Transactional sex among young women in rural South Africa: socio-demographic factors, motivations and association with HIV infection

Background: ‘Transactional sex’, is generally defined as a sexual relationship in which money or material goods are exchanged for sex. As this may entail sex with older or multiple partners, it is likely to be associated with young women’s increased vulnerability to HIV or HSV-2 infection. Existing research illustrates that the motivations for young women’s engagement in transactional sex are complex. This PhD study explores the socio-demographic factors that motivate young women to engage in transactional sex and the relationship with HIV or HSV-2 infection. Methods: This thesis uses a combination of quantitative and qualitative methods. The quantitative analysis uses baseline data from HPTN 068, an ongoing randomised controlled trial (RCT) in rural Mpumalanga province, South Africa. Using both descriptive statistics and multivariable logistic regression analysis, I have quantitatively explored the relationship between household socio-economic status and socio-demographics, young women’s self- reported engagement in transactional sex, specific characteristics of her consumption patterns and the relationship between transactional sex and HIV and HSV-2 infection. I have also used qualitative methods to explore the strategies young women deploy for accessing money or gifts, the role that transactional sex plays in meeting these aspirations and the agency she exhibits in these encounters. Results: Multivariable analysis shows that young women from low socio-economic status households who engage in transactional sex have higher odds of consuming a combination of both high cost essential items (such as school fees, transport to school and food and groceries) and entertainment related items (such as beer/alcohol, movie tickets and birth control/condoms) compared to young women who do not engage in transactional sex. In addition, after adjusting for age and household level socio-demographics, young women who report engaging in transactional sex had significantly increased odds of being HIV seropositive. No association with HSV-2 infection was seen. The association between transactional sex and HIV does not appear to be mediated by any of the other dimensions of HIV risk that might ordinarily overlap with transactional sex. Qualitative findings suggest that belongingness, peer acceptance and status were all factors that motivated young women to aspire for items considered needs or wants. In-depth interviews also showed how young women have a deep-seated need to feel financially independent and have aspirations for lucrative job opportunities in the future, which they hope to achieve through education. But, given their current context where economic opportunities are circumscribed, young women use the money received from transactional sex to fill gaps in their needs and wants. Most of them appear to be in “love” with their boyfriends and have romantic notions of what they want from the relationship, but underlying it all very clearly is the need to be provided for by the man, in the form of money. Thus, the balance between the emotional and transactional elements in a relationship is blurred. Young women appear to express considerable agency when it comes to partner choice, but not necessarily after the choice of partner is made; as within the relationship they invariably submit to male authority within unequal gendered power structures. Discussion: Findings suggest that there is not a clear dichotomy between the survival sex of the passive victim and the consumption sex of the active sexual agent; rather, these distinctions are far more nuanced. Engagement in transactional sex seems to be driven by poverty and economic need, but also by aspirations within the context of a globalising emerging economy like South Africa. In addition, these findings also indicate the subtle position that transactional sex or sexual exchange occupies within a continuum of adolescent sexual relationships in South Africa where sexual exchange occurs within the context of loving peer relationships. This potentially weakens the negotiating or bargaining position of young women if they are receiving money or items, thus having implications on HIV prevention and programming.