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Epidemiology

What’s in a Name? A Mixed Method Study on How Young Women Who Sell Sex Characterize Male Partners and Their Use of Condoms

Busza, Joanna MSca; Hensen, Bernadette PhDb; Birdthistle, Isolde PhDc; Chabata, Sungai T. MScd; Hargreaves, James R. PhDa; Floyd, Sian MScc; Chiyaka, Tarisai MAd; Mushati, Phillis MScd; Cowan, Frances M. MBBSd,e

Author Information
JAIDS Journal of Acquired Immune Deficiency Syndromes: May 1, 2021 - Volume 87 - Issue 1 - p 652-662
doi: 10.1097/QAI.0000000000002623
  • Open

Abstract

INTRODUCTION

HIV incidence in Southern Africa remains concentrated among adolescent girls and young women aged 15–24 years.1 Young women who sell sex (YWSS) have a particularly high risk of acquiring HIV2,3 due to the high number of partners, difficulties negotiating condom use, poor access to services,4–7 and power imbalances within relationships.8–10 Exposure to sexual and physical violence is a further driver of HIV among this group.11

Increasingly, HIV prevention interventions for YWSS target “upstream” determinants of vulnerability, offering education subsidies, or cash transfers designed to lessen dependence on sexual relationships.12,13 The DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) Partnership provided a combined package of skills-building and entrepreneurial opportunities, social protection and sexual and reproductive health services in 10 sub-Saharan African countries.14–16 DREAMS also acknowledged that reducing HIV risk among YWSS requires engaging their male sexual partners, and thus collected data on male sexual partners of high-risk adolescent girls and young women to better target them with HIV services.

Existing research on the male partners of adolescent girls and women focuses on their age, educational attainment, number of partners, and partner concurrency.17 Evidence on HIV risk for women in age-disparate relationships is mixed,18 but power differentials common to sexual partnerships with male partners 10–15 years older can exacerbate girls' and young women's susceptibility to HIV.19,20 Qualitative studies exploring transactional sex find that young women identify multiple and distinct partner categories, from whom they receive a range of economic, material, social, and emotional support.5,21–23 Understanding how YWSS, including those self-identifying as sex workers, perceive and experience relationships with men has been less closely examined or used to inform programming.

We used mixed methods to characterize the male sexual partners of YWSS recruited to an evaluation of DREAMS in Zimbabwe.24 Drawing on qualitative data, we examined how YWSS describe, understand, and navigate different kinds of sexual relationships. We used these qualitative insights to interpret quantitative data across predefined partner typologies, exploring associations between how YWSS characterize their partners, their behaviors with these partners, and likelihood of engaging in condomless sex. The aim of this analysis was to better understand YWSS' sexual relationship dynamics vis-à-vis risk to help inform targeted HIV prevention interventions.

STUDY METHODS

Study Location and Population

In Zimbabwe, DREAMS worked in partnership with the Centre for Sexual Health and HIV/AIDS Research (CeSHHAR) to reach YWSS within the national Sisters with a Voice program for female sex workers. YWSS were offered tailored HIV prevention and treatment services and referred into the DREAMS network of organizations providing the DREAMS “core package” of social, educational, and economic interventions.24

Data were collected between April and July 2017 in 6 sites across Zimbabwe, 2 large cities where DREAMS was being implemented (anonymized as sites A and B), and 4 smaller towns without planned DREAMS activities (sites C, D, E, and F).24 As described elsewhere, sociogeographical mapping was conducted to identify where and how young women sell sex and to recruit 44 “seeds,” representative of the typology of YWSS, to initiate respondent-driven sampling.25 Mapping identified different typologies of YWSS, including street-based YWSS, university students who transact sex during school terms, and rural migrants who sell sex to men with disposable income.25

The 44 seed participants were given 2 coupons each to recruit women aged 18 to 24 years whom they knew and who sold sex to men, defined as “sex in exchange for money and/or material goods, and in the absence of the exchange, the sex would not happen.” Each new recruit was assessed for eligibility, and after completion of survey procedures, given 2 coupons to recruit a further 2 YWSS. This process continued over 6 waves, with wave 1 women recruiting the second wave of women, who in turn recruited a third wave, until the target sample size of 2400 YWSS was reached by the sixth wave.24

Qualitative Interviews

Qualitative data were collected from 19 seed participants. We intended to interview 20 women: 6 in each of the 2 DREAMS intervention cities (A and B) and 4 in 2 smaller comparison towns (C and F), selected for diversity in type and location of sexual exchange identified during mapping.25 We completed all planned interviews except 1 in intervention site A. Semistructured interviews explored experiences of initiating selling sex, current involvement in sexual exchange, relationships with different male sexual partners, health-related risk perceptions, and engagement with services. The topic guides were developed for the initial mapping exercise to identify different YWSS typologies and guide recruitment into the respondent-driven sampling (RDS) survey and subsequent cohort, and thus specifically examined YWSS' perceptions of their sexual relationships, focusing on those for financial or material gain. A female researcher conducted interviews in a local language (Shona or Ndebele), which lasted roughly 45–60 minutes and were transcribed and translated into English by research assistants for entry into NVivo software.

Thematic content analysis was conducted using a 2-stage process: first, each transcript was read and “case notes” written to summarize the respondent's relationship history and number/description of all current sexual partners. Based on the frequency of terms used to describe partners, we created 3 primary relationship nodes: “husband/permanent partner,” “boyfriend,” and “client” that we used to conduct “broad brush” coding of all interviews. Given the considerable overlap between these categories, particularly as women referred to the same individual using different terms, we next examined each of these 3 original nodes in detail, to identify patterns in characteristics, relationship dynamics, and behaviors for each partner type.

Behavioral Survey

Women enrolled into the DREAMS evaluation completed a questionnaire covering demographics, HIV service use, sexual behaviors, and history of selling sex, and whether they self-identified as a sex worker. YWSS were asked about their 3 most recent sexual partners, as follows: “How would you describe your relationship with [INITIALS] the last time you had sex?” Women could select: “husband,” “regular/steady partner/boyfriend,” “casual partner known to you before having sex,” “one-off partner not known to you before having sex,” “sex work client,” or could specify their own description. If women reported that last sex with the partner involved an exchange, they were asked whether they received money, school supplies, support with bills, groceries, or other items.

Using data on 3 most recent partners, we described total numbers, characteristics, and behaviors by 3 partner types: husband/regular partner, casual/one-off partner, or sex work client, as well as the number and percentage of partners with whom women reported any episode of condomless sex in the previous month. In regression analyses, the outcome of interest was condomless sex in the past month with a partner, and the unit of analysis was the partnership. Factors explored for their association with condomless sex were based on findings emerging from the qualitative analyses. As condomless sex in the previous month was ∼10–40% across partner types in descriptive analyses, the log (probability of reporting condomless sex) was the outcome variable in our regression analysis; age- and site-adjusted and adjusted risk ratios were estimated using a generalized linear regression model, assuming that the outcome followed a normal distribution, with robust standard errors to allow for departures from this assumption.26 Analyses were adjusted for women's age, level of education, marital status, self-identification as female sex worker (FSW), and site of recruitment. Data were weighted using the RDS-II estimator,27 namely by the inverse degree of number of YWSS each woman reported knowing and normalized these by site. All seeds were excluded from analysis. Analysis was conducted using Stata 14.0. RDS diagnostics, described elsewhere, suggested our sites were broadly representative of age, HIV prevalence, and identification as FSW in 5 sites.28

Findings from quantitative and qualitative data analysis were interpreted together to understand how YWSS perceived and categorized male sexual partners, identify whether and how well our prespecified measures related to narrative descriptions, and describe patterns of vulnerability and risk behavior within each type of partnership.

Ethics

Ethics approval was obtained from the Medical Research Council of Zimbabwe (Ref MRCZ/A/2085) and the London School of Hygiene & Tropical Medicine (Ref 11835). Written informed consent from participants was obtained before enrollment.

RESULTS

Partner Typology

During qualitative interviews, women referred to 3 partner categories, of which 2 corresponded to predefined variables used in our survey. Approximately half the interview respondents (9/19) referred to having a spouse or “permanent” partner at some time, defined by a history of setting up a shared home, having a child/children together, and/or traditional or legal marriage. At the other end of the spectrum, “clients” paid cash in direct exchange for sex, at the time of sex, and the relationship did not involve personal attachment.

The largest category, however, was “boyfriend,” covering numerous, diverse relationships that did not match the survey's use of “regular” or “casual” partner. For some YWSS, “boyfriend” implied emotional attachment and/or hopes for marriage. Others described how clients could become “boyfriends” through increasing frequency or amount of financial contributions. YWSS who did not self-identify as sex workers referred to clients as “boyfriends,” perhaps reluctant to adopt the language of sex work. Having 2–5 “boyfriends” was a common means of maximizing financial security. Often, one boyfriend was considered the most important emotionally and might provide regular support such as food and rent, instead of cash. YWSS were more likely to establish informal arrangements with boyfriends, who were expected to pay regular household expenses instead of paying money at the time of sex.

A further distinction was based on time, ie, husbands were referred to solely in the past, with initiation of selling sex after the end of the marital relationship. In the present, YWSS called partners “boyfriends.” “Permanent partner” referred to previous spouses or current relationships that they defined as “serious.” Age differences did not feature prominently in interviews.

Table 1 provides illustrative excerpts from interviews for the 3 partner categories.

TABLE 1. - Characterizations of Male Sexual Partners
Husband or permanent partner I then got pregnant with this child. So …in living together… I noticed that, aah! my husband was cheating, you see. I was faithful to my husband. He was now cheating me and did not buy food and I was pregnant. He only payed rentals and water bills and went away. He could take all the money he had given me and buy beer and come home empty handed. (age 23, completed “O” level, 1 child, DREAMS site B)

I was married when I was 16. … He was doing engineering course … He then finished the course and wanted to pay for lobola. I then said “alright its fine’. … I then stayed with my mother-in-law. He could visit weekends. He skipped some of the weekends and never came. He never sent money at month-end. At times he would sent $400 and that will be great, he was payed $800. He then transferred and said he was now working in town… He would come home, park his car, and take his computer inside then go out. He would come back home the next morning around 4 or 5. I could not take it, so I came back home … to my father's place, and that led me to develop a habit of going to the club [to sell sex]. (age 20, left school grade 8, no children, DREAMS site B)

My boyfriend is good because of the money he provides … even rent money. Almost every day he gives me money to buy food in the house such as bread and vegetables. Money to get my hair done and [buy] clothes. … I only have one permanent lover. (age 20, left school grade 10, 2 children, non-DREAMS site C)
Boyfriend I met this guy during a basketball match … He heard from other guys that I was selling sex … He then asked me if this was true and I explained to him how my mother passed away and my brother leaving, which led to my situation. He said he could help me with money monthly if I could quit the trade. He even said he was willing to give me money to go back to school. He actually thinks I stopped [selling sex] and does not know that I have not quit. … He treats me like a proper girlfriend. (age 18, left school grade 8, no children, non-DREAMS site C)

I was just walking to the shops and I met him, and he said he liked me, then I went home. On the next day he called me and said that I should come to his house and I went. So I was at the house and we slept together and then I came back here. … I went home and he then called me again saying “come and get this’. So I went to his house and he gave me 10 dollars. (age 22, current university student, no children, non-DREAMS site F)

The relationship with my boyfriend started off as short time. Those if he had money he would come for the night. Then he said may I provide you money for anything you need or money for rent or anything you are short of. … It is about making money. Right now there is no money, so if you base on one person that will not work. … have 2 boyfriends. (age 24, left school grade 10, 1 child, non-DREAMS site F)

Yes he is sort of a client but also my boyfriend.
How much does he pay you after sex?
Maybe $10.00 at times $15.00 when he is happy. At times he can give you $5.00 and tell you that he does not have money. (age 20, completed “O” level, no children, DREAMS site A)

I had a boyfriend and I had other clients. Not just one boyfriend, I had 2 boyfriends. So it happened that the one who got me pregnant knew about the other boyfriend that I had, so it was difficult for me, and the guy denied the pregnancy. I had to continue with my sex work in order to buy [supplies] for my daughter and raise money to take care of myself and help my mother out. (age 24, completed school, no children, DREAMS site A)
Client I already have a lot of my clients who are here. So most of them will call me then I will be gone for 2 minutes and we do our deals and then I come back home. … I meet all types, I do not want to lie. I like to meet up with old men, those are the ones that I like the most to have sex with. I do not like little boys because they do not give you money. They give you money that does not buy anything. But a grown man who has his wife will treat you well. He will give you your money when you are done having sex. (age 22, completed “O” level, no children, DREAMS site B)

We would just go in the streets to look for clients. We would go on the streets and look for clients and they would “catch” us. After that they would give us money. … $2.00 or $5.00 it depends on the day but you would see that at the end of the day in the morning you would have $10 or $20 depending.
How many clients were you getting per night?
3 or more (age 24, completed school, no children, DREAMS site A)

We just meet and deal and he goes away.
How many people do you sleep with per day?
Sometimes 6 or 7. Sometimes you meet people saying short time $2 and you cannot go for $2. … I charge $4 or $5. They give me my money first. … I do not do nights. Since I started sex work I have never liked to go and sleep with people. When I want to sleep I do not want anyone turning me. You cannot sleep, some people will really make you work for your money. (age not known, left school grade 10, 1 child, non-DREAMS site F)

Exposure to Violence

YWSS experienced sexual and physical violence across relationships, feeling most vulnerable when it occurred within a romantic relationship by a husband/permanent partner or “boyfriend” for whom they felt personal attachment. Three young women described how their spousal relationships started with sexual assault or rape.

A particularly violent case was a YWSS who was just 12 or 13 at the time of the rape. After the episode below, she stayed with her assailant until her second pregnancy with him at age 15. He then abandoned her, leading her to sell sex to support herself and her baby:

He started by touching me and I refused and kept refusing. And then he removed my underwear and continued touching me. The day he touched me I cried, he took my virginity. … He raped me because I never consented to it. …I stayed and he was bringing food and we were acting like husband and wife … I was not [having] my periods, I then got pregnant but I had a miscarriage. I had a miscarriage because he had hit me (Age 23, left school grade 5, 1 child, DREAMS Site B)

Another respondent described how her husband's increasing violence caused her to leave the relationship, after which she started selling sex.

He [husband] would do strange things and beat me up for no reason. … He would even injure me. … He would return from the bar and start beating me…. He would beat me up sober or drunk. … He would beat me up thoroughly. That is when I left him. (Age 24, left school grade 3, 2 children, non-DREAMS site C)

Although some YWSS started selling sex after leaving a violent relationship, others experienced violence as a consequence of selling sex when a boyfriend learned about other partners. Some YWSS hid the existence of competing boyfriends from each other to maintain secrecy.

This one is my boyfriend so l would not want him to know what I do. (Age 24, completed school, no children, DREAMS site A)

When a client texts me a message and I forget to delete the message. Obviously, the message will be talking about sex. … When he checks [my phone] and sees a message he always shouts … He says I will be sleeping with other guys when he is not here. I just lie and say it is my friend or something, just tell a small lie (Age 22, completed “O” level, 1 child, DREAMS site A)

Others did not hide their involvement in sex work from boyfriends but tried to avoid confronting them directly with its reality to avoid violence.

He might get jealous of my clients in the bar and then beat me. … Only when I have disrespected him, by talking to my clients and hooking up with them in his face in the bar. He does not like that. I will have to arrange with my client to wait for me outside the bar in his absence and then we go. He told me he does not like it and I do not do it in his face. (Age 19, left school grade 7, no children, non-DREAMS site C)

Violence from clients, on the other hand, was portrayed as an expected part of selling sex. Conflicts with clients occurred over cost of sex, condom use, or were seen to reflect a client's violent personality.

Violence [comes] from clients who demand their money after [receiving the sexual] service. To avoid noise [hassle] at times I give back the money and continue with my job. (Age 21, left school grade 7, 1 child, non-DREAMS site F)

They may even beat you up for no reason. Some clients are just like that by nature. … Like I said before in the bar if you bring a client home you might have misunderstandings and be beaten up. This is what usually happens. (Age 24, left school grade 3, 2 children, non-DREAMS site C)

Condomless Sex

YWSS reported that negotiating condoms with clients was possible, but depended on immediate economic needs.

But was there a time when you had to sleep with a client when they refused to use condoms?

Yahhh. … It was not often. It was when I saw that I was desperate and needed money I had to go to school. So if that client had money and did not want to use condoms, I had to risk because l knew l had to go to school. (Age 24, completed school, no children, DREAMS site A)

A few YWSS reported that they themselves disliked condoms. One described preferring the female condom, and another explained low condom use as her preference for condomless sex.

I do not like condoms

You do not like condoms, so you are not scared to get pregnant?

No, he withdraws before the sperms comes out

Oh he withdraws, what about sexual-related diseases?

Ummm they are there (laughs), I am scared but I do not like condoms. …with my boyfriend I just tell him that I do not want condoms and we do not wear [them], I do not know why…. I think it is because I trust my boyfriend a lot (Age 19, completed “O” level, no children, DREAMS site B)

Although women reported unplanned pregnancies and STIs, usually within established relationships, these were not considered as serious as HIV. As illustrated in the quote above, there was little motivation to avoid these outcomes through condom use with partners described as “boyfriends.”

Analyses of the Behavioral Survey

Through recruitment chains, 2387 women were recruited to the study; 20.9% (n = 448) were aged 18 years, 44.4% (n = 1060) had completed some secondary education, and 67.3% (n = 1637) self-identified as FSW. Most women were confident in discussing HIV testing and condom use with regular and/or new sexual partners (Table 2).

TABLE 2. - Characteristics and Behaviors of Women Recruited to the Study (N = 2387)
Number (Column %) RDS-Weighted %
Age at enrollment
 18 yrs 448 (18.8) 20.9
 19 yrs 371 (15.5) 15.8
 20 yrs 267 (11.2) 10.7
 21 yrs 291 (12.2) 11.3
 22 yrs 374 (15.7) 15.2
 23 yrs 471 (19.7) 19.6
 24 yrs 165 (6.9) 6.5
Marital status
 Single/never married 1397 (58.5) 57.5
 Married/cohabiting 49 (2.0) 2.3
 Divorced 918 (38.5) 39.3
 Widowed 23 (0.9) 0.9
Highest level of education attained
 No education/incomplete primary 171 (7.2) 8.7
 Complete primary education 220 (9.2) 10.0
 Form 1–3 (Secondary education) 1060 (44.4) 44.9
 Form 4–6 (Secondary education) 923 (38.7) 36.0
 College, cert, or degree 13 (0.5) 0.4
Self-identifies as FSW
 No 730 (30.8) 32.7
 Yes 1637 (69.2) 67.3
Age started selling sex
 10–14 94 (3.9) 4.0
 15–17 972 (40.8) 40.5
 18–19 721 (30.2) 29.9
 20–24 597 (25.0) 25.6
No to Number to match others
 <2 724 (30.4) 32.9
 2–3 967 (40.6) 39.8
 4–5 420 (17.6) 17.7
 6+ 273 (11.5) 9.7
Number partners sold sex to past month
 1–3 965 (40.7) 44.2
 4–9 662 (27.9) 26.2
 10+ 745 (31.4) 29.6
I am confident in my ability to discuss HIV testing with any sexual partner*
 Strongly agree 633 (26.5) 23.9
 Agree 1240 (52.0) 54.6
 Disagree 365 (15.3) 15.6
 Strongly disagree 148 (6.2) 6.0
I am confident I could ask a regular sexual partner to go for HIV testing
 Strongly agree 654 (27.5) 24.6
 Agree 1366 (57.4) 59.9
 Disagree 287 (12.1) 12.9
 Strongly disagree 72 (3.0) 2.6
I am confident I could ask a new partner their HIV status before sex
 Strongly agree 493 (20.7) 18.2
 Agree 1122 (47.1) 49.2
 Disagree 499 (20.9) 21.7
 Strongly disagree 270 (11.3) 10.8
I am confident in my ability to ask a new sexual partner to use a condom
 Strongly agree 695 (29.2) 26.2
 Agree 1518 (63.7) 66.1
 Disagree 132 (5.5) 6.0
 Strongly disagree 38 (1.6) 1.7
*One woman missing data.
Eight women missing data.
Three women missing data.
§Fifteen women missed data.

Most women (91.4%) reported on 3 recent partners, and 6929 partners were included in this analysis. Only 0.4% (n = 26) provided an alternative “other” partner label, namely “friend,” “friend with benefit,” and “ex-boyfriend/husband.” Overall, half of partners (47.9%, n = 3143) were defined as regular (including few reports of “husband”; 0.8%, n = 49), 26.1% (n = 1693) as casual, and 26.0% (n = 2093) as clients (Table 3). Among women who self-identified as FSW, a higher percentage of partners were defined as clients (31.8%; n = 1707/4839) compared with women not-identifying as FSW (13.4%; 369/2030).

TABLE 3. - Characteristics of and Behaviors With Male Sexual Partners by Type of Partner (N = 6929)
Characteristics and Behaviors by Type of Relationship Regular (N = 3143) Casual (N = 1693) Sex Work Client (N = 2093)
Number (Column %) RDS-Weighted % Number (Column %) RDS-Weighted % Number (Column %) RDS-Weighted %
Partner's age (y)
 Younger/same age 691 (22.0) 25.0 352 (20.8) 21.7 281 (13.4) 14.4
 Up to 5 yrs older 1235 (39.3) 39.7 471 (27.8) 29.3 622 (29.7) 29.4
 5–10 yrs older 883 (28.1) 24.6 480 (28.4) 27.7 717 (34.3) 32.6
 >10 yrs older 271 (8.6) 8.3 235 (13.9) 13.2 311 (14.9) 16.5
 UNK/refuse answer 63 (2.0) 2.3 155 (9.2) 8.1 162 (7.7) 7.1
Where she first met male sexual partner
 Bars/nightclub/entertainment venue 648 (20.6) 19.4 773 (45.8) 45.3 1089 (52.1) 51.8
 In the market place/street/shops 1452 (46.2) 45.8 596 (35.3) 36.5 709 (33.9) 34.7
 In a lodge/hotel/restaurant 69 (2.2) 2.1 35 (2.1) 1.9 63 (3.0) 2.8
 At school/college or church 363 (11.6) 12.5 64 (3.8) 3.6 40 (1.9) 2.3
 Friends/relatives house or her own/partners workplace 386 (12.3) 13.2 128 (7.6) 8.1 117 (5.6) 5.1
 Other—including social media, taxi, and in neighborhood 223 (7.1) 7.1 93 (5.5) 4.6 71 (3.4) 3.4
Whether first had sex in the past year (N = 6883)
 No 575 (18.5) 18.1 86 (5.1) 5.3 154 (7.4) 6.8
 Yes 2540 (81.5) 81.9 1601 (94.9) 94.7 1927 (92.6) 93.2
Whether first had sex in the past month (N = 6883)
 No 2573 (82.6) 81.2 661 (39.2) 42.2 1241 (59.6) 58.6
 Yes 542 (17.4) 18.8 1026 (60.8) 57.8 840 (40.4) 41.4
Whether last sex involved an exchange (N = 6916)
 No 590 (18.8) 20.0 108 (6.4) 6.3 61 (2.9) 2.9
 Yes 2543 (81.2) 80.0 1582 (93.6) 93.7 2032 (97.1) 97.1
Money (N = 6157)
 No 396 (15.6) 14.9 111 (7.0) 7.5 147 (7.2) 7.3
 Yes 2147 (84.4) 85.1 1471 (93.0) 92.5 1885 (92.8) 92.7
Support with rent/bills/school-related expenses (N = 6157)
 No 2405 (94.6) 94.5 1561 (98.7) 98.5 1999 (98.4) 98.3
 Yes 138 (5.4) 5.5 21 (1.3) 1.5 33 (1.6) 1.7
Phone/airtime (N = 6157)
 No 2405 (94.6) 94.9 1541 (97.4) 97.2 1972 (97.1) 96.9
 Yes 138 (5.4) 5.1 41 (2.6) 2.8 60 (2.9) 3.1
Clothes/shoes/accessories/cosmetics (N = 6157)
 No 2196 (86.4) 86.9 1483 (93.7) 93.5 1931 (95.0) 95.6
 Yes 347 (13.6) 13.1 99 (6.3) 6.5 101 (5.0) 4.4
Groceries/food (N = 6157)
 No 2100 (82.6) 82.7 1443 (91.2) 90.5 1816 (89.4) 89.2
 Yes 443 (17.4) 17.3 139 (8.8) 9.5 216 (10.6) 10.8
Other items (including alcohol, drugs, and supplies for children; N = 6157)
 No 2464 (96.8) 96.8 1548 (97.8) 98.2 2000 (98.4) 98.8
 Yes 81 (3.2) 3.3 35 (2.2) 1.8 32 (1.6) 1.2
Used a condom at last sex (N = 6193)
 No 805 (25.7) 26.5 116 (6.9) 7.4 127 (6.1) 6.4
 Yes 2328 (74.3) 73.5 1574 (93.1) 92.6 1963 (93.9) 93.6
Who brought condom if condom was used at last sex (N = 5861; 4 missing data)
 Me 1011 (43.5) 42.3 1028 (65.4) 66.6 1233 (62.8) 64.9
 Partner 1247 (53.6) 55.3 504 (32.0) 31.0 653 (33.3) 31.1
 We both brought a condom 68 (2.9) 2.3 41 (2.6) 2.4 76 (3.9) 4.0
Any condomless sex with partner in previous month (restricted to partners with whom she reports sex with in last month; N = 6206)
 No 1712 (63.5) 62.6 1397 (90.3) 89.9 1752 (89.3) 88.9
 Yes 984 (36.5) 37.4 151 (9.7) 10.1 210 (10.7) 11.1
Confident in negotiating condom use with partner (N = 6917)
 Strongly agree 812 (25.9) 22.7 711 (42.1) 36.2 730 (34.9) 31.7
 Agree 1766 (56.3) 58.5 870 (51.5) 57.6 1231 (58.8) 62.0
 Disagree 408 (13.0) 14.5 81 (4.8) 5.0 111 (5.3) 5.4
 Strongly disagree 149 (4.8) 4.3 27 (1.6) 1.2 21 (1.0) 1.0
Can avoid sex with partner if refuses condom use (N = 6911)
 Strongly agree 672 (21.5) 19.9 681 (40.3) 34.6 667 (31.9) 29.0
 Agree 1639 (52.3) 54.0 838 (49.6) 55.6 1209 (57.9) 60.9
 Disagree 560 (17.9) 19.3 120 (7.1) 7.5 153 (7.3) 7.7
 Strongly disagree 261 (8.3) 6.8 50 (3.0) 2.3 61 (2.9) 2.4
Drank alcohol before last sex (N = 6917)
 No 2664 (85.0) 86.3 1337 (79.1) 80.5 1533 (73.2) 76.8
 Yes 470 (15.0) 13.7 353 (20.9) 19.5 560 (26.8) 23.2
Whether MSP ever forced her to have sex (N = 6922)
 No 2808 (89.5) 89.0 1582 (93.6) 93.8 1962 (93.7) 93.7
 Yes 330 (10.5) 11.0 109 (6.4) 6.2 131 (6.3) 6.3
Knows partner's HIV status (N = 6922)
 No 1904 (60.7) 63.1 1519 (89.8) 90.3 1797 (85.9) 87.2
 Yes 1234 (39.3) 36.7 172 (10.2) 9.7 296 (14.1) 12.8
Partner's status known as HIV-positive 89 (7.2) 7.1 18 (10.4) 14.5 31 (10.4) 13.4

Regular partners were more likely to be ≤5 years older than women (39.7%, n = 1235) compared with casual partners (29.3%, n = 471) and clients (29.4%, n = 622; Table 3) and less likely to be new sex partners in the past month (regular: 18.8%, n = 542; casual: 57.8%, n = 1026; client: 41.4% n = 840). At last sex with 80.0% (n = 2543) of regular partners, women reported an exchange, compared with 93.7% (n = 1582) of casual partners and 97.1% (n = 2032) of clients. Money was most commonly received from all partners, followed by groceries/food. Women were less likely to agree/strongly agree that they could negotiate condom use with regular partners (81.2%, n = 2578) relative to casual partners (93.8%, n = 1581) and clients (93.7%, n = 1961). Regular partners more likely to have ever forced women to have sex (11.0%; n = 330) than casual partners (6.2%, n = 109) and clients (6.3%, n = 131).

Women reported at least one occurrence of condomless sex in the past month with 22.8% (n = 1345) of partners. The most commonly cited reason was that the partner did not want to use condoms (regular: 29.8%, n = 278; casual: 44.0%, n = 53; client: 47.7%, n = 88). With regular partners, the second most common reason was that women did not want to use a condom/that it was more enjoyable without (19.1% n = 169; casual: 11.7%, n = 18; client: 11.8%, n = 24). Other reasons included not having access to condoms (10.2% n = 89; casual: 26.2%, n = 34; client: 19.2%, n = 32), low perceived HIV risk (11.7% n = 124; casual: 3.0%, n = 2; client: 3.6%, n = 8), either/both being drunk (2.7%, n = 35, casual: 6.4%, n = 11, client: 4.3%, n = 11), and “other” (14.0%, n = 165), including “trust” and “mutual agreement.”

In regression analyses, women were less likely to report condomless sex with clients than regular partners (11.1% vs 37.4%, adjRR = 0.28, 95% CI 0.24 to 0.34; Table 4), with partners with whom last sex involved an exchange (20.0% vs 47.5%, adjRR = 0.61, 95% CI 0.55 to 0.69), and with partners they strongly disagreed they could negotiate condom use with (86.4% vs strongly agreed 11.6%; adjRR = 4.56, 95% CI 3.67 to 5.68). Women were more likely to report condomless sex with partners who ever forced them to have sex (37.5% vs 21.5%, adjRR = 1.34, 95% CI 1.14 to 1.57).

TABLE 4. - Levels of and Factors Associated With Condomless Sex in the Past Month With at Least One Recent Partner (N = 6206)
Number (column %) RDS-Adjusted % Number Reporting Condomless Sex With Any Partner RDS-Adjusted % Age of Woman and Site Adjusted Risk Ratio (RR) Adjusted RR* P-value
Overall 6206 1345 22.8
Partner's age (y)
 Younger/same age 1159 (18.7) 20.9 279 (24.1) 27.3 1.0 1.0
 Up to 5 yrs older 2045 (33.0) 33.5 479 (23.4) 23.8 0.87 (0.74, 1.01) 0.84 (0.72, 0.98) <0.001
 5–10 yrs older 1913 (30.8) 28.4 408 (21.3) 21.6 0.81 (0.69, 0.96) 0.79 (0.67, 0.93)
 >10 yrs older 750 (12.1) 12.1 156 (20.8) 21.1 0.77 (0.62, 0.96) 0.78 (0.63, 0.97)
 Unknown/refuse to answer 339 (5.5) 5.1 23 (6.8) 8.0 0.37 (0.22, 0.62) 0.35 (0.21, 0.61)
Type of relationship
 Husband/regular partner 2696 (43.4) 45.5 984 (36.5) 37.4 1.0 1.0 <0.001
 Casual partner 1548 (24.9) 26.8 151 (9.8) 10.1 0.28 (0.23, 0.34) 0.26 (0.21, 0.33)
 Client 1962 (31.6) 27.8 210 (10.7) 11.1 0.30 (0.25, 0.35) 0.28 (0.24, 0.34)
Whether partner ever forced her to have sex (N = 6205) <0.001
 No 5711 (92.0) 91.9 1167 (20.4) 21.5 1.0 1.0
 Yes 494 (8.0) 8.1 178 (36.0) 37.5 1.61 (1.35, 1.90) 1.34 (1.14, 1.57)
Whether last sex involved an exchange (N = 6203)
 No 591 (9.5) 10.2 262 (44.3) 47.5 1.0 1.0 <0.001
 Yes 5612 (90.5) 89.8 1082 (19.3) 20.0 0.45 (0.40, 0.52) 0.61 (0.55, 0.69)
Whether money was exchanged at last sex that involved an exchange (N = 5612)
 No 560 (10.0) 10.0 148 (26.4) 26.3 1.0 1.0 0.58
 Yes 5052 (90.0) 90.0 934 (18.5) 19.3 0.77 (0.64, 0.93) 0.94 (0.77, 1.16)
Confident in negotiating condom use with partner (N = 6199)§
 Strongly agree 2093 (33.8) 30.1 213 (10.2) 11.6 1.0 1.0 <0.001
 Agree 3411 (55.0) 58.1 569 (16.7) 16.1 1.39 (1.15, 1.68) 1.19 (0.98, 1.45)
 Disagree 509 (8.2) 9.0 403 (79.2) 82.8 6.92 (5.82, 8.23) 4.47 (3.59, 5.57)
 Strongly disagree 186 (3.0) 2.8 155 (83.3) 86.4 7.30 (6.14, 8.69) 4.56 (3.67, 5.68)
*N = 6150 as 20 women missing data on whether they self-identified as FSW; all variables adjusted for partner's age, woman's age, marital status, educational attainment, and whether she identified as FSW
Additionally adjusted for type.
Additionally adjusted for partner type and forced sex.
§Additionally adjusted for partner type, forced sex, and whether last sex involved an exchange.

DISCUSSION

In this mixed-methods analysis, we found consistencies and divergence in how YWSS characterized male partners in semistructured interviews and a behavioral survey. Our qualitative data suggest that although survey categories of “husband” and “client” reflected YWSS' definitions fairly well, the prespecified labels “regular partner/boyfriend” and “casual partner” did not. These categories seemed subsumed within wider use of the term “boyfriend,” referring to relationships along a continuum rather than a specific “type.” “Boyfriend” could signify close emotional attachment, a former client transitioning from direct exchange to longer-term financial support, or a short-term client when used by YWSS who did not consider themselves sex workers. Survey respondents might allocate “boyfriends” across categories in unpredictable ways, making understanding risk across relationships challenging to determine or usefully apply to an intervention design.

Nonetheless, survey and interview findings reinforce that condomless sex is more common with longer term, more “regular” partners, as found elsewhere.29–31 YWSS reported the highest condomless sex at last sex and in the past month with “regular” partners. “Regular” partners were younger than casual partners and clients, being more similar in age to the young women themselves. Almost all these relationships involved material exchange, including money and assistance with rent, groceries, and other household expenses likely to be longer-term support. YWSS might value these contributions more highly than cash if they are more reliable or signify greater personal involvement in daily life, thus catalyzing a partner's transition from “client” to “boyfriend.” Increasing financial reliance on a boyfriend might be one reason YWSS report lowest perceived condom negotiation confidence with “regular” partners. In South Africa, a nuanced account of men's HIV risk profiles revealed 2 groups of moderate-to-high risk younger men who engaged in transactional sex but had limited access to available HIV services.32 These male partners may be subsumed within the “regular” partners described by the women in our study. Critical to the HIV response is developing strategies to reach these “regular” partners with HIV prevention and care services.

Women were more likely to report experiences of IPV for “regular” partners, which was nearly double that reported for “casual” or “client” partnerships. As highlighted in our qualitative data, selling sex could be a consequence and a determinant of IPV. Experience of violence led to some YWSS initiating sex work as an alternative to dependence on the violent partner, yet selling sex could also exacerbate violence because of partners' jealousy or feeling disrespected. Exposure to IPV is known to be a risk factor for HIV, independently and because of its association with alcohol use,33–36 and DREAMS' core package targeted IPV as a structural driver of HIV.16 To minimize risk of IPV among YWSS, prevention programs need to understand the drivers of IPV, such as poverty and interpersonal communication, with a focus on partners classified by women as “regular,” to deliver effective intervention strategies.37

We found women's own dislike of condoms negatively affected use with nonclient partners, suggesting factors other than unequal power dynamics determine HIV prevention practices. YWSS reported their own reluctance as the second most common reason for not using a condom in the past month with a “regular” partner, suggesting in interviews that they associated condoms and HIV risk with clients more than with boyfriends, reducing motivation to use condoms with the latter. This highlights the need for greater attention to YWSS' risk of unwanted pregnancy and other STIs, both of which were discussed in interviews but did not seem to motivate YWSS to use condoms. The sole focus on HIV and neglect of other sexual and reproductive health outcomes for female sex workers has attracted previous criticism.38,39 It also suggests that PrEP could be better promoted as a means to increase pleasure in sex with regular partners in addition to offering protection where condoms are difficult to negotiate.40,41

Overall, this study suggests that the partner labels commonly used on behavioral surveys remain a useful indicator of partnerships that likely place women at higher HIV risk, but remain blunt tools. Although YWSS had mostly clear delineations for “husband/spouse” and “client” on either side of the emotional continuum, they applied the term “boyfriend” to a very diverse range of relationships that are unlikely to be captured through “regular” or “casual” categories. This suggests the need for an extensive and in-depth qualitative inquiry to understand local perceptions and behaviors, and how these map on to the risk of HIV and other outcomes before selection of targeted behavioral change messages.

Our analysis is subject to limitations. Our quantitative analysis excluded seed participants, yet our qualitative analysis focused solely on seed participants. Seed participants, however, represented the typology of YWSS in study sites so we thus consider our qualitative findings likely to reflect YWSS relationship dynamics in this context. Self-reported data on condomless sex and violence are subject to bias and likely to be underreported. Our finding that confidence in condom negotiation was associated with fewer occurrences of condomless sex may be due to reverse causality. The women in our study reported a high number of partners in the past month, yet our quantitative analysis is limited to characteristics of and behaviors with their 3 most recent partners, making our findings potentially less generalizable to all partners.

CONCLUSION

Among adolescent girls and young women, YWSS are at a disproportionately high risk of HIV. Our mixed-methods analysis found that partners defined as “regular” are diverse but often characterized by stronger emotional ties and an increased risk of violence and condomless sex than other partner types. For YWSS in Zimbabwe, the most salient category of male partner was “boyfriend,” which subsumed a wide range of experiences, including sex work clients for those YWSS who did not self-identify as FSW. This complexity adds to the challenges of appropriately targeting messaging and programs to YWSS. To reduce HIV risk among YWSS, prevention programs need to move beyond relying on the limitations of partner labels and focus on improving women's access to multiple HIV prevention options, including integrating IPV services within broader sexual and reproductive health services. Programs need to recognize that young women's needs change over time, within relationships and between partners, and provide services that are flexible to these changing needs.

J.B. and B.H. jointly conceived and drafted the paper and led qualitative and quantitative data analysis, respectively. I.B., J.R.H., and S.F. led study design for the DREAMS evaluation. S.F. and S.T.C. contributed to quantitative data analysis and commented on previous drafts. T.C. and P.M. led qualitative data collection. F.M.C. was the PI for the DREAMS evaluation in Zimbabwe and helped revise the paper. All authors have read and approved the manuscript.

ACKNOWLEDGMENTS

The authors thank the women who participated in the study and the RDS survey team.

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Keywords:

young women; male partners; mixed methods; condoms; Zimbabwe

Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.