SOUTH AFRICA HAS THE highest number of estimated HIV-positive individuals in the world, ranging between 4.9 and 6.1 million.1 In 1999 the prevalence among pregnant women, a proxy for the prevalence trends in the sexually active population in generalized HIV epidemics, was 22.4% [95% confidence interval (CI), 21.3%–23.6%] and by 2005 it further increased to 30.2% (95% CI, 29.1%–31.2%).2,3 By 2006 HIV prevalence has stabilized and demonstrated a slight decline to 29.1% (95% CI, 28.3%–29.9%). HIV prevalence among young pregnant women has stabilized at high levels and shows some decreases between 2004 and 2006: from 16.1% (95% CI, 14.7%–17.5%) to 13.7% (12.8%–14.6%) among under 20-year olds and from 30.8% (95% CI, 29.3%–32.3%) to 28% (95% CI, 26.9%–29.1%) among 20- to 24-year olds.3 The slight declines followed stability in prevalence between 1999 and 2005 among under 20-year olds, and between 2000 and 2005 among 20- to 24-year olds. This was in contrast to an increase in all other age groups during those years (Fig. 1).2–4
The reasons for the stabilization of HIV prevalence are yet to be determined, though a number of studies have shown important early factors,5 changes in sexual behavior of South Africans,6 individual factors associated with being infected with HIV among young South Africans aged 15 to 24,7 and increases in condom use among young South African women.8,9
The extent to which South African youth have modified HIV-related risk behaviors before and during HIV prevalence stabilization can be compared to changes in sexual behaviors in other countries, for example to Ugandan youth before and during the decline in their prevalence. Uganda is one of the few large-scale success stories in HIV prevention.10–12 HIV prevalence increased rapidly until 1989. Uganda was ranked seventh among the world’s most HIV/AIDS infected nations at the beginning of the 1990s, with 1.3 million people living with HIV.13–15 In 1990 and 1991, there was relative stability in the number of infected people. This was followed by a 54% decline between 1991 and 1998 with a 75% decline among 15- to 19-year olds and 60% among 20- to 24-year olds. Substantial reductions have also been seen in other age groups linking youth and adult prevention.10,16,17 The decline in HIV prevalence is the result of behavioral change rather than mortality, fertility, migration, or possible biases in the HIV surveillance systems.10,17,18 In both South Africa and Uganda, the epidemic is prevalent among the general population rather than being limited to certain risk groups. South Africa seems to have a wider age distribution of high HIV prevalence into older age groups, with similar high HIV prevalence among youth during the HIV stabilization in both countries (Fig. 2). However, HIV prevalence in Uganda declined over a 5-year period to as low as 5.2% among 15- to 19-year-old pregnant women and 10.6% among 20- to 24-year olds,12 less than half the HIV prevalence among South African youth in 2006.
In this article, we investigate whether the stability in HIV prevalence among South African youth, defined here as 15- to 24-years old, could be explained through standard indicators of behavioral change. Four sexual behaviors are compared with those of their Ugandan counterparts to test this hypothesis, before and during HIV prevalence stabilization and decrease, respectively. Second, we attempt to explain what other behavior factors may explain the trends, which may shed light on why the Southern African region with apparently moderate risk behaviors has such severe epidemics. Temporal analysis of sexual behaviors of young South African women is further applied to understand any trends in risk behaviors related to HIV. Finally, the article concludes with several practical steps for HIV prevention to tackle the epidemic.
Data and Methodology
Seven knowledge, attitudes, behavior, and practice surveys (KABP surveys) were used to compare 4 sexual behaviors of South African 15- to 24-year olds, with those of their Ugandan counterparts.
Four KABP surveys were used to analyze the sexual behavior of South African youth. The first is the 1998 South Africa Demographic Health Survey (1998), a nationally representative, 2-stage sample in which South Africa’s 9 provinces were stratified into urban and nonurban groups. The survey was conducted on 11,735 15- to 49-year-old South African women. Its main limitation was the absence of male respondents.19 The second survey is the 2002 Human Sciences Research Council survey (2002 SAHSRC), in which 9963 males and females aged 2 and above were surveyed (though when under the age of 12, a parent/guardian was asked to respond). The sample was designed to report the results at a provincial level by geographic location (urban formal, urban informal, rural formal, and tribal areas) and by race.20 The third survey was the 2005 HSRC survey (2005 SAHSRC), which followed similar sampling methods to its predecessor. The survey included 23,275 respondents.21 The last survey for mapping South African youth behaviors was the 2003 loveLife survey (2003 SALL) a nationally representative household survey of 11,904 15- to 24-year olds. The sample design employed a 3-stage disproportionate, stratified sample of 15- to 24-year olds from the 9 provinces of South Africa. The final sample was weighted for gender, age, race, province, and geography type, to be representative of 15- to 24-year olds in South Africa.22
The 3 remaining KABP surveys were carried out on Ugandan youth. The nationwide 1989 Uganda Survey was conducted on 15- to 60-year olds in Uganda by Makerere University, Kampala, in 1989. The second survey is the 1995 Ugandan DHS, carried out between March and August 1995 among Ugandan males aged 15 to 54 and females aged 15 to 49. This is a nationwide survey with a 2-stage sample.23 The third was the 1995 Ugandan World Health Organization survey (1995 Ugandan WHO survey) conducted in 1995 on Ugandan 15- to 49-year olds. The results from the 2 surveys are presented in the relevant figures. Unless there are significant differences in the analyzed parameters, only one is reported in the text.
Four parameters representing the sexual behavior of youth have been extracted from the 7 surveys. The first 2 included the percentage who are sexually inexperienced (also known as primary abstinence), i.e., those who never had sexual intercourse, and the percentage of those engaged in secondary abstinence, i.e., those who did not have sex in the last 12 months. The third risk behavior to be analyzed was condom use during last intercourse, or if absent as in the 1989 Uganda survey, condom use at the last 5 instances of intercourse. In all these three behaviors, the higher the proportion of those engaging in each behavior, the lower the risk of HIV infection.10,24,25 The last sexual behavior was the percentage of those with more than one sexual partner in the last 12 months, extracted from all surveys except the 1995 Uganda DHS. This behavior is directly correlated with the risk of being infected with HIV.10
The sample obtained from each KABP survey is shown in Table 1. Analysis was conducted on the raw data of all but the 2002 SAHSRC, 2005 SAHSRC, and 2003 SALL surveys. Figures from the 3 latter surveys were taken from publicly available reports.20–22 The remaining four surveys were analyzed in SPSS 11.5 (LEAD Technologies Inc.), applying a weight where this was supplied with the survey, i.e., 1995 Ugandan DHS and 1998 South Africa Demographic Health Survey. Unless mentioned otherwise, in all the results the denominator was the entire youth population. A 95% CI has been calculated for each result using the standard error of a percentage estimate.26
In addition to the 4 behavioral parameters comparable across the above surveys, we examined consistent use of condoms using the 2003 SALL and a study conducted among secondary-school students aged 15 to 21 (n = 1,113) in KwaZulu-Natal province.27 Finally, we studied age mixing in South Africa through examination of age differences between sexual partners and analysis of South African female-male HIV prevalence ratios by age groups using the 2002 SAHSRC and 2003 SALL surveys.
The results show significant risk factors in South African youth, related to age and sexual patterns which are not apparent from standard behavior indicators. After testing the hypothesis, the analysis does not show significantly higher risk behaviors according to standard behavior indicators in South Africa compared with Uganda, before or after HIV prevalence declines. First, the sexual behaviors as reflected in the 1998 South Africa survey prestabilization are not apparently riskier according to standard behavior indicators, than those reflected in the 1989 Uganda survey, predecline (Fig. 3). More than one-third of young South African females [34% (95% CI, 32.5%–35.4%)] reported never having sex, compared with 14.7% (95% CI, 11.8%–17.7%) among Ugandan young females in 1989, and only 3.1% (95% CI 2.6%–3.7%) had more than one sexual partner, compared with 15.1% (95% CI, 12.1%–18.1%) in Uganda in 1989. In addition, a lower proportion of young South African females prestabilization practiced high-risk behaviors compared with their Ugandan females during the decline in HIV prevalence. Among 1995 Ugandan females, during the decline, 22.5% (95% CI, 20.4%–24.7%) were sexually inexperienced and 7.3% (95% CI, 6%–8.7%) had more than one sexual partner in the last 12 months, reflecting riskier sexual behavior than their 1998 South African counterparts. Only in secondary abstinence did young South African females in 1998 demonstrate higher risk [7.4% (95% CI, 6.6%–8.3%) compared with 10.4% (95% CI 8.8%–12%) among their 1995 Ugandan counterparts].
Secondly, young South African females did not practice riskier behaviors during the stabilization in HIV prevalence compared with their Ugandan counterparts of 1995 (during the decline), yet their HIV prevalence was more than twice as high. A higher proportion of young South African females in 2002, 2003, and 2005, during stabilization, practiced 2 low-risk behaviors compared with their 1995 Ugandan counterparts: condom use (Fig. 5) and primary abstinence (Fig. 3). The proportion of those sexually inexperienced among 2002, 2003, and 2005 young South African females was 42.1% (95% CI, 39.3%–44.9%), 35.1% (95% CI, 33.8%–36.3%), and 37.7% (95% CI, 36%–39.4%), respectively, higher than the 22.5% (95% CI, 20.4%–24.7%) in 1995 young Ugandan females. There were no significant differences in secondary abstinence between the 2002 and 2003 South Africa surveys and 1995 Uganda surveys. Secondary abstinence among 2005 young South African females was significantly higher than the equivalent in the 1995 Uganda DHS survey [12.5% (95% CI 11.3%–13.6%) and 8.9% (95% CI 7.9%–9.9%), respectively], but not different from the reported figure in the 1995 Uganda WHO survey [10.4% (95% CI 8.8%–12%)]. The data regarding the proportion with more than 1 sexual partner in the last 12 months is inconclusive as there was a significant difference only between the 2002 and 2005 SAHSRC surveys and the 1995 Ugandan WHO survey, but not between the latter and the 2003 SALL survey.
Similar to their female counterparts, 2005 young South African males did not practice riskier sex compared with 1995 Ugandan 15- to 24-year-old males according to standard behavioral indicators (Fig. 4). Only 11.3% (95% CI, 10%–12.6%) had more than one partner and another 46.1% (95% CI, 44.1%–48.1%) were sexually inexperienced compared with 17.4% (95% CI, 14.9%–19.9%) and 33.3% (95% CI, 30.2%–36.4%), respectively, in Uganda in 1995, during the decline. The 2003 SALL survey does show potentially significant risk behavior among men, for example 21.7% (95% CI 20.6%–22.9%) with more than one partner, yet in the 2002 SAHSRC survey the figure is much lower, 10.4% (95% CI, 8.6%–12.2%). Identifying trends in sexual behaviors of young South African males before the stabilization is hard because of the lack of robust surveys before 2002, and the data shows significant differences between the 2002 and 2003 South African surveys. Further investigation of male behaviors, which are critical to behavior trends, is required building on the 2005 South African survey.
In addition, there is evidence of sexual behavior change in South Africa, particularly focused on condom use. One parameter in which both African males and females consistently reported safer sex was condom use at last intercourse in the last 12 months, as shown in Figure 5. Of particular importance is the substantial increase in the proportion of sexually active young females reporting condom use at last intercourse with regular partners, from 14.2% (95% CI, 12.8%–15.6%) to 48.2% (95% CI, 46.4%–50%) between 1998 and 2003 (Fig. 6). A similar trend of increase in condom use with regular partners was shown in the 2002 SAHSRC survey. The percentage of 15- to 24-year olds with one current partner reporting condom use at last intercourse was more than double compared with 25- to 49-year olds with one current partner (both men and women) (51.1% compared with 23.3%).20 Importantly, Figure 6 further shows that the practice of sex with a casual partner had declined between 1998 and 2003.
However, the results show significant risk beyond standard indicators. First, despite the increase in condom use, the evidence suggests condoms are not used routinely and consistently. Consistent condom use among men and women was 19.7% (95% CI, 18.7%–20.8%) and 16.6% (95% CI, 15.7%–17.6%), respectively, according to the 2003 SALL survey. These figures are substantially less than the proportion reporting condom use at last intercourse [30.1% (95% CI, 28.9%–31.3%) and 28.3% (95% CI, 27.2%–29.4%)] among men and women, respectively.22 In another study conducted among secondary-school students aged 15- to 21-year olds (n = 1113) in rural and urban areas in KwaZulu-Natal province, less than half (41.8%) of the sexually active in the last 6 months who used condoms reported protecting themselves every time.27 There is a large difference between the measure of condom use at last sex and consistent condom use.
Second, the epidemiologic and behavioral data further suggests that age mixing is a significant source of infections among South African youth. HIV prevalence among females is higher compared with HIV prevalence among males in the same age group, with a female-male HIV prevalence ratio of 1.8 among 15- to 19-year olds and 2.1 among 20- to 24-year olds in 2002,20 and 2.9 and 3.2, respectively, in 2003.22 Corresponding to it is the higher HIV prevalence of males in a given age group compared with females in a younger age group. According to the 2002 SAHSRC survey, the HIV prevalence of male 20- to 24-year olds was 8%, slightly higher than HIV prevalence among female 15- to 19-year olds (7%). The HIV prevalence of men 25- to 29-year olds was 22%, higher than the 17% prevalence among women 20- to 24-year olds.20 Because the majority of women reported only one sexual partner in the last 12 months (Fig. 3), which on average are 4-years older,22 it follows that many were infected by men from older age groups. Importantly, the 2005 SAHSRC survey found HIV prevalence to be higher among men who have sex with women 5-years younger than themselves, than if their partner is within a 5-year-age range or older.21 Hence the conclusion of age mixing as a substantial source for HIV infections among South African youth.
HIV prevalence among South African youth remains very high despite prevention activities focusing on this group. Despite this, there are signs of significant increases in condom use, and primary abstinence, and standard behavior indicators do not suggest higher risk behaviors. According to standard behavioral indicators, 15- to 24-year-old 1998 South Africans (prestabilization) were not engaged in more risky sexual behavior than their 1989 Ugandan counterparts (predecline). The same pattern also appeared when comparing the 2002, 2003, and 2005 South Africa surveys (during stabilization) to the 1995 Uganda surveys (during decline). Yet HIV prevalence in these age groups remains more than twice in South Africa than Uganda, despite increases in condom use to levels 2 to 3 times greater and increases in secondary abstinence.
To decrease HIV prevalence among South African youth, two sexual behaviors may require particular attention, the number of partners and inconsistent condom use. Greater attention is required to male behaviors in survey trends, and behaviors not captured by standard indicators. In addition, age mixing patterns suggest a comprehensive prevention approach beyond youth is needed to reduce HIV prevalence, even among youth themselves. Lower absolute levels of sexual behavior risk, but extended over a longer age period, present a particular risk in South Africa. These are not fully captured by annual rates of sexual risk.
Inconsistent condom use is shown to be a significant risk behavior for HIV infection. A study conducted in Rakai, Uganda demonstrated the effectiveness of consistent condom use in reducing HIV infections and other STIs, such as syphilis. By way of contrast, irregular condom use was not effective protection against HIV and other sexually transmitted infections and was associated with an increased risk of Gonorrhea and Chlamydia.28 A study in Thailand reported inconsistent condom use to be a risk factor in STIs among 19- to 23-year-old male military conscripts.29 It is important to promote consistent condom use among South African youth, and stress inconsistent use as a risk behavior. Standard indicators of condom use at last sex do not capture this key risk. A population which uses condoms 50% of the time, would show 50% condom protection according to this indicator, although none may use them consistently.
Age mixing seems to be a substantial source of infection among South African youth. Sexual partners from different age groups increase the mixing of the two populations, one with higher and the other with lower HIV prevalence.30 In addition, such wide gaps decrease the chance that the younger partner, usually the woman, will negotiate safer sex, having less experience and being less confident than her partner.31 Prevention needs to focus on the transmission dynamics across age groups to reduce HIV prevalence in youth. The wider age distribution of HIV prevalence and sexual behavior in South Africa may be particularly important. In East Africa, higher levels of sexual risk are focused in a particular age group. The challenge in South Africa is to engage with lower apparent annual risk, but over a much longer age period. Annual measures of sexual risk may not capture this cumulative risk. For example, 1 sexual partner in the last year, if changed every 2 years for 20 years, can result in considerable risk over time, not captured by standard indicators. Much more careful analysis of behaviors is required as a basis for HIV prevention programs in Southern Africa.
The 3 obstacles to prevent the further spread of HIV, namely, the lack of decrease in the proportion of women with more than 1 sexual partner in the last 12 months, inconsistent condom use, and substantial transmission of HIV from older to younger age groups, correspond to the findings of multivariable analysis of the 2003 SALL survey. The study found young women with older partners to be at increased risk of HIV infection. It further reported that increasing partner numbers and inconsistent condom use among both genders were significantly associated with HIV infection.7
There are important limitations to the analysis. The above conclusions derive from analysis at the national level, yet the South African HIV epidemic is far from homogenous across the country. The comparison across 7 surveys have limited the analysis to standard indicators at the national level, with no ability to breakdown behaviors by various possible cofactors such as settlement type, provinces, education level, and marital status. Despite detailed analysis of several surveys for the 2 countries, there were important limitations to the behavior trends identified within and between countries. In addition to limitations in the data in analyzing sexual mixing patterns and inconsistent condom use (not measured in the South African HSRC 2002 and 2005 surveys), there are other biologic factors which may be important in explaining HIV prevalence including HSV prevalence and other STDs, pregnancy, and possibly circumcision. The very use of reported sexual behavior is subject to reporting and social desirability biases.32 A further problem is the wide difference in the results between the South African surveys from 2002 and 2003. For example, the proportion of young males reporting more than one sexual partner in the last 12 months is 10.4% in the 2002 SAHSRC against 21.7% in the 2003 SALL. Additional analysis of male behaviors is required. The analysis of behavioral data will also need to be updated over time, particularly given recent signs of increased risk in Uganda.
The article presents a fundamental issue in HIV prevention. Despite increases in condom use to levels 2 to 3 times higher than in Uganda, HIV prevalence remains 2 to 3 times higher. It has not shown declines possible in a five year period in Uganda, 15 years later in South Africa. The article shows the importance of careful behavioral analysis behind HIV programming, to assess risks beyond standard indicators. These need to address the communication and behavioral dynamics in context, which distinguish successful HIV prevention. It also requires careful age disaggregation, which with extended risk to older ages and mixing patterns, shows the significant risk behind apparently medium risk behaviors and significant condom use. In South Africa, comprehensive HIV prevention across all age groups, needs to be intensified to ensure the signs of stabilization and small declines in HIV prevalence, reduce the very high absolute levels of HIV in this country.
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