highlighted as fuelling the HIV epidemic.

Regarding the role of the loveLife campaign in preventing HIV infection, the investigators write that their “analysis is consistent with the hypothesis that the programme is having an effect on HIV risk among young people.”

Limitations with the study are admitted by the investigators, in particular the self-report of sexual risk activities. Indeed, they comment that 3% of men and 4% women who reported never having had sex tested HIV-positive.