Background
HIV infection is arguably the single greatest threat to public health in South Africa, particularly for women who remain disproportionately affected by the disease [
1]. While HIV prevalence in the Western Cape Province is significantly lower than the national estimate, the Western Cape is one of the few provinces where the prevalence of HIV appears to be increasing [
2]. As unprotected heterosexual contact is the primary mode of HIV transmission among South African women [
2,
3], HIV prevention efforts in the country have focused on mass screening for HIV and education about the importance of knowing one’s HIV status and using condoms at every sexual encounter [
4,
5]. However, these prevention efforts fail to address one of the major contributors to South African women’s vulnerability to HIV, namely alcohol and other drug (AOD) use. AOD use increases vulnerability to HIV largely through its associations with sexual risk taking and also through weakening the immune system [
6,
7]. Specifically, AOD use leads to disinhibition and impaired judgment that may result in inconsistent condom use and other risky sex behaviors [
6‐
8]. In addition, vulnerable AOD-using women may engage in unsafe sex practices, such as trading sex in exchange for AODs (or money to buy AODs) or they may use AODs to cope with sex trading [
9‐
11] which in itself holds multiple risks for exposure to HIV [
10,
11].
The failure to address AOD use as part of HIV prevention efforts is of particular concern for women residing in the Western Cape where there are high levels of AOD use [
12‐
16]. Given the high rates of AOD use in the province and evidence of associations between AOD use and sexual risks for HIV, adequate responses to HIV in the Western Cape should include prevention interventions that target AOD-related sexual risk behaviors. Yet, as HIV is not evenly dispersed across all population groups in the Western Cape [
1,
2,
17], it is a more efficient use of scarce resources to focus such interventions on population groups where AOD use is prevalent and HIV incidence is on the rise. In the Cape Town metropolitan area, HIV prevalence and incidence is highest in the predominantly Black African
a health districts of Khayelitsha and Gugulethu and second highest in the predominantly Coloured health district of Mitchell’s Plain [
17]. These health districts account for the vast majority of the Metro South-East region of the Cape Town metropole which encompasses several large Black African and Coloured communities [
18]. Also, the Metro South-East district is disproportionately affected by AOD use, with the bulk of AOD-related treatment admissions in the province stemming from this area [
14]. The concentration of AOD use and HIV incident cases in this part of the metropole clearly reflect the need for interventions to reduce AOD-related risks for HIV among Black African and Coloured women residing in this region.
However differences in the health risk profiles of poor Black African and Coloured women are likely given South Africa’s socio-political history of inequality and racial segregation. During apartheid, ethnicity was a major determinant of access to health and other public services, with White South Africans having more access to public services than Coloured South Africans and Coloured citizens having marginally better access to services than Black African South Africans [
19‐
21]. These disparities arose from the legislated geographic segregation of race groups and the distribution of resources along racial lines. Geographical apartheid forced Black African and Coloured South Africans to live in (separate) township areas with limited resources and economic opportunities that were located considerable distances from the well-resourced urban areas reserved for White South Africans [
20]. This contributed to greater poverty in township areas which, together with poor access to health services, underpinned ethnic disparities in health risk profiles and disease prevalence [
19‐
21]. Despite 18 years of democracy, South Africa is still grappling with the legacy of apartheid and, for the most part, Black African and Coloured South Africans continue to reside in underserved township areas that, for the most part, remain racially segregated [
19]. Ethnicity thus remains an important marker of socio-economic advantage and an important determinant of health in South Africa [
19,
20]. Consequently, it is important to consider ethnic differences in AOD and HIV-risk profiles when designing AOD-related sexual risk reduction interventions for vulnerable women.
Although earlier work identified differences in AOD use patterns and sexual risk behaviors between Black African and Coloured women [
22,
23], this work was conducted before the use of methamphetamine became entrenched in the Metro South-East district [
14,
15,
24]. As these prior studies were conducted close to ten years ago, it is quite possible that these ethnic differences in AOD use and sexual risk profiles may have changed. The lack of current knowledge on ethnic differences in AOD-related sexual risk behaviors is cause for concern as it restricts the extent to which HIV risk reduction interventions can be designed to target the different risk profiles of Black African and Coloured women. This paper aims to address this gap through describing differences in AOD use and AOD-related risks for HIV among vulnerable Black African and Coloured women in Cape Town, South Africa.
Discussion
Our findings have several implications for the design and implementation of behavioral interventions to reduce AOD use and AOD-related sex risks for HIV among vulnerable women in South Africa. First, findings highlight the need for AOD use interventions among vulnerable women, irrespective of ethnicity. However, findings also indicate that Black African and Coloured women have different profiles of AOD use. Specifically, we found that Coloured women had significantly greater odds of testing positive for methamphetamine and self-reporting heavy episodic alcohol use and significantly reduced odds of testing positive for cannabis than Black African women. These findings suggest that while Black African women are more likely to use cannabis than Coloured women, they are less likely to have problematic AOD use (as indicated by the pervasiveness of methamphetamine use and heavy episodic drinking among Coloured women in this sample). This is supported by the finding that Coloured participants in our study were also significantly more likely to report that they believed they had a drug problem compared to their Black African counterparts. These findings are broadly in keeping with those from earlier studies that reported less AOD use (with the exception of cannabis) among women from Black African communities relative to women from Coloured communities in the Western Cape [
22,
23].
Continuing ethnic disparities in access to income provide a possible explanation for these different profiles of AOD use, with Coloured persons being marginally better off and therefore potentially more able to afford AODs than Black African citizens [
19‐
21]. Yet differences in income do not account for our findings. Even after controlling for the potentially confounding effects of age income, education and employment status, ethnic differences in AOD use outcomes remain. It is possible that contextual (such as drug marketing practices [
28]) and cultural differences between Black African and Coloured communities may contribute to these unique profiles of AOD use, however this requires further investigation. Regardless of the reasons for these differences, our findings imply that AOD use interventions should be tailored to the distinct profiles of AOD use among Black African and Coloured women. Our findings suggest that AOD interventions for vulnerable Coloured women should focus on reducing heavy episodic drinking and providing treatment for methamphetamine use. While there are several drug treatment programs that address methamphetamine-related problems in the Western Cape, vulnerable women face more affordability and geographic access barriers to utilizing these services than men [
29]. The high prevalence of methamphetamine use and self-identified drug problems among Coloured women in our sample indicate an urgent need to address these barriers to treatment through introducing (where absent) and scaling up (where available) community-based AOD treatment services that are affordable and easily accessible for vulnerable Coloured women.
In contrast, our findings suggest that AOD interventions for vulnerable Black African women should consist mainly of low-intensity, brief interventions that focus on reducing cannabis use and educating women about the risks associated with methamphetamine and other drug use. As several studies have shown that frequent and regular use of cannabis is associated with increased risk of transition to other illicit drug use [
30,
31], providing Black African women with brief interventions focused on reducing cannabis use may not only help them reduce the negative consequences associated with their cannabis use, but may also prevent progression from cannabis to methamphetamine use.
However, this does not mean that AOD interventions focused on reducing methamphetamine use are not needed in Black African communities. Ensuring that Black African women have access to interventions for methamphetamine use is essential given that more than a third of Black African participants tested positive for the recent use of methamphetamine. This unexpected finding is in sharp contrast to earlier work which has consistently pointed to low rates of methamphetamine use among Black African populations in Cape Town [
22,
32,
33]. This sudden increase in the use of methamphetamine among Black African women points to the urgent need for AOD prevention interventions that address the underlying risk factors that predispose Black African women to initiate methamphetamine use as well as treatment interventions that address risk factors for the continued use of methamphetamine. These interventions, combined with other interventions that address environmental and structural risk factors for drug use [
34], may help curtail the further escalation of methamphetamine use within Black African communities.
Failure to provide and, where available, scale up AOD interventions for vulnerable Black African and Coloured women not only represents a missed opportunity to intervene with their AOD use but may have unintended negative consequences for efforts to curb the spread of HIV in the region. This study found that AOD-impaired sex is widespread among vulnerable AOD-using women, with close to 40% of our sample reporting that their last sexual encounter was not only AOD-impaired but also unprotected. Compared to Black African participants, Coloured participants had four-fold greater odds of reporting that their last sexual encounter was AOD-impaired and unprotected, even after adjusting for age, education, income and employment status. One explanation for this finding is that AOD use before or during sex reduces personal perceptions of risk for HIV thus leading to less condom use [
35]. Personal perceptions of risk for HIV might already be lower among Coloured women than among Black African women because of the lower prevalence of HIV in Coloured communities [
2,
17]. This explanation is supported by prior studies conducted in this region that identified a negative relationship between HIV risk perception and engagement in sex risk behaviors for women [
36]. Regardless of the reason for these findings, they clearly point to the urgent need for behavioral interventions that focus on reducing AOD use before or during sex and reducing other barriers to condom use among vulnerable women in Cape Town. While findings suggest that vulnerable women from both ethnic groups would benefit from AOD-related sex risk reduction interventions, the need seems particularly great among women from Coloured communities where AOD-impaired sex is prevalent and condom use low.
Third, our findings suggest that for AOD-related sex risk reduction interventions to be impactful, such interventions should target AOD use among vulnerable women as well as their main sexual partners. Close to two-thirds of our sample reported that their main sexual partner had either been drunk or had used drugs during the month preceding the study and almost one in two participants reported that their main sexual partner had been AOD-impaired during their last sexual encounter. This is cause for concern as evidence from earlier studies suggests that women with partners who use AODs have a poorer response to AOD interventions than women with partners who do not use AODs [
37]. In addition, the likelihood of implementing sex risk reduction strategies (such as consistent condom use) within relationships is diminished if one or both partners are AOD-impaired during sex [
38,
39]. Finally, as we found ethnic differences in partner-related AOD-impaired sex (with Coloured women having three-fold greater odds of reporting that their main partner was AOD-impaired at last sex relative to Black African women), the need for these proposed interventions seems most pressing among Coloured women and their main sexual partners.
Despite the important implications that these findings have for HIV prevention programming, these results should be considered in the light of some methodological limitations. First, this paper was based on the analysis of baseline data from a larger HIV and AOD risk reduction project. The strict inclusion and exclusion criteria of this study may have adversely impacted the ability to recruit a representative sample of Black African and Coloured South African women. Second, as the sample was recruited from poor communities within one region of the Cape Town metropole, the extent to which findings can be extrapolated to other parts of the province or country are unclear. Third, in this study women provided self-report data on their main sexual partner’s AOD use. These perceptions are open to several reporting biases and it is quite possible that social desirability and other processes may have affected the accuracy of the information provided. This last limitation highlights the need for future work among vulnerable women and their main sexual partners so that AOD use and related sexual risk behaviors that occur within the context of relationships can be further explored.
Conclusions
This paper provides evidence of ethnic differences in AOD use patterns and AOD-related sex risks for HIV among vulnerable women in Cape Town, South Africa. Findings suggest that Coloured women have more entrenched AOD problems, particularly related to the use of methamphetamine, and are more likely to report AOD-related sex risks than Black African women. Findings suggest that while vulnerable women from both ethnic groups would benefit from behavioral interventions to reduce AOD use and AOD-related sex risk behaviors, tailored interventions are needed that target the unique profiles of AOD use and AOD-related sex risks for HIV among Black African and Coloured women.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
BM was a co-investigator on the study and was responsible for planning, writing and reviewing all aspects of the manuscript. TLK conducted the statistical analyses with inputs from BM and WMW and assisted with writing the methods. FAB, KJ, TC and CP reviewed the draft manuscript and provided critical comments. WMW is the principal investigator for this project and takes responsibility for the integrity of the data and the accuracy of the data analysis. She is the senior author on this paper and provided inputs into every aspect of the paper. All authors read and approved the final draft.