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HIV Prevention Knowledge Base

A Collection of Research and Tools to Help You Find What Works in Prevention

Behavioral Interventions: Transactional and Age-disparate Sex in Hyperendemic Countries

I.    Definition of the Prevention Area

Transactional sex (TS) is the practice of exchanging sex for financial or lifestyle rewards. Distinct from formalized sex work, transactional sex is thought to be a fairly common form of sexual partnering in parts of sub-Saharan Africa. Young women may engage in transactional sex with older men to support their basic needs (e.g., food, clothing, school fees) or to obtain desirable consumer goods (e.g., cell phones, fashionable clothing, jewelry, meals at expensive restaurants) and the social status that goes with them. Gifts for sex may be seen as symbolizing the love and respect a man feels for his partner and the importance he places on the relationship. In contrast, “giving away” sex can stigmatize young women as “loose” and lacking self-respect.

“Age-disparate” relationships are those occurring between young people and individuals five or more years their senior. Sexual relationships between individuals 10 or more years apart in age are referred to as “intergenerational” or “cross-generational” relationships. While these relationships take different forms, this document focuses on age-disparate transactional sexual relationships involving older men and young women.

II.    Epidemiological Justification for the Prevention Area

Young women and girls are especially vulnerable to HIV due to biological and social factors. For example, unequal access to economic opportunity often compels them to trade on their sexuality. The epidemiological record shows that young women in sub-Saharan Africa are two to four-and-a-half times more likely to be living with HIV than their male counterparts. There is compelling evidence that these gender disparities stem in part from the frequency of age-disparate and transactional sexual networking in parts of sub-Saharan Africa.

Transactional sex, which has been strongly associated with increased risk of HIV among young women, is common in the region. One recent study, conducted in South Africa, found that nearly a quarter of all young women respondents report ever having sex with a non-primary male partner (for example, a man who is not her husband or boyfriend) in exchange for material goods or money. Other studies report similarly high levels of transactional sex among youth in Africa, ranging from 2 percent among some young women in Tanzania to 90 percent among 15- to 19- year-old women in one Ugandan study. Transactional sex often occurs as a feature of age-disparate sexual networks (because older men are likelier than boys to have the means to offer gifts for sex) or of multiple concurrent partnerships. Even independent of these contexts of increased risk, women may have less power to negotiate condom use when engaging in transactional sex.

Age-disparate sexual relationships put young women and girls at heightened risk because older men often have higher HIV infection rates than adolescent boys or young men. The age disparity may also decrease a young women’s ability to negotiate for safer sex for a variety of reasons, including not wanting to challenge an elder. Various studies have shown that these relationships are common throughout sub-Saharan Africa and that they are associated with unsafe sexual behavior, low condom use, and increased risk for HIV. One study in Zimbabwe provided clear evidence that age-disparate sexual networking explains gender differences in HIV infection rates among youth in that country.

III.    Core Programmatic Components

Effective programming to address age-disparate transactional sexual relationships builds upon the social and cultural contexts that influence sexual behavior. Promising practices have included a combination of microeconomic approaches (such as small loans or conditional cash incentives), interpersonal and community activities (such as support groups, youth groups, mentoring programs, and clubs), and broad-scale interventions using the media. These activities challenge social norms that condone age-disparate sex and give girls support and information to empower them to make healthier choices.

The greater involvement of men in prevention programs that challenge gender and other social norms is another important programmatic component. Examples of such programs include Program H, which promotes gender-equitable norms among young men, and Men as Partners, which works with men to address gender norms, improve access to reproductive health care, and reduce intimate partner violence.

Some programs, like the Stepping Stones strategy, help communities discuss and identify their own solutions to the risks associated with normative sexual practices. Finally, more studies are needed to better understand and evaluate the cultural factors in transactional and intergenerational partnerships, their associated risks, and the impact of interventions to address them.

IV.    Current Status of Implementation Experience

While the effect of age-disparate and transactional relationships on HIV epidemics has long been understood, these factors have only recently emerged as salient dimensions of the hyperepidemics in Southern Africa. Large-scale programming to address these issues is in its infancy, with new anthropological research expanding knowledge of the cultural issues underlying sexual risk.

Moving forward, programmers must identify and account for possible variations in the populations engaged in transactional sexual relationships, where age disparities are and are not involved, and how these various forms of sexual partnering affect HIV vulnerability in different settings. Successful programs will also be based on an understanding of specific social norms that influence transactional and age-disparate sexual relationships. It will then be critical to integrate such knowledge into combination prevention programs addressing the biomedical, cultural, behavioral, and structural factors contributing to sex-related HIV risk and vulnerability.