In this analysis of the narratives of the 71 women participating in discussions, we found no noticeable differences in the sexual scripts of women by trial arm. For most women (including both those living with HIV and not), HIV remained largely unacknowledged in their described sexual experiences. When asked about ‘prevention’, women referred almost exclusively to contraceptive methods and researchers had to probe to elicit responses specifically related to HIV, with HIV prevention descriptions limited to condom use. When the team asked about biomedical prevention modalities, including TasP, no participants reported hearing of these options before. All participants in intervention communities had received the door-to-door testing services but did not relate this to TasP. Rather, the intervention was perceived as an effort to expand access to HIV testing. In addition, generally people believed in the therapeutic benefits of ART, and, even after being informed of TasP, somewhat hesitant about but its prevention benefits.
More broadly, we identified three dominant framings of women’s intrapsychic sexual scripts: (1) the idealisation of romantic sex; (2) the conceptualisation of sex as being about relationships; and (3) the positioning of risky sex as ‘other.’ HIV and ‘prevention’ were framed as challenges to normative sexual scripts. Finally, we demonstrate specific points of disjuncture in women’s intrapsychic scripts, where women had to manage the imposition of HIV, including risk perceptions, in the ‘meanings’ they attached to sex.
Sexual scripts and the silence around HIV
We found that spontaneous references to HIV and risk were mostly absent in the narratives of women, especially for women who were not living with HIV. Women’s descriptions of their sexual interactions with their intimate partners seldom included HIV prevention methods. When probed on ‘protection’ during sex, women readily referred to contraceptive methods, including the Depo-Provera injection, contraceptive implants, or occasionally the “pulling out” method, rather than HIV prevention. Pregnancy prevention was framed as women’s responsibility with few men reportedly engaging with their partners on birth control.
Nita (20, Arm B), had been diagnosed with HIV a few months prior to our discussion. She had a casual relationship with her partner, whose HIV status was unknown to us. Nita told us that she ‘sometimes’ used protection. When we asked why, she explained:
Nita | It is when I think that my contraceptive [injection] is finished [needs to be replaced] |
Researcher | Then what does [your partner] say when you are taking [condoms] out? |
Nita | I give it to him and he doesn’t say anything, I tell him that I don’t have contraceptives, and I don’t want a baby |
While Nita did occasionally incorporate condoms as part of her sexual interaction, it was not for the purpose of HIV prevention for her partner, but rather for pregnancy prevention, as gendered cultural norms often dictate women do. When probed about HIV prevention specifically, descriptions of biomedical modalities were wholly absent in the women taking part in this study’s narratives. None of the participants mentioned treatment-based options as HIV prevention options. After we described the potential of ART as a means to viral load supression and to prevent onwards HIV transmission, none of the women indicated that they had heard of this message. This despite the participants living in communities where HIV testing and referral for ART (and TasP) had been offered door-to-door and annually for each of the preceding 2–3 years and government HIV treatment guidelines changed to allow all PLHIV treatment since 2016. When we described the concept of TasP to Zinhle (19, HIV negative, Arm B), she had several questions on viral suppression. She told us she had never used condoms with her boyfriend of the past 4 years, Robert, and expanded:
My boyfriend is positive, but we tested, three times, I’m negative … We went to the clinic last month … because I saw that he was sick. I told him, ‘Baby, you are taking treatment and you are hiding [things] from me’. He told me, ‘Baby I’m [HIV] positive’. ‘Okay fine’, I said to him, ‘let’s go to the clinic’ … I was negative, he was positive.
Zinhle explained that she anticipated that she would receive a positive HIV test because she had had sex with Robert who was positive—she assumed transmission was automatic and immediate. Her confusion about her repeated HIV negative test results illustrated that, while the couple used no other form of prevention, they were unaware of the potential of HIV treatment as an effective prevention strategy. Although Zinhle was concerned with Robert’s physical health, she did not frame this concern as connected to their sexual script.
Chantelle (31, Arm A), who was living with HIV, was also in a sero-discordant relationship and had disclosed her status to her long-term friend and then partner, Kyle. When asked explicitly about HIV prevention, she reported that she always insisted on using condoms, but that they had recently started discussing having children together. Although Chantelle had heard that it was possible to become pregnant without transmitting HIV to her partner, she was unsure of what they should do to make this happen:
He asked me if maybe, [we could] have a baby. I said that when the time comes the two of us need to go to the clinic … He also wants to know how [it works]. I don’t know either … We have to go to the clinic and find out about condoms and so on. I don’t know, because when a child gets made, then the condom has to be gone! I can’t give him an answer.
Most women reported occasional condom use during sex, while few told our research team that they insisted on consistent condom use with intimate partners. A few women also presented HIV testing, including proxy testing (where a sexual partner’s HIV test result is adopted or assumed as one’s own without confirmation through testing oneself) as a way to mitigate HIV risk without taking other steps to counter potential HIV transmission, which might have jeopardised the continuation of the relationship. Regular testing was seen as a protective measure, one that many women welcomed. Landi (33, Arm A) who was in a longterm relationship with her partner, Timo, declared that she was HIV negative. When we enquired about Timo’s status, she explained:
He is too, because the two of us, how can I say, if I test myself, obviously the two of us sleep together. If we have sex tonight, he climaxes, the two of us both [climax]. I will get that ailment [HIV] from him and he will get the ailment from me … He doesn’t test himself, but I do it. If I go again to get myself tested and they say I have the illness [HIV], obviously who does it come from?
Landi’s relationship with Timo also illustrates the gender-related nature of care and the responsibility of managing health for people in intimate relationships. Landi, as with many other women, takes on the role of the partner who receives the HIV test and confirms the joint status of the couple.
Rosalie (33, HIV negative, Arm A) told us that she tested with her partner every month. When asked why they tested so often, she explained, “because, around here, a person doesn’t know … We share toilets [communal ablutions]. Things like infections and stuff can come”. She also described that she was not worried about her partner “messing around”, because “he made a promise to me and I need to trust him”. For Rosalie, HIV risk is not located in the domain of her intimate relationship. As part of her intrapsychic script, or the ‘motivational elements’ [
33] attached to sex, she, like many other women, emphasised the need for ‘trust’ and an unfaithful partner associated with HIV risk was not considered as an option. Rosalie rather deems her relationship as a safe and appropriate space for sex and blames, perhaps as a deflection, communal ablutions as the potential source of HIV. Interestingly, we found that the same participants (like Rosalie) would, in other conversations, readily describe accurate HIV prevention knowledge, but not in their narratives about sex.
Women’s intrapsychic scripts
While HIV did not feature in the way that most participants constructed their intrapsychic scripts, internalised framings around sex were constructed along the following: (1) the idealisation of romantic sex; (2) sex as being about relationships; (3) and risky sex as ‘other’.
1.
The idealisation of romantic sex
Many women defined the act of sex as synonymous with love, trust, respect, and care. This is consistent with romanticised normative scripts described by researchers in other contexts [
52,
53]. However, for most of our participants, as with many women in Southern Africa, experiences with intimate partners are often removed from these idealised scenarios, as violence, betrayal and distrust were frequently experienced. Despite these tensions, idealised concepts of sex formed an integral part of the intrapsychic scripts of participants.
Carli (31, HIV negative, Arm C) had been in a relationship with her partner, Ronaldo, for approximately 6 years. In her descriptions of how sex during the early stages of their relationship, Carli employed normative and even stereotypical imagery of romantic sex:
We were very in love. When I got home in the evenings, the roses were scattered on the bed with the red nighty [lingerie] and the chocolates! … And there’s champagne! … [Ronaldo] and I were hungry for each other! They [friends] said … it looks like I can’t wait to get home so I can jump [claps hands for emphasis] on him or he wants to kiss me!
Both Carli and Ronaldo adhered to normative romanticised scripts of sex, and idealised conceptions of sex show how scripts operate across the intrapsychic and cultural spheres. It was also reflected in Carli’s description of the sex act:
[Sex is] not supposed to be with anyone. And the person with who you’re doing it has to respect you. Sex isn’t just for sex. You should know the person and don’t just let him, like “shoot a card” [make sexual advances].
Despite these conceptualisations of sex as respectful and intimate, Carli’s recent experiences were not aligned with these ideals and she acknowledges that there are discrepancies between her internalised expectation and her lived reality. She explained:
Look, I don’t experience it, like I would tell you “it’s fantastic” [claps hands] or “nice” or “I enjoyed it”. To me … it’s a matter of, I have to. It must happen because otherwise I’m going to be bothered for the entire night …You see it’s not the right reasons anymore, to be intimate.
For Carli, sex with Ronaldo was no longer for the ‘proper reason’ of intimacy, but rather a task that needed to be done to avoid being ‘bothered’ by her insistent partner. Carli also described how the relationship became violent: “He hit me a lot, he’s very aggressive, violent, he has probably tried several times to kill me.”
Similarly, Rosalie (33, HIV negative, Arm A) who emphasised the importance of trust in her relationships in the section above, had been with her boyfriend, James (35, HIV negative), for a few weeks when we also met him. They were both regular methamphetamine users. Rosalie would often explain to us that sex and romance was an important part of her life and that she prioritised what she called her weekly ‘mommy’s night’, or date night, where the couple would be intimate. She explained:
If we have sex, I say we make love, or we share each other … Others say ‘fuck’, but that isn’t what you should call it. Because if you really love someone, and you are going to have sex, then you two are sharing each other … You can’t just say you are going to ‘mount’ her; you must say that you are going to make love. [Otherwise] you think nothing of her.
Rosalie describes sex as an act beyond the physical. She emphasised intimacy and suggested that a lack of respectful sex indicates a disregard for your partner. However, while Rosalie prioritised intimacy, her understanding of sex and pleasure was also framed around the needs of her male partner. When asked how important sex is in her life, Rosalie said:
It is very important to satisfy your guy because that is what a man needs. If you can’t satisfy your man, he is going to have a look around to find what he wants. If your guy wants sex, you should never refuse him. You owe him that.
For Rosalie, her intrapsychic sex script was framed around the idealisation of romance, but also the gendered utilitarian function of sex as a means for women to sustain their intimate relationships.
2.
Sex as about relationships
We found that sexual narratives were not concerned with the physical health and wellbeing of bodies, but rather about the wellbeing of perceived intimate relationships. Wilma (27, HIV negative, Arm A) explained to us that:
Sex for me, it is part of who I am … because thats how me and my boyfriend now again get to know each other and … I look forward to trying something new [sexually] … [but] God, I am also not in the mood for that anymore ... I just stay so tired .. but sex is part of it [their relationship].
Wilma explained that sex is seen is an essential part of their relationship and maintaining intimacy, regardless of her lack of physical energy.
Even more pointedly, when an HIV diagnosis was revealed in relationship, for many women the primary concern was the interpersonal implications. For instance, Mara (21, LHIV, Arm A) and her boyfriend, Zonke (22), opted to test together for HIV with a team of community health workers at Mara’s house. The couple had been together for a few months and, according to Mara, trusted each other. While Mara received a positive result, her boyfriend tested negative. The unexpected diagnosis meant that the couple had to renegotiate their sexual relationship. Mara explained that she thought she should end the relationship because she feared infecting her partner. Zonke, however, insisted that the relationship should continue. After using condoms once after the positive test result, Zonke told Mara that they should stop using condoms and return to their normal routine of condomless sex.
Since Mara’s diagnosis, she briefly linked to treatment but had since stopped taking ART. When asked about this decision, she replied: “When I’m drinking pills, it’s as if my love would be low on Zonke. Maybe he would be embarrassed”. Mara infers that taking treatment would lower her libido which would challenge her expected role of engaging and enthused sexual partner. This could make Zonke feel less desirable and possibly less masculine, which would lead to embarrassment on his part. The couple briefly considered the implications of Mara’s HIV diagnosis on the future of their relationship and potentially Zonke’s health. However, they soon reverted to established sexual scripts, where condoms did not form part of their sexual interaction. Mara’s concerns about HIV and treatment were not framed around health (her own or Zonke’s), but rather about the implications for her sexual relationship with her partner. Their relationship illustrates the interaction between intrapsychic and interpersonal scripts as the couple confirms their accepted sexual script. Additionally, in this case, both Mara and Zonke dismissed the seriousness of the risk of HIV and preferred to focus on other aspects of the relationship, such as pleasurable sex and intimacy.
3.
Locating risk in the ‘other’
When women were asked specifically about HIV, risk was presented as fluid, context-specific, and mostly relevant to ‘others’, often those who were believed to be involved in ‘morally transgressive’ behaviours. ‘Others’ included sex workers and their clients, men who have sex with men, and teenage girls, who were described as easily persuaded to have unprotected sex with older men. While most participants described how they had been sexually active as teenagers and almost half had had children while still in their teens, there was a dissociation between participants’ behaviour and their beliefs about risky ‘others’. Again, intrapsychic scripts and the internalised meaning of sex (appropriate, desired, and acceptable) were in conflict with lived experience.
Cherise (31, HIV negative, Arm A), who had an unplanned pregnancy in her twenties, noted that with “the teenage pregnancies the HIV comes in, because the men make them dumb, they can easily be manipulated.” She added, “every person has his own life and what he does with his life is his business, but if you are begging to get sick, then you should just go to the sex workers.”
Carli (31, HIV negative, Arm C) who, as described in the section above, was in a contentious relationship with Ronaldo, did not consider her relationship ‘risky’. This was despite describing how her partner cheated on her and how she contracted an STI. In her account, she described the other woman as dirty, locating sexual risk as ‘other’:
Researcher | Have you guys ever used condoms? |
Carli | Never during our entire relationship. In the 6 years we have been together we’ve never used condoms |
Researcher | Do you think he used condoms with other partners? |
Carli | I’ve asked him about that many times. He says yes, but I don’t know. Because the one time when he also had a girl [cheated] and then after a while, he came back. Then we … got together [had sex], then I picked up that thing [STI]. It was almost like the girl was dirty. You see my lower body [vagina] itched very much and burned. I went to get pills, then they [health workers] said the girl was dirty. That’s why she gave him that filthy disease |
HIV was placed as belonging outside of accepted intrapsychic scripts, where women understood themselves to engage only in proper and respectable sex [
54], and where an association with HIV would cast doubt on the perceptions that they have of themselves [
47].
Various participant used observations to reaffirm the position of being ‘safe’ in their relationships. When Viv (28, HIV negative, Arm A) described how she made decisions around sex with her partner, Trevor, she assumed that he was HIV negative because he carried condoms, although she had never used condoms with him. The assumption was that he used condoms with ‘other’ women, and that, because they had a trusting relationship, HIV risk was minimal. She explained: “[We] always had clean [condomless] sex. But I trusted him, and he trusted me. He should know I wouldn’t go to another guy.” In her explanation, Viv does not consider the possibility that Trevor might be unfaithful.
Points of disjuncture in intrapsychic scripts
In the extracts above, we have shown how HIV prevention, is largely absent in women’s sexual scripts. Most women positioned HIV prevention methods as difficult to incorporate into preferred sexual scripts—much like intimate partner violence or unfaithfulness. When HIV and risk is considered, it was positioned as ‘in tension with’ or as an imposition to accepted intrapsychic scripts.
When prompted to discuss HIV prevention, Rosalie (33, HIV negative, Arm A) had fluid descriptions of her perceived HIV risk. When she was in her teens, Rosalie engaged in sex work, although she rarely spoke about it and did not disclose her past to James. When asked for a timeline of sexual partners, she excluded clients from this period of her life. Her time selling sex was seemingly omitted from her understanding of sex. She also readily stated that she had never used condoms during sex. She considered her stable relationships as safe sexual spaces, and was therefore concerned when her previous partner cheated on her:
Researcher | Earlier you said that you were worried about HIV. When was this? |
Rosalie | It was the time my children’s father was messing around [cheating] |
| … I had myself tested and I stayed clean [negative] |
Researcher | Have you ever used condoms? |
Rosalie | No, never. I am not one for condoms … [reconsiders] I mean, previously, when I was on the street [sex work], then it was important to use them |
Rosalie was aware of the protection offered by condom use during transactional sex. However, her intrapsychic understanding of sex with her trusted intimate partner was markedly different from the script related to sex work. Sex with James was, as described above, romantic (‘mommy’s night’, ‘making love’), condomless, and by association, risk free, while sex work was risky and thus required protection. Rosalie positioned her relationships with James as exceptional, allowing (and welcoming) condom-less sex, understanding it to be the “safe” exception.
Others experienced a shift in their perceptions of risk when unexpectedly confronted by a partner living with HIV. Lihle’s (32, HIV negative, Arm A) partner, Nhlobo, had recently disclosed his HIV status to her. The information forced her to reconsider her perceptions of sex, risk, and the relationship:
Lihle | Last week he told me about his status. I was like, I don’t know if I must continue with that [relationship] or not |
Researcher | Have you had sex with him? |
Lihle | Not yet. I’m scared. What if we make a mistake, or the condom will break and then I’ll be at higher risk of getting it [HIV]. I’m not sure … because he’s so decent and quiet |
Nhlobo’s revelation prompted Lihle to go for an HIV test, which she had not done in more than 2 years:
As soon as I heard his status, I ran [to get] mine … I’m still fine [negative]. But now it seems like I’m taking a risk here with my life. This person is older than me, [he] achieved more things in his life … I’m still confused ... Sometimes I’ll say ‘No, it’s not a problem’. But now it’s practical … I used to tell myself, I’ll [use] condoms. It was a theory [hypothetical] that time, now it’s practical. I have a lot of negative thoughts in my mind … There is risk and then it’s a responsibility. What if we have sex? Then all the time, I must be careful.
Her partner’s revelation meant that Lihle had to reassess her own level of risk, and her potential acceptance of being in a sero-discordant relationship. The act of sex that was safe in one context, was repositioned as risky in another. To manage the disjuncture, Lihle questioned the viability of the sexual relationship as it did not meet her (idealised) expectations. At this moment of rupture, where she is confronted with a reality that challenges her accepted understanding of the meaning of sex meant that she had to rewrite her sexual script—either accepting and including sex with a partner living with HIV as an option, or rejecting a partner based on his HIV positive status and the associated risk.
HIV prevention was positioned outside of intrapsychic scripts about sex, and HIV risk assigned to ‘others’. When women were confronted with the possibility of HIV exposure in their partnerships they managed this—by adjusting their scripts—in three ways: (1) dismissing the seriousness of the risk and focussing on other aspects of the relationship, (2) questioning the viability of the sexual relationship since it did not meet their idealised expectations—although this was limited to their talk about the relationship and we did not find any women to have actioned this talk by ending their relationship; (3) relabelling and making exceptions for some sex acts within relationships.