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Southern African Journal of HIV Medicine
ISSN: (Online) 2078-6751, (Print) 1608-9693
Page 1 of 9 Original Research
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Authors:
Paence G. Manjengwa1,2
Kerry Mangold3
Alfred Musekiwa1
Lazarus R. Kuonza1,2
Aliaons:
1South African Field
Epidemiology Training
Programme, Naonal
Instute of Communicable
Diseases, Johannesburg,
South Africa
2School of Health Systems
and Public Health, University
of Pretoria, Pretoria,
South Africa
3South African Naonal
AIDS Council Trust, Pretoria,
South Africa
Corresponding author:
Paence Manjengwa,
manjengwa.paence
@gmail.com
Dates:
Received: 07 May 2018
Accepted: 14 Feb. 2019
Published: 10 June 2019
How to cite this arcle:
Manjengwa PG, Mangold K,
Musekiwa A, Kuonza LR.
Cognive and behavioural
determinants of mulple
sexual partnerships and
condom use in South Africa:
Results of a naonal survey.
S Afr J HIV Med. 2019;20(1),
a868. hps://doi.org/10.4102/
sajhivmed.v20i1.868
Copyright:
© 2019. The Authors.
Licensee: AOSIS. This work
is licensed under the
Creave Commons
Aribuon License.
Introducon
Globally, human immunodeficiency virus (HIV) poses a major public health concern, causing
high rates of mortality and morbidity.1 In 2013, there were 35.3 million people living with HIV,
with approximately 2.3 m new HIV infections and more than 1.6 m HIV-related deaths.2 In sub-
Saharan Africa, it was estimated that there were 23.5 m people living with HIV in March 2015.2 In
2012, HIV prevalence in South Africa (SA) among all age groups was 12.2%, an increase from
10.6% reported in 2008.2 With an HIV incidence rate of 4.5%, the increased prevalence of HIV in
2012 could be attributed to the combined effects of new infections and a successfully expanded
antiretroviral treatment (ART) programme.2
Numerous societal, cultural and personal intrinsic factors have been identified as important social
and structural drivers of the HIV epidemic in SA, including high population mobility and
inequalities in wealth and gender.3 Other contributing drivers of HIV include attitudes and
behaviours of men, intergenerational sex, gender and sexual violence, stigma and untreated viral
sexually transmitted infections (STIs).3,4,5,6,7
SA is continuing to address social and structural factors that influence HIV and prevent new HIV
infections.2,6 One of the goals of the South African National Strategic Plan on HIV, STIs and
Background: Human immunodeficiency virus (HIV) risky behaviours including multiple
sexual partnership (MSP) and non-condom use (nCU) are known to be drivers of the spread of
HIV; cognitive factors including perceived susceptibility of HIV, self-efficacy and attitudes
play a significant role in influencing risky sexual behaviours.
Objectives: We sought to investigate personal beliefs, perceptions, thoughts and actions that
are associated with MSP and nCU in South Africa.
Methods: We analysed nationally representative data from the 2012 National HIV
Communication Survey (NCS) that included about 10 000 participants aged 16–55 years. Five
constructs were created to measure psychosocial and cognitive determinants. Cronbach’s
alpha coefficient for internal consistency reliability was calculated. Multivariable logistic
regression was used to determine factors associated with MSP and nCU.
Results: Of the 6061 sexually active respondents, 13% (95% CI: 11.47–13.12) reported MSP and
52.7% (n = 3158 of 6039) (95% CI: 51.0–53.55) nCU at last sex. Factors associated with MSP
included perceived benefits, adjusted odds ratio (aOR) = 2.16 (95% CI: 1.80–2.58), perceived
susceptibility to HIV, aOR = 2.22 (95% CI: 1.83–2.69) and engaging in intergenerational sex,
aOR = 2.14 (95% CI: 1.78–2.56). Predictors of nCU were perceived benefits, aOR = 1.25 (95% CI:
1.09–1.43); perceived susceptibility to HIV, aOR = 1.6 (95% CI: 1.39–1.83); and personal beliefs,
aOR = 1.35 (95% CI: 1.13–1.62).
Conclusion: Cognitive and behavioural factors were found to be predictors of risky sexual
behaviours for HIV. This highlights the importance of considering personal perception and
reasoning when attempting to understand and influence an individual’s sexual behaviour.
This could be done through enhancing awareness of HIV risk in the general population and by
influencing cognitive behaviour change through community mobilisation, advocacy and
creating activities to improve self-esteem.
Keywords: HIV; Multiple sexual partnerships; Non-condom use; Cognitive factor;
Intergenerational sex; Perceived benefits; Perceived susceptibility; Personal beliefs.
Cognive and behavioural determinants of mulple
sexual partnerships and condom use in South Africa:
Results of a naonal survey
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TB 2012–2016 is to reduce new HIV infections by at least 50%,
using a combination of prevention approaches combining
biomedical and behavioural interventions.8 In 2012, the South
African government made a commitment to address issues
related to social and structural factors that influence HIV
through scaling up accessibility of services including ART,
rolling out the HIV counselling and testing campaign,
expanding medical male circumcision programmes and
provision of basic needs grants.6,7,9 To reduce new HIV
infections, a combination of biomedical, behavioural, social
and structural interventions have been set in place and are
being constantly improved for better alignment.8
Multiple and concurrent partnerships, low and inconsistent
condom use, alcohol abuse (together termed risky sexual
behaviours) and low levels of male circumcision have been
shown to be the key drivers of the epidemic.10,11 While HIV
risky behaviours are known to be drivers of the spread of HIV,
cognitive factors including perceived susceptibility to HIV,
perceived monetary or material benefits of having sex for
material gain, self-efficacy and attitudes play a significant role
in influencing risky sexual behaviours.12,13,14 Based on the
health belief model, an individual’s personal belief influences
their behaviour.12 Despite the large number of research studies
carried out on risk factors of HIV in SA, which include age of
sexual debut, age disparate or intergenerational relationships
(5 year age difference), multiple sexual partnerships (MSPs)
and condom use, there have been limited studies of cognitive
behaviours that influence risky sexual behaviours. Cognitive
behaviours include a perceived lack of susceptibility to HIV,
perceived benefits, personal beliefs surrounding risky sexual
behaviours, condom self-efficacy, social norms and the impact
self-esteem has on engaging in risky sexual behaviours.15
A study conducted by Tarkang in Cameroon in 2013 revealed
that only 39% of the sexually active secondary school learners
had a high HIV risk perception.16 A study conducted by
Pettifor et al. in SA reported that only 14.0% of school learners
had high HIV risk perception.17 Perceptions, ideas and
behaviours that determine people’s actions need to be explored
further in order to better understand the drivers of risky sexual
behaviours in SA.
There are a number of psychological concepts that show how
ideational and cognitive factors can have an impact on behaviour
modification. The acquired immune deficiency syndrome
(AIDS) risk reduction model states that knowledge of HIV and
AIDS is a prerequisite that will enable an individual to take
action and change their behaviour. This model links HIV
knowledge to behaviour change. However, findings regarding
the correlation between knowledge and behaviour have been
inconsistent.3 Other theories and models of health risk
perception assert that cognitive ideational factors that are related
to attitudes, beliefs, knowledge, intentions and perceived self-
efficacy are sufficient to foster safer sex behaviour.3,12
This study sought to investigate personal beliefs, perceptions
and other ideas, thoughts and actions that are associated
with MSP and non-condom use (nCU) among the South
African population aged 16–55 years.
Methods
We analysed secondary data from the Third National HIV
Communication Survey (NCS) conducted in all nine
provinces in SA between February and May 2012. This survey
was designed to be representative of 16–55 years old. The
methodology has been previously published,16 but briefly a
multi-stage, cluster sampling approach was first used to
draw a sample of 400 primary sampling units. Secondly, a
systematic sampling interval was calculated by probability
proportional to size techniques. The third stage of the
sampling focused on randomly selected households,
followed by individuals.
Measurements and variables
An interviewer-administered structured questionnaire
was used to collect data, including socio-demographic
characteristics, exposure to television and radio
communication messages or programmes on HIV and AIDS,
perception of risk and indicators on knowledge, attitude
and behaviour related to HIV and AIDS.
Five constructs were created to measure psychosocial and
cognitive determinants. Responses to the questions that
made up the constructs were graded on a five-point Likert
scale, ranging from strongly disagree to strongly agree.
Cronbach’s alpha coefficient for internal consistency
reliability was used to assess the correlations between the
items that made up each construct. Values of 60% or higher
were considered to indicate acceptable internal consistency.
A composite score was obtained for each construct by
calculating an average score of the responses to all the
questions that made up the construct. We calculated the
average scores in percentages. The composite score was
used to create a dichotomous variable for the construct,
which was graded as either high if the composite score
was above 65% or low if the composite score was 65% or
lower. This cut-off number was used to accommodate the
small number of questions used on other constructs
because we used questions from a survey that was
intended to measure communication programmes in SA.
Box 1 shows single-item questions that were used for each
behavioural construct.
Denions
The perceived benefits construct was defined as beliefs that
there are positive outcomes related to engaging in a specific
behaviour. The self-efficacy construct was defined as beliefs
that one is capable of completing a certain task on their own.
Perceived susceptibility was defined as the individual’s
belief that they would acquire HIV infection. Social norms
are beliefs of how the society thinks people should perform
or how the society views things. Personal beliefs are intrinsic
cognitive beliefs that people have on their own. Multiple
sexual partnerships (MSP) refers to having had more than
one sexual partner in the past 12 months and nCU is defined
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BOX 1: Single-item quesons from the quesonnaire of the Naonal HIV Communicaon Survey 2012 used to create cognive and social behaviour constructs.
Mulple sexual partnership
Percepon suscepbility: An individual’s view about HIV risk percepon
What do you think your chances are of geng infected with HIV
Condom self-ecacy: A person’s feeling about ability to eecvely use condoms
Somemes, in the morning aer having sex without a condom, I think ‘my God, what did I do?’
I can use a condom even when I have too much to drink
I can refuse to have sex if someone I like refuses to use a condom
I can buy a condom without feeling embarrassed
[WOMEN] I am condent that I can correctly put a condom on a man when having sex with him
Personal beliefs: An individual’s views about HIV-related issues
If someone ever has trouble pung on a condom, they will be embarrassed to try to use a condom again
Men who use condoms with their wives are opening the door for her to have sex with other men
Using a condom will make your partner think you do not trust him or her
Now and then, I go to someone else besides my main partner because the sex is so good
It is ok to have sex with others as long as your main partner does not nd out
Perceived benets: An individual’s percepon of posive consequences brought by a certain behaviour
When you use a condom, you cannot get enough pleasure
If you have good communicaon with your partner, you can be sexually sased with one person
I need someone else to ll the gap in case I ever break up with my main partner
Now and then, I go to someone else besides my main partner because the sex is so good
Self-esteem: An individual’s condence in his or her self-worth
If someone has problems pung a condom, they will be ashamed to put it again
Using a condom will make your partner think you do not trust him or her
I feel that I am a person of worth, at least on an equal plane with others
I take a posive atude towards myself
Social capital and norms: How an individual thinks about HIV and other issues that aect people in their community
People in my community take HIV and AIDS seriously
People in my community are joining together to help people with HIV and AIDS
If you wait to have sex, you will nd the right person for yourself
When a relaonship ends, you should wait a few months and do not rush into a sexual relaonship
as not using either a male or a female condom at last sex.
Intergenerational sex was defined as having a sexual
relationship with someone with a 5 year or more age
difference.
Stascal analysis
A descriptive cross-sectional analysis was conducted to
describe the demographic and risk factors by age, sex and
province. We used weighted data in our analysis to be
representative of the SA population with respect to age, sex,
province, population group and urban or rural residence.
Sample weights were corroborated using the 2007
Community Survey conducted by Statistics South Africa.
Chi-squared test was used to test for an association between
the outcomes MSP and nCU and psychosocial and cognitive
constructs. Univariate logistic regression was used to
determine factors associated with the outcomes MSP and
nCU. Manual forward stepwise procedure was used to
select variables for the multivariable model. Multi-
collinearity tests were performed and only non-collinear
variables were analysed. Multivariable logistic regression
was used to determine independent factors associated with
outcome after adjusting for potential confounders such
as sex, employment, age, relationship type, geography,
settlement type, HIV status, condom use at last sex,
intergenerational sex (difference in ages by 5 years) and
alcohol use at last sex, perceived susceptibility, personal
benefits, personal beliefs, social norms, self-esteem and
condom self-efficacy. A p-value of less than 0.05 was
considered statistically significant. All analyses were
conducted using STATA 13.0 (Stata Corporation, College
Station, TX, USA).
Ethical consideraon
All procedures performed in studies involving human
participants were in accordance with ethical standards of the
institutional and/or national research committee and with
the 1964 Helsinki Declaration and its later amendments or
comparable ethical standards. For this type of study, formal
consent was not required.
Results
The socio-demographic characteristics of the sampled
population are shown in Table 1. Of the total sample of 10 034
participants, 6061 reported that they had at least one sexual
encounter in the past 12 months. Of these sexually active
participants, 41% (2467 of 6061) were men. The overall mean age
was 31.3 years (s.d.: 11). Twenty-three per cent (1378 of 6061) of
the participants were aged 20–24 years and 6% (371 of 6061)
were aged 45–49 years. Overall, 39% (2374 of 6061) lived in
urban formal settlements, 37% (2158 of 6061) were from urban
informal settlements, 11% (659 of 6061) lived in peri-urban areas
and only 2% (286 of 6061) lived in farming settlements. The
majority of participants had some form of education, but 1% (56
of 6061) had no schooling. Participants with a high socio-
economic status were 34.7% (2107 of 6061) and medium socio-
economic status was almost similar at 38.5% (2335 of 6061).
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Demographic characteriscs of
respondents who reported mulple
sexual partnership
A total of 13% (744/6061; 95% CI: 11.47–13.12) of the sexually
active population aged 16–55 years reported having had MSP
in the past 12 months. The mean age was 28 years (s.d. 7.62),
with the majority (65%) being men (481/744). Table 3 shows
that the majority (93%) were black people (696/744), 5%
(41/744) were mixed race and less than 1% (7/744) were
white people or Indians. Almost half had medium socio-
economic status 45% (330/744). The highest percentage of
people who engaged in MSP was recorded among single
respondents 41% (306/744) followed by those not married or
living together but in a steady relationship 33% (247/744).
Demographic characteriscs of
respondents who reported
non-condom use
Out of the total number of sexually active respondents, more
than half reported not using a condom at last sex 53%
(3158/6039, 95% CI: 51.03–53.55, p < 0.05). Mean age was 33
years (s.d. 10.02). Of the people who did not use condoms at
last sex, 62% (1956/3158) were women. Twenty per cent of
the people who reported nCU were from Gauteng province
(GP) (632/3158) followed by Western Cape (WC) 18%
(568/3158) and KwaZulu-Natal (KZN) 17% (562/3158).
Among those with no schooling, 79% (44/56) did not use
condoms at last sex. Non-condom use at last sex was common
among those who had education up to Grade 11 (43%;
1355/3158). The prevalence of nCU among people with a
high socio-economic status was 54% (1134/2097) and those
with a low socio-economic status were 52% (852/1610). Of
the people who reported not using condoms at last sex,
married participants had the highest prevalence of nCU at
last sex (35%; 1102/3158), followed by single (22%; 700/3158)
and not married or living together but in a steady relationship
(21%; 648/3158).
Univariate analysis – Predictors of
mulple sexual partnership
The odds of reporting MSP were two times higher among
those engaging in intergenerational sex than those having
sex with people in the same generation (OR 2.10, 95% CI:
1.79–2.46, p < 0.001). Participants who had consumed alcohol
before sex were 1.3 times more likely to report MSP than
those who did not consume alcohol before sex (OR 1.33, 95%
CI: 1.06–1.67, p < 0.02). People who engaged in transactional
sex were almost six times more likely to have MSP in the past
12 months than those who did not engage in transactional sex
(OR 5.97, 95% CI: 4.89–7.29, p < 0.001). People who lived in
Free State province were nearly four times more likely to
report MSP (OR 3.73, 95% CI: 2.67–5.21, p < 0.001) than people
living in WC province. Those living in GP were two times
more likely to report engaging in MSP (OR 2.35, 95% CI: 1.74–
3.09, p < 0.001) than people living in WC province. Students
were almost 1.5 times likely to report having engaged in MSP
than unemployed participants (OR 1.47, 95% CI: 1.13–1.89,
p < 0.005).
Univariate analysis – Predictors of
non-condom use at last sex
Employed participants were 1.17 times (OR 1.17, 95% CI:
1.05–1.31, p < 0.005) more likely to report to have not used
condoms at last sex than their unemployed counterparts.
People living in farming settlements were almost two times
more likely to have not used a condom at last sex than those
living in urban formal (OR 1.91, 95% CI: 1.35–2.68, p < 0.001).
Drinking alcohol in the past month was significantly
associated with nCU at last sex (OR 1.27, 95% CI: 1.07–1.53,
p < 0.001).
Mulvariable analysis – Predictors
of mulple sexual partnership and
non-condom use
The multivariable analysis showed that perceived benefits
(aOR 2.16, 95% CI: 1.80–2.58, p < 0.001) and low perceived
susceptibility (aOR 2.22, 95% CI: 1.83–2.69, p < 0.001) to
HIV infection were the two psychosocial and cognitive
constructs that were significantly associated with MSP.
Intergenerational sex (aOR 2.14, 95% CI: 1.78–2.56,
TABLE 1: Background demographic characteriscs of parcipants who had at
least one sexual encounter in the past 12 months of the survey in the South
African 16–55-year-old populaon, 2012.
Characteriscs n = 6061 %
Sex
Women 3594 59.0
Men 2467 40.0
Age
16–24 1799 30.0
25–49 3894 64.0
50–55 368 6.0
Race
Black people 5029 82.0
Mixed race 824 14.4
White people 102 1.8
Indian people or Asian people 2 1.7
Selement
Urban formal 2374 39.0
Urban informal 2158 35.6
Peri-urban 659 10.87
Tribal selement 712 11.75
Farming 158 2.61
Socio-economic status
High 2107 34.7
Medium 2335 38.5
Low 1619 26.7
Marital status
Single 1884 31.0
Not married, serious relaonship 1516 25.0
Not married, living with partner 797 13.1
Married living with spouse 1425 23.5
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TABLE 2: Demographic, HIV risk, cognive and social predictors of mulple sexual partnership in the past 12 months among 16–55-year-old parcipants in
South Africa, 2012.
MSP predictors n = 744 %Crude 95% CI pAdj 95% CI p
Sex
Men 481 64.65 3.06 2.61–3.6 < 0.001 - - -
Women 263 35.35 1 - - - - -
Age
16–24 282 37.9 1 - < 0.001 - - -
25–49 451 60.6 0.70 0.60–0.82 < 0.001 - - -
50–55 11 1.5 0.16 0.09–0.30 < 0.001 - - -
Race
Black 696 93.6 1 - - - - -
Mixed races 41 5.5 0.32 0.23–0.45 < 0.001 - - -
White 4 0.5 0.25 0.09–0.69 0.007 - - -
Indians 3 0.4 0.18 0.05–0.58 0.004 - - -
Marital status
Single 306 41.0 1.13 0.70–1.83 0.602 - - -
Not married or living together 247 33.2 1.14 0.70–1.84 0.594 2.1 1.07–4.11 0.03
Not married but living together 76 10.2 0.61 0.36–1.03 0.069 - - -
Married living with spouse 64 8.6 0.27 0.16–0.46 0.074 - - -
Married not living with spouse 17 2.3 0.53 0.27–1.06 0.897 - - -
Widowed 21 2.8 1 - - - - -
Socio-economic status
Medium socio-economic status 330 44.3 1.42 1.18–1.71 < 0.001 1.24 1.01–1.55 0.05
Low socio-economic status 196 26.3 1.19 0.95–1.82 0.05 - - -
High socio-economic status 218 29.3 1 - - - - -
Highest level of educaon
Up to Grade 11 312 41.9 1.37 1.00–1.89 0.05 1.72 1.13–2.63 0.01
Matric 267 35.9 1.32 0.95–1.82 0.093 1.7 1.11–2.62 0.014
Terary 107 14.4 1.45 1.01–2.08 0.04 2.04 1.27–3.28 0.003
No schooling 4 0.54 0.73 0.25–2.12 0.57 - - -
Primary school 48 6.5 1 - - - - -
Perceived benets
High 423 57.2 2.29 1.96–2.68 < 0.001 2.16 1.80–2.58 < 0.001
Low 316 42.7 1 - - - - -
Perceived suscepbility
High 272 42.7 2.53 2.13–3.01 < 0.001 2.22 1.83–2.69 < 0.001
Low 365 57.3 1 - - - - -
Transaconal sex
Yes 199 26.8 5.97 4.89–7.29 < 0.001 - - -
No 545 73.2 1 - - - - -
Alcohol use before sex
Yes 373 75.1 1.33 1.06–1.66 0.013 - - -
No 124 24.9 1 - - - - -
Intergeneraonal sex
Yes 435 58.4 2.1 1.79–2.45 < 0.001 2.14 1.78–2.56 < 0.001
No 309 41.5 1 - - - - -
Provinces
Eastern Cape 42 5.6 1.16 0.79–1.71 0.426 - - -
Free State 100 13.4 4.26 2.88–6.28 < 0.001 - - -
North West 61 8.2 2.63 1.73–3.99 < 0.001 2.4 1.48–3.89 < 0.001
Limpopo 39 5.2 1.38 0.92–2.08 0.116 - - -
Gauteng 225 30.2 2.54 1.77–3.63 < 0.001 - - -
KwaZulu-Natal 157 21.1 2.33 1.63–3.32 < 0.001 - - -
Mpumalanga 32 4.3 2.63 1.73–3.99 <0.001 - - -
Northern Cape 19 2.5 2.07 1.14–3.77 0.017 - - -
Western Cape 69 9.2 1 - - - - -
MSP, mulple sexual partnership; OR, odds rao; CI, condence interval.
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p < 0.001), medium socio-economic status (aOR 1.24, 95%
CI: 1.01–1.55, p = 0.05) and having tertiary education (aOR
2.04, 95% CI: 1.27–3.28, p < 0.005) were additional predictors
of MSP. Results in Table 1 show that after adjusting for
confounders, personal belief around condoms (aOR 1.35,
95% CI: 1.13–1.62, p < 0.005), high perceived benefits (aOR
1.25, 95% CI: 1.09–1.43, p < 0.005) and low perceived
susceptibility to HIV infection (aOR 1.6, 95% CI: 1.39–1.83, p
< 0.001) were identified as psychosocial and cognitive
factors that influence nCU at last sex. The final multivariable
model for nCU, Table 3, retained living in farming
settlements (aOR 2.15, 95% CI: 1.46–3.15, p < 0.001) and age
group (30–34) compared to 16–19 year olds (aOR 2.28, 95%
CI: 1.74–3.01, p < 0.001) together with the psychosocial and
cognitive factors mentioned above.
Discussion
In this study, low perceived susceptibility of HIV infection
and perceived monetary, material or cognitive benefits were
significantly associated with both MSP and nCU at last sex.
Similar associations were found in a study conducted in
Cameroon in 2012, which revealed the association of MSP
and low-risk perception of HIV infection.16 It is very
concerning to note that people perceive themselves to be at
lower risk of acquiring HIV infection despite engaging in
risky sexual behaviour. It is generally known that people
judge a potential threat through their past experiences and
anticipated consequences.12,18 Low perceived susceptibility
could be partially attributed to the fact that HIV and AIDS
is a highly stigmatised disease. Therefore, when a person
acknowledges his or her risk of acquiring HIV infection, he
TABLE 3: Demographic, HIV risk, cognive and social predictors of non-condom use at last sex among sexually acve 16–55-year-old parcipants in South Africa, 2012.
Non-condom use predictors n = 3158 %Crude pAdj p
OR 95% CI OR 95% CI
Sex
Men 1202 38.1 0.79 0.72–0.88 < 0.001 - - -
Women 1956 61.9 1 - - - - -
Age
16–19 421 7.0 1 - - 1 - -
20–24 1378 22.7 1.48 1.17–1.86 0.001 1.46 1.13–1.88 0.003
25–29 1294 21.4 1.95 1.54–2.46 < 0.001 1.72 1.33–2.22 < 0.001
30–34 995 16.4 2.75 2.16–3.24 < 0.001 2.28 1.74–3.00 < 0.001
35–39 718 11.8 2.90 2.25–3.74 < 0.001 1.96 1.46–2.63 < 0.001
40–44 516 8.5 3.57 2.72–4.68 < 0.001 2.12 1.54–2.92 < 0.001
45–49 371 6.1 5.24 3.86–7.10 < 0.001 3.03 2.11–4.34 < 0.001
50–55 368 6.0 8.89 6.39–12.97 < 0.001 5.25 3.54–7.77 < 0.001
Race
Black people 2415 76.5 1 - - 1 - -
Mixed race 595 18.8 0.32 0.23–0.45 < 0.001 3.11 2.57–3.75 < 0.001
White people 73 2.3 0.25 0.09–0.69 0.007 2.12 1.29–3.49 0.003
Indian people 74 2.3 0.18 0.05–0.58 0.004 2.67 1.60–4.45 < 0.001
Marital status
Single 700 22.0 0.53 0.37–0.74 0.001 0.94 0.62–1.43 0.790
Not married or living together 648 20.5 0.67 0.47–0.94 0.023 1.30 0.85–1.98 0.218
Not married but living together 476 15.1 1.33 0.93–1.90 0.069 2.04 1.32–3.14 0.001
Married living with spouse 1102 38.9 3.11 2.19–4.41 0.074 4.09 2.70–6.20 < 0.001
Married not living with spouse 123 3.9 1.41 0.91–2.17 0.897 1.88 1.13–3.12 0.014
Widowed 76 2.4 1 - - 1 - -
Alcohol use before sex
Yes 859 73.1 1.27 1.07–1.52 0.006 - - -
No 315 26.9 1 - - - - -
Selement type
Urban formal 1211 37.1 1 - 0.998 1 - -
Urban informal 1101 26.9 1.00 0.88–1.12 0.998 1.24 1.01–1.55 0.002
Peri-urban 361 35.9 1.16 0.97–1.38 0.090 1.28 1.04–1.57 0.017
Tribal selement 381 12.0 1.10 0.93–1.30 0.265 1.59 1.30–1.94 < 0.001
Farming selement 104 3.2 1.90 1.35–2.68 <0.001 2.15 1.46–3.15 < 0.001
Personal beliefs
Yes 2522 80.5 1.38 1.21–1.59 < 0.001 1.35 1.13–1.62 0.001
No 610 19.4 1 - - - - -
Perceived benets
High 1302 41.6 1.22 1.10–1.35 < 0.001 1.25 1.09–1.43 0.001
Low 1824 58.4 1 - - - - -
Perceived suscepbility
High 766 27.0 1.24 1.09–1.40 0.001 1.6 1.39–1.83 < 0.001
Low 2070 72.9 1 - - - - -
OR, odds rao; CI, condence interval.
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or she becomes vulnerable to being stigmatised. Because of
this risk, people may avoid self-disclosure and by so doing
downplay their personal risk.
A high proportion of black participants reported engaging
in MSP, followed by mixed race participants as compared to
the Indian participants. Multiple sexual partnership was
significantly higher among men than among women. This is
consistent with other studies where generally wealthy men
in patriarchal societies like SA are expected to have numerous
partners or wives. This follows the polygamous culture in
African countries.19 Furthermore, women have been found
generally to under-report sexual behaviours.8,20 This can be
explained by the fact that women want their manner to be
viewed favourably by others. MSP in women is often viewed
in a derogatory sense.
The proportion of respondents who had reported not using
condoms at last sex was 57%. This was higher among women
(62%) than among men (38%). The figure appeared similar to
the findings of the South African National HIV Prevalence,
Incidence and Behaviour Survey, 2012, which reported nCU
as 63% in the whole population.2 Engaging in MSP and
having unprotected sex increases HIV risk because of the fact
that individuals may be linked through sexual networks and
become more vulnerable to high viral load exposure during
the early phases of new HIV infection.21
Low socio-economic status was predictive of nCU at last sex
but there was a significant association with MSP. In this
study, MSP was frequently reported among those with
medium socio-economic status and least reported among
respondents with a high socio-economic status. Similarly,
according to a survey conducted on young men and women
in SA in 2004, MSP was reported least among those with high
socio-economic status. An explanation of a similar finding
suggested that if people with lower socio-economic status are
compared to the ones with a high socio-economic status,
those with lower socio-economic status may choose to
spend more of their income pursuing various forms of
relationships.2,5 Another possible explanation could be that
respondents in the high socio-economic group may have
higher educational attainment and better health information;
hence, they reduce risky sexual behaviours.22,23
MSP was prevalent among participants who engaged in
intergenerational sex. It has been shown in this study and
other studies that intergenerational sex fuels the HIV epidemic
among the younger generations.19,24 Research studies argue
that when young women mix with the older generation, their
risk for contracting HIV increases.2,25 Interventions targeted at
reducing intergenerational sex could reduce the prevalence of
HIV among younger generations. It is concerning that the
highest proportion of MSP is among the 20–24-year age groups
where both boys and girls are affected. Age mixing with older
generations further exacerbates this problem because young
girls are likely to mix with both older men and young boys.26
In this case, old men infect young girls who then infect young
boys. Studies have confirmed that sex with older men is more
risky than sex with younger men because HIV prevalence
among older men is significantly higher than younger men.24
The age differential with older men also introduces a power
dynamic into the sexual relationship where younger women
are more vulnerable and less likely to successfully negotiate
condom use. Intergenerational sex is also closely entwined
with transactional sex – where economic factors push young
girls to engage in various forms of sex in exchange for cash or
material benefits.1
It is not surprising then that transactional sex was also
associated with MSP. Almost half of the participants reporting
both MSP and transactional sex were among those with
medium socio-economic status. This implies that these
participants were not poor but rather alludes to need for
economic gains or advancements and wealth inequalities as a
push factor towards engaging in HIV risk behaviours. The
need for social upward mobility could explain the need for
participants to engage in MSP and transactional sex.3
Increased HIV incidence has been associated with low socio-
economic status in recent studies.1,20 However, the practice of
MSP is not untouched by employment status. With regard to
employment status, students recorded a higher prevalence
of MSP than the unemployed category. This finding is in
contradiction to another study conducted in SA that showed
that nearly half of the participants who engaged in MSP were
unemployed and only 10% were students.24 These differences
in findings could be because of the differences in how the
studies defined unemployed group. This study considered
informal employment as employed, while the other study
categorised it as unemployed. The geographical coverage of
the two studies could also explain the different findings. This
analysis utilised data from a national survey, whereas the
other study referred to was only undertaken in two provinces
in SA. Further research will need to be undertaken to confirm
these findings.
The high prevalence of non-condom use is exacerbated by
the consumption of alcohol.1,9,27 Alcohol has adverse side
effects that include sexual risk behaviours and these have
been documented in various different studies in SA.1 Poor
judgement and risky sexual behaviours are often exacerbated
as a result of alcohol consumption as it impairs judgement
and reduces inhibition. These findings emphasise the risks
associated with the mix of sexual risk behaviours, MSP,
transactional sex and alcohol; therefore, interventions better
equipped for the complexities of the behaviour mix need to
be put in place.
Perceived material, monetary or cognitive benefits were
strongly associated with nCU and this was furthermore
compounded by the association found between nCU,
engaging in transactional sex and having MSP. While
perceived benefits could be judged by anticipated rewards,
in this study, there was an association with both nCU and
MSP.28 Among those who did not use condoms at last sex,
Page 8 of 9 Original Research
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perceived benefits were significantly high. Similarly, other
studies have found that people engage in a mix of MSP, nCU
and transactional sex to access a fashionable lifestyle.19,24 This
may be also explained why we found that students were
more likely to engage in risky sexual behaviours as they are
vulnerable to peer pressure and living up to a standard. The
findings of this research showed that the participants did not
use condoms because of their perception of benefits acquired.
They perceived that not wearing condoms will make them
get more money as compared to wearing condoms and the
risk for HIV infection.
The findings of nCU after adjusting for confounders of
transactional sex, alcohol use before sex and MSPs revealed
that personal beliefs had an impact on condom use.
Participants believed that it was unpleasurable to use
condoms. This is consistent with other studies that have
revealed that attitudes about condoms are predictive of
condom use.29 While marital status strongly correlated with
nCU and remained stronger after adjusting for confounders,
being married was significantly associated with nCU; this is
consistent with most studies. This finding is concerning and
people in all types of relationships should be encouraged to
use condoms, especially in a country where MSP is common
practice regardless of marital status.
Living in a rural area or farming settlement was found to be
a risk factor for not using condoms at last sex. This could be
because of stigma and patriarchal norms which play a larger
role in determining behaviour.30 This could also be because of
logistical challenges of condom supply because of these areas
being in difficult to reach or sparse areas of the country.
In our analysis, we had some limitations which included the
fact that data used in this study analysis relied on self-
reported sexual behaviour on sensitive issues, such as
condom use and HIV and AIDS. Self-reported data are
prone to social desirability bias where respondents tend to
respond to questions in a manner that is viewed favourably
by others. There is the possibility that participants could have
exaggerated behaviour or under-reported undesirable
behaviour. It is, however, unlikely that this bias affected our
results because assurance of confidentiality and anonymity
was given and the questionnaire was administered in a
consistent manner across the whole sample. A further
limitation is that the survey was cross-sectional in nature, and
hence causality was difficult to establish. To overcome this
challenge, we only reported on associations and correlations.
Conclusion and recommendaons
Our study analysed determinants of MSP and nCU and
revealed that a low perceived susceptibility to HIV infection
and that a high perception of benefit are common cognitive
constructs correlated strongly to risky behaviours. Our
results highlight the need to expand on several initiatives
including prevention efforts and changing cognitive and
psychosocial thinking. Firstly, HIV prevention efforts could
be performed through encouraging avoidance of extramarital
sex and the importance of condom use in all types of
relationships, especially where high-risk sexual behaviour
takes place such as MSP. Secondly, these results show that
initiatives need to focus more closely on changing cognitive
and psychosocial thinking in terms of personal beliefs and
norms including the constructs of perceived benefits and
perceived susceptibility. This could be done through
enhancing awareness of HIV risk in the general population
and other cognitive behaviour change interventions.
Therefore, community mobilisation, advocacy, creating
activities to improve self-esteem and aim to increase risk
perception are of paramount importance.
Multi-sectorial efforts focusing on the social and structural
drivers of risky sexual behaviours and HIV need to be
prioritised. This includes psychosocial, health, educational
and economic interventions. Lastly, the findings of this
research will contribute to the knowledge about personal
intrinsic factors and the psychosocial factors that predispose
people to engage in risky sexual behaviours and help close a
literature gap in understanding the dynamics of the epidemic.
Cognitive factors must be prioritised and explored further in
terms of the roles they play in HIV incidence.
Acknowledgements
The authors acknowledge access to the analysed data from
the Third NCS. The NCS is a collaborative survey undertaken
by Johns Hopkins Health and Education in SA, loveLife
and Soul City. The survey was managed by Health and
Development Africa (HAD). The Johns Hopkins Bloomberg
School of Public Health Center for Communication Programs
(JHU-CCP) provided technical support and oversight at
all stages of the study. Data were gathered by Freshly
Ground Insights (FGI). The authors wish to thank the South
African National AIDS Council Trust, South African Field
Epidemiology Training Programme (SA FETP). Appreciation
is also given to Dorothy L. Southern for providing scientific
writing support and critically reviewing this article.
Compeng interests
The authors declare that they have no financial or personal
relationship(s) that may have inappropriately influenced
them in writing this article.
Authors’ contribuons
P.G.M., K.M., A.M. and L.R.K. equally contributed to the
writing and research of this article.
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