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These data add to findings from this cohort showing that women who had a violent partner or who were relatively powerless in a relationship were more likely subsequently to acquire HIV. The authors therefore argue that HIV prevention programmes need to find ways to help young women to avoid gender inequity, violence and transactional relationships. In order to clarify the links between gender issues and HIV infection, Rachel Jewkes of the South African Medical Research Council examined data from the cohort of young women recruited to evaluate the impact of a behavioural intervention known as Stepping Stones.
Women from both the intervention and control groups are included in this analysis, as long as they were HIV negative at the beginning of the study, had sex whilst in the cohort and completed follow-up after 12 and 24 months. The researchers examined the behaviour and experiences that the women reported at the beginning of the study and whether they subsequently acquired HIV. The study de is therefore more robust than a one-off cross-sectional survey, as it can suggest whether a link between one factor and HIV infection is causal or not.
Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Stigma can be questioned and challenged. Studies aim to give information that will be applicable to a large group of people e. Because it is impractical to conduct a study with such a large group, only a sub-group a sample takes part in a study. Confounding exists if the true association between one factor Factor A and an outcome is obscured because there is a second factor Factor B which is associated with both Factor A and the South african women looking for sex.
Confounding is often a problem in observational studies when the characteristics of people in one group differ from the characteristics of people in another group.
This can lead to biased. Confounding is not usually a problem in randomised controlled trials. It asks questions about how and why. Qualitative research might ask questions about why people find it hard to use HIV prevention methods. Qualitative research methods include interviews, focus groups and participant observation. Included in the analysis are women aged 15 to 26 years, with an average age of 18 at baseline the beginning of the study. The majority were very poor, still in school, unmarried and already sexually active. The cohort was recruited in primarily rural parts of the Eastern Cape province.
During the two years of follow-up, women acquired HIV. In other words, the incidence of new infections was extremely high, but not unusual in this setting, at 6. Data from this cohort, published two years ago in The Lancetshowed that women who reported having relatively little power in sexual relationships at baseline for example, feeling obliged to sleep over when a boyfriend wanted her to were more likely to subsequently acquire HIV.
In women with medium or high relationship power equity, incidence was 5. Similarly, women who reported at baseline that sexual partners had been either physically or sexually violent were also more likely to go on to acquire HIV.
Women reporting either one or no incidents of intimate partner violence had an incidence of 5. Both these differences in incidence were statistically ificant after adjustment for confounding factors. Rachel Jewkes suggests that certain ideals of masculinity which are widely accepted in some South African communities legitimise unequal and often violent relationships. Men are expected to dominate and control women, and violence may be justified to enforce and demonstrate this. This may place women at increased risk of HIV infection by creating psychological distress, encouraging women to be more acquiescent, preventing women from influencing the circumstances of sex including condom use and the frequency of sex and allowing men to have multiple and concurrent partners and therefore more likely to themselves have HIV and sexually transmitted infections.
These South african women looking for sex are seen in terms of men fulfilling a traditional provider role, rather than as being akin to prostitution. Transactional sex was asked about, at the beginning of the study, in relation to different types of partners. A total of women reported it in relation to main partners, 59 women reported it with ongoing and usually secret second partners known as makhwapheni in the Zulu and Xhosa languagesand seven women reported it with one-off partners.
In relation to main partners, there were no statistically ificant differences in HIV incidence between those women reporting and not reporting transactional relationships. However, when looking at makhwapheni and one-off partners, women who did not report transactional relationships had an HIV incidence of 5. The researchers then adjusted their figures for other factors which are known to influence HIV incidence including condom use, age, herpes infection, relationship inequity and intimate partner violence.
They calculated that having transactional relationships with makhwapheni or one-off partners doubled the risk of acquiring HIV incident rate ratio 2. The authors suggest financial and material vulnerabilities may introduce a particular type of vulnerability into sexual relations.
These highlighted the range of qualities women were looking for in a partner. Some women expected to be provided for:. I wish I should just have a person whom I know that I am in love with, but I wish he should give me money when there is something that I need. I would see that this person does not love me if he gives me nothing, but he sees that I am suffering, no I could see that he does not love me… I wish he should not spend a long time without seeing me and if there is something I need from him knowing that he has it, he should give it to me.
For many of the participants, obtaining and keeping boyfriends was a central pursuit. But many desperately needed the items and money they received, although it was often inadequate for their needs. This teenager was bringing up the child she had had with a married man. When dating, women had considerable agency and took care in choosing a partner they felt able to submit to. Others, especially those who had gone through the Stepping Stones intervention, expressed a desire for mutual respect and autonomy, and said they would not accept violence and controlling behaviour.
These social expectations can put a pressure on men which may be resented by those who are unemployed or underpaid. Data from a household survey conducted with a randomly selected sample of men in the Eastern Cape and Kwa-Zulu Natal provinces sheds light on the issue. Two thirds of men reported relationships where they perceived that their partner had got involved in the expectation of receiving goods and services. This was reported for all types of partners and men tended to give similar items cash, food, clothes, cosmetics, accommodation, etc. Prevalence was high across a range of social and demographic groups.
The proportion of men reporting transactional relationships was much higher than in the cohort of Stepping Stones women. This may be because perceptions of what relationships are about can be different or because men want to present themselves as being able to provide. In contrast to transactional relationships, fewer than one-in-five men South african women looking for sex sex with a prostitute, and there was relatively little overlap between the two.
These are seen as very different behaviours and prostitution is stigmatised. Moreover, participants answered questions about their attitudes to women and relationships, which suggested that men involved in transactional relationships tend to have socially conservative and hostile attitudes towards women as well as an idea of sexual entitlement. Rachel Jewkes and colleagues conclude with the implications of their research for HIV prevention. In this respect, both skills building communication and other skills and tangible economic empowerment are important.
Jewkes R et al. for free full text. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. The Lancet for free abstract.
Sexuality and the limits of agency among South African teenage women: theorising femininities and their connections to HIV risk practices. Social Science and Medicine Transactional relationships and sex with a woman in prostitution: prevalence and patterns in a representative sample of South African men. BMC Public Health Primary tabs View active tab Preview. Roger Pebody. This article is more than 9 years old.
for more recent articles on this topic. Relationships and HIV infection In order to clarify the links between gender issues and HIV infection, Rachel Jewkes of the South African Medical Research Council examined data from the cohort of young women recruited to evaluate the impact of a behavioural intervention known as Stepping Stones.
Glossary stigma Social attitudes that suggest that having a particular illness or being in a particular situation is something to be ashamed of. Find out more in our About HIV s. More news from South Africa. for free full text Jewkes R et al. for free abstract Jewkes R et al.
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