Women who don't have enough to eat taking more sexual risks in Africa

Not having enough food is associated with a higher frequency of multiple high-risk sexual behaviours among women in Botswana and Swaziland, a study published in the October edition of PLoS Medicine has found. Women who reported food insecurity in the previous year had an 80% increase in their likelihood of transaction sex, a 70% increase in their risk of reporting unprotected sex with a non-primary partner, and a 50% increase in their likelihood of intergenerational sex.

All these are factors associated with an increased risk of HIV infection in previous research. The study’s investigators suggested that targeted food support could help reduce HIV transmission amongst women in sub-Saharan Africa.

HIV and food insecurity are the two leading causes of illness and death in sub-Saharan Africa. There is a growing recognition that lack of food may increase HIV risk behaviours and it's thought that malnutrition can suppress the immune system increasing susceptibility to HIV infection in individuals exposed to the virus. However, no study has previously examined the independent relationship between not having enough food and sexual risk-taking.

Investigators therefore designed a cross-sectional study that involved 1,050 women and 999 men in Botswana and Swaziland. Between 2004 and 2005 participants completed structured interviews to see if there was a relationship between food insecurity and risky sexual behavior in the previous twelve months (after controlling for variables such as knowledge of HIV, income and education), and to see whether gender roles in relationships modified any associations.

Food insecurity was defined as reporting not having enough food to eat in the previous twelve months. The risky sexual behaviours examined were inconsistent condom use with a non-primary partner, transactional sex, intergenerational sex (a partner ten years older or younger), lack of control in a sexual relationship and forced sex. Individuals were also asked about their alcohol consumption.

All the participants were aged between 18 and 49 years.

Food insecurity was reported by more women than men (32% versus 22%). Eight percent of women and 11% of men reporting unprotected sex with a non-primary partner in the previous year. Furthermore, 5% of women reported transactional sex in the previous twelve months, with 10% of men saying they had paid for sex during this period. Intergenerational sex was reported by 17% of women and 15% of men. Forced sex was reported by 5% of women and 26% of women said they’d experienced a lack of control in their sexual relationships in the previous year.

The investigators then performed statistical analyses to see if they could find a relationship between food insecurity and sexual risk taking.

Among women, a lack of food was associated with a 70% increase in the likelihood of inconsistent condom use with a non-primary partner in the previous year (adjusted odds ratio [AOR], 1.73; 95% confidence interval [CI], 1.27 – 2.36). Women who were heavy drinkers were almost seven times more likely to report inconsistent condom use (AOR, 6.95; 95% CI, 2.20 – 23.94). However, older age, a higher level of education, and a good knowledge of HIV prevention were all associated with a lower likelihood of reporting unprotected sex for all women.

Food insecurity was associated with an 84% increase in the likelihood of a woman engaging in transactional sex (AOR, 1.84; 95% CI, 1.74 – 1.93). Women who were heavy drinkers were over 15 times more likely to report transactional sex (AOR, 15.77; 95% CI, 3.70 – 67.33).

Intergenerational sex was also associated with food insecurity amongst women, with an almost 50% increase in the likelihood among food-insecure women (AOR, 1.46; 95% CI, 1.03 – 2.08). Yet again, heavy drinking significantly increased the risk of intergenerational sex for all women (AOR, 3.94; 95% CI, 2.52 – 6.18).

Women reporting food insecurity had a 70% increase in the risk of reporting a lack of control in sexual relationships (AOR, 1.68; 95% CI, 1.24 – 2.28), although a higher level of education reduced this risk overall for all women.

Food insecurity was associated with a doubling in the odds of a woman reporting forced sex (AOR, 1.98; 95% CI, 0.57 – 6.91). Heavy drinking increased the odds of forced sex further for all women (AOR, 3.58; 95% CI, 1.7 – 7.4).

The associations between food insecurity and sexual risk taking were much weaker for men. Lack of food was associated with a modest 14% increase in the likelihood for men reporting inconsistent condom use with a non-primary partner (AOR, 1.14; 95% CI, 1.10 – 1.18). Heavy drinking increased these odds further (AOR, 2.63; 95% CI, 1.66 – 4.15). Heavy drinking was also associated with transactional sex (AOR, 3.87; 95% CI, 3.27 – 4.59) and intergenerational sex for all men (AOR, 1.95; 95% CI, 1.65 – 2.27).

“Our population-based study found that food insecurity was associated with multiple risky sexual practices for women in Botswana and Swaziland”, write the investigators.

They note that food insecurity was more prevalent amongst women and more likely to lead to sexual risk taking in women than men. They comment, “women within households in various parts of sub-Saharan Africa may be less food secure than men as a result of unequal household food allocation, a situation exacerbated by their lack of control over decisions”.

The investigators add, “our findings suggest that interventions that use targeted food supplementation and food production strategies could help address some of the gender and economic disparities that drive unsafe sexual behaviors, and should be considered as a way to reduce HIV transmission behaviors in specific high-risk populations.”