Sexual behaviour of women in rural South Africa: a descriptive study

Sexual behaviour is the most important determinant of the burden of HIV and sexually transmitted infections (STI) in South Africa [1]. This country has generalized HIV and STI epidemics that rank among the highest in the world; HIV prevalence is estimated to be 17.8 % among women of reproductive age [2‐4]. These epidemics are largely driven by heterosexual contact but key and vulnerable populations should not be ignored [3, 5].

In recent years many strategies have been employed to reduce the burden of HIV and STIs in Africa including the distribution of free male and female condoms, financial incentives for abstinence programmes, roll-out of antiretroviral therapy (ART) and promotion of voluntary medical male circumcision. Also, the potential impact of mass treatment of STIs, antiretroviral pre-exposure prophylaxis, and topical microbicide use has been explored. However, efforts to modify sexual behaviour, one of the core determinants of these epidemics, have been relatively limited despite the acknowledged importance of a combination approach of behavioural change and biomedical interventions [6‐9]. Initiatives to modify sexual behaviour for prevention are important. For example, a review demonstrated that the majority of the countries with a reduction in HIV transmission were accompanied by changes in sexual behaviour [10]. A recent study from sub-Saharan Africa showed the importance of targeting the general sexually active population and not only HIV serodiscordant couples because of the large contribution of extra-couple transmission to new HIV infections [11].

Sexual behaviour of women varies across the globe and over time, including in Africa [4, 12]. Efforts to monitor the HIV epidemic are complicated by the geographical evolution of many sub-epidemics at provincial and district level, partly associated with differences in geographic characteristics [3, 13]. Important determinants of variation in sexual behaviour include setting (urban or rural), age, socio-economic level, ethnic group and HIV status [14]. A recent review of sexual behaviour of women in sub-Saharan Africa, excluding South Africa, showed that women with lowest education and those living in more rural environments were of younger age at sexual debut and had more pregnancies [14]. A study from Uganda showed significant differences in sexual behaviour of women living in rural compared to urban regions with rural women having more often a partner that is more than 10 years older, reporting less frequent condom use and to know their HIV status [15]. Studies from South Africa show differences in sexual behaviour (i.e. alcohol use, unprotected intercourse and concurrency) between ethnic groups [16, 17]. A recent study showed a higher point prevalence of concurrent sexual partnerships among the ethnic groups most affected by HIV in South Africa [18]. Finally, HIV-status may influence sexual behaviour towards higher or lower risk behaviour: a recent study showed a decline of unprotected sex after HIV-positive diagnosis and a further decline after awareness of HIV discordance, but other studies have shown an increase in risk behaviour associated with HIV-infection [10, 19‐21]. Information about sexual behaviour is warranted to inform the design of prevention messages and programmes as one size may not fit all. Information about specific groups is required to build cultural competence in healthcare and therewith different opportunities and entry points for prevention messaging. For example, messages for adolescent discussion groups (age) could be different from those at the HIV clinic (HIV status) and could vary by geographic region (different ethnic groups). In this study we describe sexual behaviour reported by women living in rural South Africa in relation to age, ethnicity and HIV status. Furthermore, associations with condom use are explored.

This study is one of the few providing insight into sexual behaviour of women in rural South Africa and the first to assess women in a region with predominantly people of Sotho and Shangaan ethnic origin. We show differences in sexual behaviour for different ages, ethnicity and by HIV-status. These differences together with the associations observed with condom use illustrate the complexity of sexual behaviour in this region. Also, they provide an entry point for further discussion towards the design of tailor-made prevention strategies for these different groups of women. The sample of women included in this evaluation is considered representative for ethnic composition, age and HIV status of women visiting PHC facilities in this area.

The relation between age and sexual behaviour is well documented and confirmed in this study. Younger women are known to engage in higher risk sexual behaviour which is reflected in our study by the higher number of concurrent sexual partners. In addition, potential lifestyle differences (e.g. more bar visits) were observed.

Recently, a study from Kenya showed considerable ethnic disparities in HIV prevalence arising from sexual behaviour [13]. The relevance of race (black, white, and coloured) as a determinant of sexual behaviour has been reported before, but information about ethnic groups in South Africa is limited [17, 18, 21]. A recent study presented characteristics of sexual behaviour by isiXhosa women but no data are available for women of Sotho and Shangaan origin [16, 17, 24, 25]. Sotho women were more likely to report concurrent sexual partners whereas intravaginal cleansing, vaginal scarring and knowledge of HIV-status of the steady partner were more frequent among Shangaan women. This may reflect a bias in recruitment although there was no specific selection and participants were representative of those visiting a primary healthcare facility on a random day. On the other hand, these differences may be an important observation to warrant further research which could, hypothetically, result in a design of prevention efforts to be implemented at the same facilities where our study population was recruited: For example, Sotho women could be targeted to promote safe sex in (concurrent) relationships whereas promoting safe sex to the woman’s steady sexual partner and safe vaginal practices should perhaps feature more dominantly in areas where the predominant ethnic group is Shangaan. Overall, knowledge of the partner’s HIV-status was low among women of both ethnic groups. Discussing safe sex and sexual practice may be taboo within relationships in this region and understanding the influence of cultural practices, social beliefs, financial dependency and local media is required to inform the design of intervention strategies [26‐29].

The association of HIV-infected status and sexual behaviour is reasonably well-documented, but information from rural Africa and rural South Africa is limited. Our study shows that HIV-infected women reported a higher lifetime number of sexual partners, were more likely to use a condom during last sexual act, and to have a known HIV-infected partner whereas HIV negative women were more likely to use hormonal contraceptives and practice fellatio. Having a circumcised partner was significantly more frequently reported by HIV-negative women. Most of these associations have been reported before [3, 12, 19, 30]. The lower frequency of practising fellatio by HIV-infected women has been reported once before [20]. This could relate to a difference in age as HIV-infected women were older and young women were more likely to engage in fellatio or a change, e.g. reduction, in sexual activity following a positive HIV-test. The findings in our study suggest an essential difference in sexual behaviour related to HIV-status, but the study design did not allow determining temporality of this relationship.

We determined factors associated with (non-)use of condoms to support the development of prevention tools [31]. Women reporting condom use during the last sex act were more likely to be single, employed, HIV-infected and have occasional sexual partners while non-users were more likely to be pregnant, engage in RAI and intravaginal cleansing, experience coercion and have a partner more than 10 years older. These factors are well known in African populations where condom use within the marriage is unusual and pregnancy frequently associated with lower uptake of condom use [19, 32]. While alcohol use before intercourse is a known factor of sexual risk behaviour, there was no difference between condom uptake between women using alcohol before intercourse or not [33, 34]. Men in age-disparate relationships, i.e. young woman with substantially older male partner, are known to use their age-related power to undermine young women’s preferences for safer sex [35]. Efforts aimed at reducing age mixing are complicated, but may decrease the risk of HIV and STIs among young women in a traditional setting such as ours [36]. In summary it appears that non-use of condoms is related to a more traditional lifestyle and such areas may be the first target of safe sex promotion and HIV/STI prevention campaigns.

This study has several limitations. First, this study design does not allow for assessment of temporality of the observed associations and the results should be interpreted with caution. Sexual behaviour is a complex entity and we can only provide some degree of insight. Most importantly, the groups compared in this analysis could provide insight into different target groups and entry points of prevention efforts. Second, we used self-reported age, HIV-status and ethnic group. We tried to limit the effect of self-report by using strict criteria for classification of HIV-status. Third, reporting and desirability bias may have occurred although we tried to create as safe as possible environment. This could play a role in particular when considering the positive association of condom use with HIV-positive status: women are reminded regularly when collecting antiretroviral therapy to use condoms. Selection bias may have occurred and extrapolation of information should be done cautiously as we only included women visiting PHC facilities. These women are of low socio-economic status, demonstrated by the high unemployment rate reported in our study compared to the average in this area, and cannot afford private healthcare. However, the study was conducted at a representative sample of PHC facilities in the district, which provide prominent locations to implement preventions campaigns.

More information about heterosexual sexual behaviour in Africa is warranted to determine the relevance and potential impact of efforts aimed at modifying sexual behaviour for HIV and STI prevention. In this regard, prevention efforts at a local level should take the population’s composition of age, ethnicity and HIV-status into account when designing a tailor-made package that combines biomedical approaches with behavioural modification efforts.

ART, antiretroviral therapy; HIV, Human Immunodeficiency Virus; PHC, primary healthcare; RAI, receptive anal intercourse; STI, sexually transmitted infection