Introduction
Young people aged 15–24 years accounted for 40% of all new HIV infections in sub-Saharan Africa in 2007, with the majority of those infections occurring in young women and girls [1]. In the southern African region the disproportionate rates of HIV infection between young men and young women are especially high. In some places in Botswana, for example, rates among girls between the ages of 15 and 19 years are estimated to be up to nine times those of boys [2]. In South Africa, studies by Pettifor et al. [3] have found that HIV prevalence among young women in the 15–24 year age group was approximately four times that of young men. For the southern African region as a whole, young women between the ages of 15 and 24 years are on average three to six times more likely to be infected with HIV than their male cohorts [4].
Biological factors associated with still-maturing vaginal mucosa that is exposed to a large inoculum of infected seminal fluid, deposited on a large surface area that may be susceptible to trauma during sexual activity, have been shown to put young women at comparatively higher risk of HIV acquisition than young men [5]. In addition to these biological factors there are social factors that contribute to the special vulnerability of young women in the region. Age-mixing in sexual relationships between older men and younger women has been offered as a probable explanation for the disproportionate rate of HIV between young women and young men. It has been argued that older men often have HIV infection rates higher than adolescent boys or young men, and that age-disparity between partners is likely to reduce the younger person's ability to negotiate safe sex successfully. A review by Luke [6] of more than 45 quantitative and qualitative studies from throughout sub-Saharan Africa revealed that relationships between young women and older male partners were common. Such asymmetries were found to be associated with unsafe sexual behaviour, low condom use and an increased risk of HIV infection. In southern Africa, the South African national household survey of 2005 found a high HIV prevalence of 29.5% among girls aged 15–19 years who had partners of 5 years or older than themselves [7], whereas a study by Gregson et al. [8] in rural Zimbabwe provided clear empirical evidence that young women's partnerships with older men accounted for the observed differences in epidemiological patterns of young men and women in that country. More recently, a study of over 8000 men in Botswana by Langeni [9] found that for every year's increase in the age difference between partners there was a 28% increase in the odds of having unprotected sex. Studies from southern Africa have tended to support findings from eastern Africa; the larger the age differences the greater the association with unsafe sexual practices and HIV infection [10–12].
Several factors have been identified within age-disparate relationships that increase the risk of sexually transmitted infections (STI) and HIV. For one thing risk perception is often very low. As Longfield et al. [13] found in Kenya, men often report a preference for young sexual partners, viewing them as more likely to be free from HIV infection. In South Africa young women often viewed older men in much the same way; as ‘safe’ partners because they appear to be less risk-taking, more stable and more responsible [14]. Young women have been found to be often more concerned about the risk of becoming pregnant or of being ‘found out’ in their relationships with older men, than of STI or HIV [15–17]. Throughout sub-Saharan Africa studies have revealed that young women's power to negotiate condom use is often compromised by age disparities and economic dependence. Young women have reported that they often cannot insist on safe sex practices, and doing so would jeopardize their economic goals in the relationship [10,12,13,18,19].
Popular perception has long held that in times of economic crisis young women enter into sexual relationships with older men, in which they have very little power to negotiate safe sex, in order to meet basic needs such as food, housing, and clothing [19,20]. Whereas ongoing sexual and socioeconomic inequalities are currently widely acknowledged to lie close to the roots of the HIV hyperepidemic in southern Africa [4], close-grained studies have revealed that poverty per se is too simplistic and inadequate an explanation for young women's exceptional vulnerability across the region. As Shelton et al. [21] and Gillespie and Greener [22] have found, even when African women are relatively well off many still continue to be at risk.
This paper reviews studies from southern Africa on age-disparate and intergenerational sex. As defined in the literature, age-disparate relationships generally refer to those in which the age gap between partners is 5 years or more. Intergenerational or cross-generation relationships usually refer to relationships with a 10-year or more age disparity between partners. For purposes of this review the term age-disparate sex is used to refer to young women's involvements with men of 5 years or more older than themselves, unless a study clearly refers to intergenerational partnerships. This paper draws upon a larger body of literature from eastern Africa. Eastern and southern Africa share many cultural similarities that derive from common traditional practices of polygynous marriage, cattle as customary bridewealth exchange, and predominantly patrilineal descent. Findings from studies of age-disparate relationships in both regions help to shed light on patterns in sexual dynamics between young women and older men that are probably not so dissimilar across the two regions. Work by Luke [6,12] in Kenya, for example, provides important insights into how HIV vulnerability is related to power differentials within relationships in that country. Luke [6,12] measured both age and economic asymmetries against risky sexual behaviour. From a sample of nearly 3000 Kenyan men, Luke [6] established that intergenerational relationships were relatively common and there was a significant and negative association between the age disparity and the likelihood of condom use. A similar association was found between the value of the gift transfer and the likelihood of safe sex; that is the larger the gift, the less likely safer sex would be practised [12]. The negative effect of larger transfers was, however, to some extent offset by what appeared to be the protective nature of higher economic status of men. Wealthier men tended to report more condom usage, but also tended to report a larger number of casual sexual partners. Luke [12] also found that as the economic disparity increased between partners, the likelihood of condom use diminished. The work of Luke [6,12] neatly demonstrates how the use of the popular term ‘sugar daddy’ is misleading and of limited scientific usefulness. Relatively poor men also play the role of sugar-daddy, with an estimated 15% of their monthly income spent on casual partnerships as opposed to a wealthy man's spending of 7% of income.
Knowledge to date
Studies of age-disparate relationships in southern Africa have tended to be qualitative in nature and focused on the motivations for young women's involvement or the challenges and difficulties faced by young women in these relationships. Few have attempted to assess HIV risks in relation to age asymmetries and safe-sex practices. Both rural and urban settings have been sites for studies of age-disparate relationships in the region.
Rural settings
Studies by Buseh et al. [23] (Swaziland), Weinrab [24], Tawfik [25] and Poulin [26] (Malawi), Gregson et al. [8] (Zimbabwe), Hallman [19] (South Africa), Karlyn [27] (Mozambique) and Wojciki [28] (southern Africa more generally) have established that in poor rural settings the lack of access to education, health services, employment and a weak economy, associated with poverty, often pushed women and girls into age-disparate sexual partnerships with potential economic benefits. Money obtained was used to help school girls to pay for education as well as to buy clothes and simple luxuries such as soaps, body lotions and snacks. In Zambia, Kambou et al. [18] found that simple gifts such as a pencil or a packet of peanuts were sometimes enough of an incentive for a girl to have sex with an older partner, a finding that also emerged from evidence for eastern Africa (i.e. Plummer et al. [29] and Wight et al. [30] for Tanzania and Cole [31] for Madagascar). Those studies revealed that pressure from parents to have a relationship with an older employed man was not uncommon, both as a means for getting money and household necessities, as well as to marry and bring in bridewealth.
In rural Zimbabwe, Gregson et al. [8] used mathematical modelling and qualitative data to obtain a better understanding of the high HIV prevalence in teenage girls. Through an examination of their sexual mixing patterns, Gregson et al. [8] found a substantial age difference between female and male sexual partners and postulated this difference as a major behavioural determinant of the more rapid rise in HIV prevalence among young women. Whereas young men had a relationship with women of a similar age or slightly younger, young women routinely formed partnerships with men 5–10 years older than themselves. Condom use in these latter relationships was reported to be rare. The authors argued that not only do large segments of successive cohorts of young women become infected through this route, but many further infections result when these women later marry and have children.
Young women in rural settings across southern Africa were found often to be anxious to acquire the socioeconomic security and status associated with marriage and subsequent motherhood. Casual relationships with older men were seen as a legitimate means for acquiring resources to increase a young woman's attractiveness to potential husbands. In this way older men played an important role in providing resources that helped young women to attract and maintain relationships with younger men with the hope that this might lead to marriage. This kind of ‘third-party’ patronage role of an older male partner was also noted in intergenerational relationships in urban settings [17,27,32,33]. Living in rural areas often meant that girls and young women were more directly subjected to traditional rules that guided relations between the generations and between men and women. Young women were often expected to be obedient, dutiful, and otherwise act in ways that demonstrated ‘respect’ towards older men. Although these cultural prescriptions were reported to make rural women especially vulnerable to coercive attempts by older men such as teachers to engage in sex [34,35], they have also been found to play an important role in undermining urban young women's ability to resist the advances of older men and to negotiate safer sex (Nkosana J, unpublished PhD thesis) [36].
Urban settings
Several studies have examined age-disparate relationships in urban and peri-urban settings across southern Africa. In Botswana, the dynamics of these relationships among Gaborone schoolgirls was closely examined by Nkosana (unpublished PhD thesis). Among a sample of 600 grade 11 and 12 urban schoolgirls who enjoyed the benefits of a relatively prosperous country with political stability, approximately 25% had been or were currently involved in relationships with older men. Material gain was found to be the main factor motivating approximately 80% of these girls to form intergenerational partnerships. Having fun was the second most cited reason for these relationships, with fun associated with glamour and the enjoyment of material goods and a lifestyle consistent with urban residence. For these girls, relationships with older men were not about meeting subsistence needs but rather about acquiring a ‘top up’ that helped to boost their status in the eyes of peers. A subsequent analysis of the determinants of these relationships by Nkosana and Rosenthal [17] revealed the importance of social connectedness and peer pressure in the lives of these urban young women. As one 17-year-old girl stated: ‘It's all about peer pressure, we compete with the type of cellphone we have, hair styles, type of vehicle our boyfriends drive, and the amount of money they give’ ([17], p. 184).
The authors later examined the factors that had a protective impact against young women's involvement with older men [33]. They found a combination of personal, social and institutional factors (i.e. strong sense of self-worth, knowledge of sexual risks, acceptance of socioeconomic circumstances, social support and religious values) helped schoolgirls to resist sexual advances from older men successfully. The authors recommended that ways be found to translate these protective factors into programmes to empower young women in that country.
Studies from South Africa have revealed similar motivations for young women's involvement in age-disparate relationships. Several studies have focused on the transactional element in normative sexual relationships that often prompted young women to seek employed partners. Hunter [37] drew attention to socioeconomic changes through time that have led to a decline in formal marriage and a rise in casual partnerships in which economic transfers have become a normative part. Wojicki [38] attempted to tease out the difference between commercial and transactional sex through a comparative study of sexual partnering in two urban communities, whereas Hallman [19] and Kaufman and Stavrou [39] focused on socioeconomic disadvantage as a major factor in unsafe sex because women could make more money if they agreed to condomless sex. Similar findings emerged from the study by Dunkle et al. [40] among women in Soweto, in which an attempt was made to discern the prevalence of transactional sex and its associations with HIV infection.
Mutual exploitation
Whereas the above studies contribute to our knowledge about the central importance of economic transfers in contemporary relationships, some of them did not specifically focus on age-disparate sex. Previous research by the current author in both a peri-urban and urban South African setting [14,32] examined the extent to which women exercise agency in their relationships with men in which material acquisition was a primary motivating factor. Attracting and maintaining a relationship with one or several older, employed men was considered to be an act of self-assertion, cleverness, and an important contribution to young women's self-perception as modern, sexually liberated women. Findings from those studies revealed that such relationships were often valued because they provided access to different kinds of capital that young women sought to acquire, including social, emotional, symbolic and financial. Media imagery of glamorous and prosperous lives was found to be an important influence in shaping the aspirations of many contemporary young women, and forming relationships with older men was viewed as useful in helping them to meet these growing aspirations.
In Mozambique, Bagnol and Chamo [41] and Karlyn [27] provided close examinations of how young women in intergenerational relationships constructed their identities and manipulated sexual and economic power imbalances. Those studies revealed that urban young women perceived themselves to be active decision-makers, and their identity as modern empowered women was largely predicted upon a strategy of extracting financial and material resources from older men through sex. Such relationships were said to be relatively widespread and largely accepted by society. The authors discussed how the goals and aspirations of young urban women in Mozambique are contextualized within changing social and economic conditions. Young women were seeking to forge new roles for themselves in societies in which sexual expectations were shifting. The Mozambique studies on age-disparate sex demonstrate that women are mindful of the factors constraining their future goals (i.e. lack of employment opportunities and access to education, corruption, low wages), and so they see relationships with older men as the easiest and most natural way to acquire the means to a better life. These findings closely mirror those from South Africa and Botswana.
From Swaziland, Jones [16] provided an analysis of sexual decision-making by youth in Mbabane. As part of a wider study on the impact of AIDS on children and their families, Jones [16] described how low family incomes and adolescent girls' perceived ‘need’ for luxury goods encouraged them to have relationships with older men. From these relationships girls sometimes obtained money for necessities such as food or school fees, but more frequently girls reported obtaining goods such as mobile phones, jewellery and fashion clothing from these liaisons. As one 16-year-old recounted to the author: ‘Parents, they don’t give their children money. These children look for people who can give them money and these people have sex with them and pay for it… the majority of us like cellphones and if someone who said that I must have sex with him will give me a cellphone, I will simply have the sex and get the phone ([16], p. 154).
Jones [16] argued that young women's sexual behaviours resonate with the traditional bridewealth system, as girls from an early age in Swaziland are enculturated with the view that their bodies are assets for transactions. Busch et al. [23] provided evidence of very similar patterns of intergenerational relationships in rural communities of Swaziland, whereas McLean [35] found that Swazi high-school girls placed a high value on relationships with older men (see Fig. 1).
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Fig. 1: Intergenerational relationships within the context of some common types of concurrent sexual partnerships.
Benefits outweighing risks of HIV
Studies on age-disparate relationships suggest that even when knowledge of HIV/AIDS is relatively high among the men and women involved, the benefits that derive from these relationships often outweigh the cost of contracting HIV. Some studies have identified young women's high awareness of high rates of AIDS illness and death in their immediate environment as a factor promoting their involvement in age-disparate liaisons, largely because they brought with them the possibility for enjoying life now while young, beautiful and still alive [14].
Although almost all studies highlight money and material acquisition as the most obvious and most easily measured benefit, other perceived benefits clearly play an important role in young women's decisions to engage in age-disparate sexual relationships. Some of the immediate benefits identified by young women include the opportunity for feeling loved or wanted, as well as the opportunity to gain social status among one's peers by demonstrating an ability to access coveted goods through relationships with men (Nkosana J, unpublished PhD thesis) [14,27].
Young women often placed a high prestige value on relationships with men who were well-known or well-respected public figures. To be seen alighting from a luxury automobile or dressed in expensive fashion clothing or possessing a valued commodity were identified as status-enhancing activities by young women throughout the region. From this social benefit came a personal benefit, the boosting of self-esteem and self-confidence that some studies have reported as especially important for young women [25,26,42]. Some women entered into these relationships with the hope of marriage, with older men perceived as more serious and better potential marriage partners than same-age partners [41]. For others such relationships were linked to a desire to avoid marriage and instead seek to become economically independent. In these cases relationships with older men were perceived primarily as a means to increase financial security, further education, secure better jobs, or otherwise assist in the achievement of longer-term personal aspirations and goals of social mobility [15,19,31,35,36]. Accumulating social capital that could be called upon to improve present or future prospects was an important benefit that women reportedly derived from partnerships with older men. Women identify potentially important opportunities that could come through sociosexual networking with older men such as the possibility of hearing about a job or meeting others who could help with the realization of future plans and dreams. It is in their capacity as people in positions to improve a young woman's circumstances and to assist with social mobility that older sexual partners across the region have acquired colloquial names such as ‘sponsors’ in Botswana [17], ‘investors’ in Tanzania and Mozambique [27,43] or ‘ministers’ in South Africa [14,44]. The popular term ‘three C girls’ is used in many of the region's urbanized communities to describe young women who sexually exploit men for cash, cars and cellphones.
Meeting physical and emotional needs are other benefits that young women associate with relationships with older men. Some young women claim that older men are better able to satisfy them sexually because they are more patient and tender [41]. The need for love, affection, and affirmation have been emphasized in some studies as important but often overlooked motivations for young women's involvement in age-disparate liaisons [15,16,41,45]. As one better-off young woman attending a tertiary institution in South Africa put it: ‘Older men are nicer than the young ones. They listen, they are patient and tender. You can see they appreciate you more. They want you to have nice things and go to nice places. Sometimes girls fall in love with them, but it's no use because they are married’ ([42], p. 9).
The findings of contradictory norms and values by young women in relation to age-disparate relationships also emerged from the southern African research. Whereas many young women hold positive perceptions and attitudes towards these relationships they are also, to some extent, simultaneously aware of dangers that include dependency and the common occurrence of unsafe sex that can result in pregnancy, STI and HIV (Nkosana J, unpublished PhD thesis) [27]. For these reasons young women often judged relationships with wide age disparities to be not good, with many claiming that they wish the benefits derived could be derived by other means. Similar negative views on intergenerational relationships were obtained from the four country sub-Saharan Africa study by Moore et al. [46] of adolescent sexual behaviour. For girls in that study, having an older partner was seen as an undertaking primarily motivated by a desire for financial gain, and were therefore viewed as akin to prostitution. Nonetheless relationships with older men on the whole represent opportunities for love, companionship, finding a husband or attracting a boyfriend, impressing peers, boosting self-esteem, acquiring social status, having fun and going places. Against these considerable benefits any perceived risk of HIV is often pushed aside in an effort to add meaning to often (but not always) difficult and uncertain lives and to create at least the illusion of romance.
Men's involvement
Few studies have explored age-disparate relationships from the perspective of the men involved, and there remains a need for such studies in the region. No doubt many men are less than eager to have their involvements with girls and young women exposed, and therefore are not so easily reached for research purposes. With masculine identity throughout southern Africa closely tied to a man's ability to attract and maintain sexual partners [47], studies of age-disparate sex often make reference to how these relationships play a role in boosting a man's self-esteem and social standing. Several studies have revealed that young women's awareness of men's need to demonstrate manhood and sexual prowess by being seen to have young girlfriends is sometimes used by women to justify their exploitation of older men [15,32,41,42]. The need for entertainment, variety and relief from domestic and workplace stress have been reported as some of the motivations for men's involvement in intergenerational sex [24,48,49]. The desire for ‘clean partners’, or young women who are perceived to be free of STI or HIV infection is reportedly a major reason for men choosing young women as sexual partners [7,13,41]. Whereas it remains difficult to measure the extent to which men seek girls and young women because they believe that sex with a virgin can provide a cure for STI and HIV, this myth appears to be widespread throughout southern Africa, and is often regarded by local people to be a significant factor in girls' and young women's vulnerability to HIV (Nkosana J, unpublished PhD thesis) [50]. Long-standing cultural allowances sometimes encourage intergenerational sex. Dube [51] reported that in some places in Botswana an ageing man is often considered to be entitled to seek a young woman for sexual rejuvenation or to ‘make his blood move again’. In some instances it is his ageing wife who is expected to be the one to find a young woman who is willing to ‘service’ her husband in this way. Anecdotal evidence would suggest that beliefs in the sexual rejuvenating powers of young women are widespread throughout the region.
Money or gift transfers are a dominant element in intergenerational relationships. Studies have indicated that men in these relationships often view their involvements with young women as primarily transactional, and are therefore not willing to use condoms when they have given their partners a valuable gift or service (Nkosana J, unpublished PhD thesis). The author argued that many older men in Botswana blamed young women for seducing them, and saw nothing wrong with using their socioeconomic power to entice attractive young women into sex.
Age-disparate sexual relationships are nested within a common system of sociosexual networking in southern Africa that includes the normative elements of multiple and concurrent partnering as well as the semiotics of sex–money transfers. Many older ethnographic accounts have described traditional communitarian values found in almost all African societies that prescribe for men with means to share their wealth in ways that are commensurate with their power and status [52]. As Swidler and Watkins [53] have argued, in all aspects of social life including relationships with women that include sex, men are subjected to cultural codes that confer upon them a moral obligation to share resources with others. In more traditional times a wealthy chief or headman who owned lots of cattle and land was naturally expected, indeed even pressurized, to take several wives. Polygyny has long served as a way to demonstrate wealth and status publicly, and bridewealth transfers have long served as a way to distribute wealth to others. With falling marriage rates throughout the region at present, informal multiple concurrent partnering and age-disparate transactional relationships are playing similar social roles.
Cultural roots
There is no evidence from either historic or ethnographic records that strong social taboos against age-disparate relationships ever existed in any part of southern Africa. As one older man in an intergenerational relationship in Botswana stated ‘In Tswana culture a woman is never considered to be too young’ (Nkosana J, unpublished PhD thesis, p. 188). Girls reaching puberty were traditionally subjected to various types of rituals largely aimed at preparing them for marriage. Girls were considered to be ready for courtship and marriage soon after attaining sexual maturity. A preferred husband was one who had wealth and one who was older than the girl and thus in a better position to assert authority in the home. Across the southern African region it is now still often the case that girls are encouraged to seek older men as husbands and are often cautioned against marrying a man of similar age, as this is believed to lead to marriage instability. The importance placed on fertility and having children, particularly boy children in patrilineal societies, is also a factor in the cultural acceptance of men's relationships with younger, presumably more fertile women [52]. Older accounts of courtship and marriage alert us to the idea that what we refer to now as age-disparate relationships as well as transactional sex and multiple concurrent partnerships, all have antecedents in older practices that have long played a part in defining the nature of social life and the particular values and norms associated with sexuality. Many culturally inscribed assumptions and expectations that once legitimized these practices still prevail at present, and continue to influence the meanings that people attach to contemporary sexual relations and the expectations that people have in relationships.
Age-disparate sex, which assumes a reciprocal/transactional element, is part of a system of interdependence that is maintained by two interlinked and long-enduring cultural prescriptions. One prescribes for men to redistribute wealth on a scale appropriate to their standing and to demonstrate love, commitment or appreciation for sex through material giving. The other prescribes for women to expect to receive a material compensation for sexual favours as a validation of their worth and as a sign of a partner's love, commitment or appreciation. For a woman to ‘do sex for free’ has meaning throughout the region as a signifier of lack of dignity and self-respect. Across socioeconomic strata young women are culturally conditioned to variable degrees to view their sexuality as a valuable resource and to view sex primarily as a male desire and need. A woman's dignity and sense of self-worth when ‘giving’ sex is tied to an implicit expectation that her giving will be reciprocated through a gift, money or service. A man who is best positioned to help young women meet various material needs and desires while simultaneously upholding sociomoral prescriptions for preserving her dignity in unmarried sexual relations would be an adult man with money. Taken together, these cultural prescriptions for sex are potent underlying factors in the HIV hyperepidemic of southern Africa.
Recommendations
In conclusion, with the image of transactional sex as a desperate expedient of impoverished young women helping to explain their involvement with older ‘sugar daddy’ partners, interventions have largely taken the approach of assuming that young women are drawn or even lured into vulnerable situations, if not directly coerced or manipulated. Whereas studies tell us that many young women are indeed pushed into unwanted liaisons with older men for survival reasons, research also tells us that many young women do not perceive themselves to be victims. Although young women are often powerless as regards safer sex negotiations in relationships with older men, they often have a high degree of control over partnership formation and choosing the number and types of partners with whom they become involved. Studies from the region tell us that many young women now perceive themselves to be in control of their relationships with older men by having the power to exploit their wealth under the aegis of a relationship.
Many changes have occurred and are currently occurring at all levels in societies throughout southern Africa. Traditional ideals, norms and values now co-exist and compete with ways of living and thinking that have undergone considerable modification over time. A confluence of old and new is finding expression in many aspects of life, including the particularities of contemporary courtship and sexual relationships. As economies expand so too are people's aspirations and expectations expanding. Young women are developing new needs and new desires consistent with the ideals of a modern lifestyle, sexual equality and relationships that simulate globalized images of glamour and romance. For many young women relationships with older men provide an easy and readily available way to meet a growing list of needs and wants that range from bread and school fees to designer handbags and access into elite social circles. These growing aspirations in societies in which gaps between rich and poor continue to widen and women have limited options for obtaining financial independence, coupled with cultural allowances for age-disparate relationships and the intertwining of sex and material giving, make young women exceptionally vulnerable to HIV.
Designing more effective policy and programmatic responses to young women's vulnerability in southern Africa will require a shift in the way we understand the problem. There is a need to look beyond the woman-as-victim paradigm and grapple with knowledge that emerges from studies such as those reviewed in this paper. The studies indicate the presence of an implicit transactional/reciprocal element as part of the sexual practices of unmarried men and women in the region, and although poor young women may be prompted to be involved with older employed men primarily to meet subsistence needs, better-off young women may be prompted to do likewise to meet other kinds of needs. Young women's involvements in age-disparate relationships need to be acknowledged in the context of, and not at the expense of, acknowledgement of the wider realities of women's lives in southern Africa, which include high levels of poverty and unemployment, growing wealth disparities, as well as high levels of sex-based violence. Better integration of programmes that address the multiple risks and vulnerabilities faced by women in the region is required for more effective HIV prevention.
Findings from this review suggest a number of opportunities for intervention. Whereas attempts at raising awareness about HIV risks in relation to intergenerational and transactional sex have been made in some countries through various communication campaigns, there remains an urgent need to rapidly and greatly increase the risk perception of young women and older men regarding involvement in age-disparate relationships. Accelerating awareness of risks should form part of more comprehensive policy and programming on girls and women that directly address the gender-based drivers of HIV in the region, including legislation that takes a zero tolerance approach to exploitation and violence against women and girls.
One-size-fits-all approaches to HIV prevention are inadequate for effectively addressing risks in age-disparate and intergenerational sex. A two-pronged approach that focuses on empowering women while working to change men's behaviour and attitudes is recommended. With financial dependence on men remaining a key factor in women's vulnerability to HIV generally and young women's susceptibility to involvement in intergenerational sex in particular, ensuring access to education remains a major route out of women's ongoing poverty and dependency. Programmes aimed at educating girls and empowering them for present and future financial independence could be linked and expanded. HIV prevention education should be more directly aimed at enabling young women to make healthier choices for realizing their right to sexual health. Creating open-ended learning opportunities in which girls are encouraged to analyse, discuss and form their own opinions are needed. Older peers who have successfully resisted engaging in age-disparate sex could play important roles in encouraging and mentoring young women to resist involvement in these relationships and other risky behaviours.
Throughout southern Africa the onus of responsibility for almost all things related to sex, reproduction, and contraception falls squarely on the shoulders of women. The need for men to become more active partners in these spheres of domestic life and in HIV prevention has been recognized for many years, yet remains a major and urgent need and challenge for the region. When addressing age-disparate relationships the onus should be placed on adult men to stop engaging in potentially exploitative relationships and to recognize that liaisons with young women represent an abuse of power and status. Such programmes should form part of a comprehensive campaign to raise risk awareness in multiple concurrent partnering and to encourage sexual partner limitation.
Greatly accelerating programmes aimed at cultivating positive peer norms and new culturally recognized markers of manhood among boys and men are required along with active campaigns on the role and participation of men in the protection and support of women and girls. At a community level, men who mirror desired behaviours and are willing to speak out against age-disparate relationships need to be identified, encouraged, mentored and supported to be role models for healthier sexual relationships. There remains a great dearth of local adult male champions of HIV prevention who are members of communities most at risk and who represent a masculinity that protects self and others from HIV. Creative ways need to be found to support such men to be maximally visible and vocal.
Finally, a community-driven decentralized approach to HIV prevention should underpin efforts aimed at addressing the vulnerability of both sexes. Increased and consistent collaboration between various actors and sectors with a cohesive message can be a powerful means through which understandings, values, norms and meanings associated with sexual behaviour are transformed in order to reduce the spread of HIV. Social networks have greater potential for encouraging changes in social norms and behaviours than individual approaches. A stronger grounding of responses in communities with the support of effective and committed leadership at all levels would help to promote the development of social sanctions against the practice of age-disparate sex and changes to how people perceive these relationships. Although supporting educational and community initiatives is only part of the solution to the exceptional vulnerability of young women to HIV infection in southern Africa, without a vision of a disease-free future that is achievable through their own individual efforts, it is not realistic to expect young women to forgo the many potential benefits that come from relationships with older men.
Acknowledgements
Publication of this article was funded by UNAIDS.
Conflicts of interest: None.
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