Sexual Risk Behaviors Among Youth in Soweto, South Africa During the COVID-19 National Lockdown

Abstract

Background:
Assessment of sexual risk behavior among youths is crucial for HIV prevention strategies. However, the literature on sexual behavior in youth during the COVID-19 pandemic is sparse.

Aim:
This study surveyed sexual risk behavior among youth in Soweto, South Africa during the COVID-19 pandemic national lockdown in 2020.

Methods:
We conducted a cross-sectional telephonic survey on socio-demographics and HIV risk behaviors among youth aged 18-24 years during level 3 of the lockdown. Frequencies and their respective percentages were determined for categorical variables and stratified by biological sex. Chi-square analysis was used to compare categorical variables. All data were analyzed using SAS software.

Outcomes:
A risk assessment for HIV questionnaire was used to assess sexual risk behaviors. Also, substance use was assessed through a developed yes/no questionnaire.

Results:
Of the 129 participants, 83.0% (n = 107) had a sexual partner; 52% of those who had a sexual partner were females, 60.7% (65/107) had one current sexual partner and 39.2% (42/107) had more than 1 sexual partner. Most reported sex within 1 week (54.2%, n = 58/107) and 30.8% within a month (30.8%, n = 33/107). Sex was with a dating partner (86.0%, n = 92/107) and 63% used a condom during last sexual contact. Males were more likely than females to have one-night stand sexual partners (23.5% vs 7.1%; P = .0176), make weekly changes in partners (17.7% vs 5.4%; P = .0442) and used condoms with their partners (92.2% vs 53.6%; P < .0001) during last sexual contact. The majority reported alcohol use (69.0%, n = 89/129). Males were more likely than females to use alcohol on a weekly basis (21.4% vs 6.4%; P = .0380). About 55.9% had penetrative sex under the influence of substances.

Clinical translation:
This study gives an insight to the sexual risk behaviors among young people which is crucial for HIV prevention interventions.

Strength & limitations:
This was the first study investigating sexual behavior in youth during the COVID-19 pandemic. The main limitations of this study relate to the sample size and sampling strategy. As the sample was not representative of the population of young people in Soweto and South Africa, the results cannot be generalized. However, the findings have relevance for future research in HIV prevention for young people in other settings in South Africa.

Conclusions:
Interventions on promoting sexual health and reducing HIV risk behavior such as sex following alcohol consumption in young people are needed, especially during a pandemic such as COVID-19. Mulaudzi M, Kiguwa P, Zharima C, et al., Sexual Risk Behaviors Among Youth in Soweto, South Africa During the COVID-19 National Lockdown. Sex Med 2021;10:100487.

Full text

ORIGINAL RESEARCH
COVID-19
Sexual Risk Behaviors Among Youth in Soweto, South Africa During
the COVID-19 National Lockdown
Mamakiri Mulaudzi, MA,
1,3
Peace Kiguwa, PhD,
3
Campion Zharima, MA,
1,4
Kennedy Otwombe, PhD,
1,4
Khuthadzo Hlongwane, MSc,
1
and Janan J. Dietrich, PhD
1,2,5
ABSTRACT
Background: Assessment of sexual risk behavior among youths is crucial for HIV prevention strategies. How-
ever, the literature on sexual behavior in youth during the COVID-19 pandemic is sparse.
Aim: This study surveyed sexual risk behavior among youth in Soweto, South Africa during the COVID-19 pan-
demic national lockdown in 2020.
Methods: We conducted a cross-sectional telephonic survey on socio-demographics and HIV risk behaviors
among youth aged 18−24 years during level 3 of the lockdown. Frequencies and their respective percentages
were determined for categorical variables and stratified by biological sex. Chi-square analysis was used to compare
categorical variables. All data were analyzed using SAS software.
Outcomes: A risk assessment for HIV questionnaire was used to assess sexual risk behaviors. Also, substance use
was assessed through a developed yes/no questionnaire.
Results: Of the 129 participants, 83.0% (n = 107) had a sexual partner; 52% of those who had a sexual partner
were females, 60.7% (65/107) had one current sexual partner and 39.2% (42/107) had more than 1 sexual part-
ner. Most reported sex within 1 week (54.2%, n = 58/107) and 30.8% within a month (30.8%, n = 33/107).
Sex was with a dating partner (86.0%, n = 92/107) and 63% used a condom during last sexual contact. Males
were more likely than females to have one-night stand sexual partners (23.5% vs 7.1%; P= .0176), make weekly
changes in partners (17.7% vs 5.4%; P= .0442) and used condoms with their partners (92.2% vs 53.6%; P<
.0001) during last sexual contact. The majority reported alcohol use (69.0%, n = 89/129). Males were more
likely than females to use alcohol on a weekly basis (21.4% vs 6.4%; P= .0380). About 55.9% had penetrative
sex under the influence of substances.
Clinical Translation: This study gives an insight to the sexual risk behaviors among young people which is cru-
cial for HIV prevention interventions.
Strength & Limitations: This was the first study investigating sexual behavior in youth during the COVID-19
pandemic. The main limitations of this study relate to the sample size and sampling strategy. As the sample was
not representative of the population of young people in Soweto and South Africa, the results cannot be general-
ized. However, the findings have relevance for future research in HIV prevention for young people in other set-
tings in South Africa.
Conclusions: Interventions on promoting sexual health and reducing HIV risk behavior such as sex following
alcohol consumption in young people are needed, especially during a pandemic such as COVID-19. Mulaudzi
M, Kiguwa P, Zharima C, et al., Sexual Risk Behaviors Among Youth in Soweto, South Africa During the
COVID-19 National Lockdown. Sex Med 2021;10:100487.
Received September 21, 2021. Accepted December 24, 2021.
1
Perinatal HIV Research Unit (PHRU), School of Clinical Medicine, Faculty of
Health Sciences, University of the Witwatersrand, Johannesburg, South
Africa;
2
Health Systems Research Unit, South African Medical Research Council,
Cape Town, South Africa;
3
School of Community and Health Development, Faculty of Humanities,
Psychology Department, University of the Witwatersrand, Johannesburg,
South Africa;
4
School of Public Health, Faculty of Health Sciences, University of the Wit-
watersrand, Johannesburg, South Africa;
5
African Social Sciences Unit of Research and Evaluation (ASSURE), School
of Clinical Medicine, Faculty of Health Sciences, University of the Witwa-
tersrand, Johannesburg, South Africa
Copyright © 2022 The Authors. Published by Elsevier Inc. on behalf of the
International Society for Sexual Medicine. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
https://doi.org/10.1016/j.esxm.2021.100487
Sex Med 2022;10:100487 1
SEXUAL MEDICINE

Copyright © 2022 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual
Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
Key Words: COVID-19; Young People; Substance Use; Sexual Risk Behavior; South Africa
INTRODUCTION
In 2017, there were 88,400 new HIV infections among young
South Africans between the ages of 15 and 24 years
1
and more than
20% of youth were living with HIV.
2
Most HIV transmissions
among young people worldwide originate from sexual risk behaviors,
including unprotected penile-vaginal or anal sex, sex with multiple
partners, and sex under the influence of alcohol or drugs.
3−7
Under-
standing sexual risk behavior among young people in South Africa
remains crucial for HIV prevention interventions.
1,8
Coronavirus disease 2019 (COVID-19) has had a devastating
impact on people’s physical and mental health and on sexual and
reproductive health worldwide.
9−13
According to the SANAC
2020 report, the COVID-19 pandemic negatively affected the
HIV response in South Africa due to disruptions in the provision
of sexual and reproductive health services.
14
While several studies
worldwide reported a decrease in the frequency of sexual activity
and multiple sexual partnerships during COVID-19 pandemic
lockdowns or stay at home measures,
15−19
other studies sug-
gested an increase in the frequency of sexual activities.
20−22
Dur-
ing China’s national lockdown, a study on sexual risk behavior
among 459 men and women aged 18−45 years found that 44%
of participants reported fewer sexual partners and 37% reduced
sexual frequency.
16
A study in the United States in 2020 of
1,051 men who have sex with other men (MSM) aged 15 years
and older reported fewer sexual partners during the COVID-19
restrictions.
17
Alcohol consumption and drug use are risk behaviors associ-
ated with HIV acquisition in young people.
23−26
Changes in
demand for alcohol during nationwide lockdowns as a result of
COVID-19 pandemic were reported across the world.
27−30
South Africa reported an increased demand for alcohol, especially
for online sales, despite certain, albeit less severe, restrictions to
alcohol consumption remaining in place during level 3 of the
lockdown.
27
While little is known about alcohol consumption
during level 3 of lockdown in South Africa, lifting the alcohol
ban may have increased demand and consumption of alcohol.
The association between sexual risk behaviors and substance use
in young South Africans is well reported.
1,2−8,23−26,31,32
Research on sexual behavior in young people during the
COVID-19 pandemic in South Africa is sparse. However, studies
in South Africa on the topic were carried out during the pre-
COVID-19 pandemic periods.
1,24,31,33,34
This paper describes sex-
ual risk behaviors (ie, number and type of sexual partner, frequency
of changing sexual partners, frequency of sexual intercourse, con-
domless sex during the last sexual encounter, frequency of substance
use, and sexual intercourse under the influence of alcohol or drugs)
among young people in Soweto during the first national lockdown
period in 2020 due to the COVID-19 pandemic in South Africa.
METHODS
We conducted a cross-sectional study between July and
August 2020 through telephonic interviewer-administered sur-
veys. The study was conducted during the national lockdown
level 3, which restricted the use of public transport. It also
restricted the use of public and shared premises such as churches,
schools and hospitals, especially without wearing a mask.
35
At
alert level 3, the alcohol ban was lifted, meaning that the sale, dis-
pensing and distribution of alcohol could resume between 9 AM
and 5 PM, Mondays to Thursdays. However, onsite sales of alco-
hol by licensed premises (eg, restaurants) was only permitted
until 8 PM, and a curfew was set from 10 PM to 04 AM.
Setting
The study was conducted at Perinatal HIV Research Unit,
and has been conducting research in Soweto for more than
20 years. The unit has an extensive walk-in HIV counseling and
testing service facility, which is available to the surrounding com-
munity. Participants of this study lived in Soweto, which is a
peri-urban township area located in Gauteng, the country’s most
densely populated province, with a population of approximately
11.3 million people.
36
Previous studies in Soweto report HIV
prevalence of between 3.2% and 4% in young people in
Soweto.
37,38
Study Participants
Eligible participants were young women and men with a self-
reported known or unknown HIV status, aged between 18 and
24 years, with access to a cell phone and living in Soweto, South
Africa. Exclusion criteria included any person younger than 18
or older than 24 years, not residing in Soweto, or without access
to a cell phone.
Recruitment Procedures
We recruited participants through the WhatsApp messaging
service. WhatsApp is a freeware instant messaging platform that
allows users to send text, video and voice messages through a
mobile device.
39
It is a widely used messaging platform among
South African youth, due to its relatively cheap rates, using data
bundles rather than voice minutes.
39
Messages with an informa-
tive digital poster were sent out via the WhatsApp platform using
2Mulaudzi et al
Sex Med 2022;10:100487

a chain referral technique.
40,41
Each participant who successfully
completed the study survey was requested to refer friends or
other young people meeting the study’s inclusion criteria in their
circle. To encourage referrals by participants, an incentive of air-
time vouchers worth R15 (1,04 US$) was offered to participants
upon each successful referral. All referred participants were con-
tacted telephonically during the recruitment and study phases.
Data Collection
The interviewers read the information sheet and consent form to
the participants telephonically and obtained their verbal consent prior
to administering the survey. The informed consent discussions and
participants’consent were recorded using an audio recording device.
Participants were informed that only the consent discussion was
recorded and that the rest of the interview would not be recorded.
Measures
Socio-demographics included questions about age, gender,
socio-economic status, marital status, level of education and
number of dependent children.
42
Sexual Risk Behavior. To assess sexual risk behavior, a risk
assessment for HIV questionnaire was used.Questions included:
current number and type of sexual partner(s) (dating
1
, living
together, one night stand and other
2
); frequency of changes to
different sexual partners; frequency of sexual intercourse, con-
domless sexual intercourse. The questions covered periods rang-
ing from 1 week to a year before the date of participation.
Substance Use. Substance use was assessed through yes/no
questions and related to current use at the time of the study and
during their lifetime. Questions on substance use included cur-
rent use of alcohol or drugs, and sexual intercourse under the
influence of alcohol or drugs.
Ethical Considerations
This study was approved by the [name deleted to maintain
the integrity of the review process] (M1811113). Study partici-
pants were aware that participation in the study is voluntary and
study procedures were conducted only after audio recorded ver-
bal consent was achieved. Participants were given R50 (3,46 US
$) airtime vouchers after completing the survey.
Data Analysis
Frequencies and their respective percentages were determined
for categorical variables and stratified by biological sex. Medians
and interquartile ranges (IQR) were presented for continuous
measures such as age. To test for statistical significance for cate-
gorical variables, Chi-square analysis or Fisher’s exact test was
used. Comparison of continuous measures was non-parametric
using the Kruskal Wallis test. All statistical analysis was con-
ducted in SAS Enterprise Guide 7.1 (SAS Institute, Cary, NC)
using SAS/STAT procedures PROC FREQ, PROC MEANS
and PROC NPAR1WAY.
RESULTS
Demographic Characteristics
The median age of the 129 participants enrolled in the study
was 22 (IQR: 19−23). About 55% (n = 71/129) were female
and all participants identified as Black (Table 1). The majority
spoke IsiZulu (a local South African language) as their home lan-
guage (51.2%, n = 66/129), most lived in a brick house owned
by their family (70.5%, n = 91/129), less than half had com-
pleted high school (42.6%, n = 55/129), less than a third had
earned more than R3000/mo in the previous three months
(23.3%, n = 30/129) and most had no children (80.6%,
n = 104/129).
Sexual Risk Behavior
Overall Sexual Risk Behavior. Of the 129 participants,
83% (n = 107) had a sexual partner, most of whom had only one
partner (60.8%, n = 65/107) at the time of the study. Most par-
ticipants had a regular (dating) partner (85.1%, n = 91/107),
and changed partners within a year (53.3%, n = 57/107). Most
typically used condoms with their partners (72.0%, n = 77/107)
and occasionally had penetrative sexual intercourse (51.4%,
n = 55/107). The majority had last had vaginal sex (87.0%,
n = 93/107) within the past week (54.2%, n = 58/107) with
their dating partner (86.0%, n = 92/107) and had used a con-
dom during their last encounter (63.6%, n = 68/107). Only
3.7% of participants in this study reported group sex activity
(Table 2).
Sexual Risk Behavior By Gender. Relative to males,
females were significantly more likely to have only one current
sexual partner (71.4% vs 49.0%; P= .0177), a dating partner
(94.6% vs 74.5%; P= .0035), changing partners within a year
(64.3% vs 41.2%; P= .0167), had vaginal sex (98.2% vs 74.5%;
P= .0003) with their dating partner during the last sexual
encounter (96.4% vs 74.5%; P= .0011) (Table 2). Males were
more likely than females to have one night stands (23.5% vs
7.1%; P= .0176), make weekly changes in partners (17.7% vs
5.4%; P= .0442), regularly use condoms with their partners
(92.2% vs 53.6%; P<.0001), to have had anal sex during the
last sexual encounter (27.5% vs 8.9%; P= .0123) and to have
used condoms during their last sexual encounter (84.3% vs
44.6%; P<.0001) (Table 2).
1
Dating partner in this study refers to main/regular partner (6)
2
Other in this study specifically refers to group sex (7)
Youth Sexual Risk Behaviours During COVID-19 National Lockdown 3
Sex Med 2022;10:100487

Table 1. Biographical information by biological sex
Variable Overall Female Male Pvalue
Age (in years)
18−20 (n, %) 49/129 (37.98) 24/71 (33.80) 25/58 (43.10) .4574
21−22 (n, %) 37/129 (28.68) 21/71 (29.58) 16/58 (27.56)
23−24 (n, %) 42/129 (32.56) 26/71 (36.62) 16/58 (27.56)
Median (IQR) 22.0 (19.0−23) 22.0 (20.0−24) 21.0 (19.0−23) .2290
Mean (SD) 21.2 (2.20) 21.5 (2.15) 21.0 (2.26) .2166
Min, Max (18−24) (18−24) (18−24)
What is your racial background?
Black (n, %) 129/129 (100.0) 71/71 (100.0) 58/58 (100.0) -
What is the main language spoken in your home?
Afrikaans (n, %) 1/129 (0.78) 0/71 (0.00) 1/58 (1.72) .3398
English (n, %) 1/129 (0.78) 1/71 (1.41) 0/58 (0.00)
IsiZulu (n, %) 66/129 (51.16) 33/71 (46.48) 33/58 (56.90)
Northern Sotho (n, %) 2/129 (1.55) 0/71 (0.00) 2/58 (3.45)
Tshivenda (n, %) 2/129 (1.55) 1/71 (1.41) 1/58 (1.72)
Sesotho (n, %) 18/129 (13.95) 13/71 (18.31) 5/58 (8.62)
Xitsonga (n, %) 13/129 (10.08) 6/71 (8.45) 7/58 (12.07)
IsiXhosa (n, %) 13/129 (10.08) 9/71 (12.68) 4/58 (6.90)
Setswana (n, %) 13/129 (10.08) 8/71 (11.27) 5/58 (8.62)
What is the main material that the walls of your house are built of?
Brick house owned by family (n, %) 91/129 (70.54) 45/71 (63.38) 46/58 (79.31) .3490
Brick house that family is renting (n, %) 2/129 (1.55) 1/71 (1.41) 1/58 (1.72)
Flat owned by family (n, %) 2/129 (1.55) 2/71 (2.82) 0/58 (0.00)
Flat that family is renting (n, %) 1/129 (0.78) 1/71 (1.41) 0/58 (0.00)
RDP house (n, %) 17/129 (13.18) 10/71 (14.08) 7/58 (12.07)
Hostel (Brick) (n, %) 1/129 (0.78) 0/71 (0.00) 1/58 (1.72)
Shack - Informal settlement (n, %) 4/129 (3.10) 3/71 (4.23) 1/58 (1.72)
Shack - Backyard (n, %) 10/129 (7.75) 8/71 (11.27) 2/58 (3.45)
Student resident (n, %) 1/129 (0.78) 1/71 (1.41) 0/58 (0.00)
What is the highest level of formal education you have completed?
Complete primary school (completed grade 7) (n, %) 1/129 (0.78) 0/71 (0.00) 1/58 (1.72) .1204
Incomplete high school (up to grade 12) (n, %) 32/129 (24.81) 15/71 (21.13) 17/58 (29.31)
Complete high school (completed grade 12) (n, %) 55/129 (42.64) 32/71 (45.07) 23/58 (39.66)
Incomplete post-high school training (Trade or technical training,
college, or university) (n, %)
23/129 (17.83) 10/71 (14.08) 13/58 (22.41)
Complete post-high school training (Trade or technical training, college,
or university) (n, %)
18/129 (13.95) 14/71 (19.72) 4/58 (6.90)
Young people can get money in many different ways, for example, a full-
time job, a part-time job, odd jobs or piece work. Thinking about all of
the different ways you get money, over the LAST 3 mo, what was your
total income?
1−400 Rand (n, %) 22/129 (17.05) 9/71 (12.68) 13/58 (22.41) .5661
401−800 Rand (n, %) 22/129 (17.05) 11/71 (15.49) 11/58 (18.97)
801−1600 Rand (n, %) 28/129 (21.71) 17/71 (23.94) 11/58 (18.97)
1601−3200 Rand (n, %) 20/129 (15.50) 13/71 (18.31) 7/58 (12.07)
3201 or more Rand (n, %) 30/129 (23.26) 18/71 (25.35) 12/58 (20.69)
Don't know (n, %) 7/129 (5.43) 3/71 (4.23) 4/58 (6.90)
How many children do you have?
None (%) 104/129 (80.62) 50/71 (70.42) 54/58 (93.10) .0012
1 (%) 20/129 (15.50) 16/71 (22.54) 4/58 (6.90) .0146
2 or more (%) 5/129 (3.88) 5/71 (7.04) 0/58 (0.00) -
4Mulaudzi et al
Sex Med 2022;10:100487

Substance Use and Sexual Risk Behavior. As depicted in
Table 3, almost two-thirds of participants were alcohol drinkers
(69.0%, n = 89/129), most of whose frequency of use ranged
from sometimes to often (84.3%, n = 75/89). Most participants
drank alcohol socially (94.4%, n = 84/89). Males were more
likely than females to use alcohol on a weekly basis (21.4% vs
6.4%; P= .0380). Most participants did not use drugs (94.6%,
n = 122/129); of those who did (5.4%, n = 7/129), marijuana
Table 2. HIV risk assessment by biological sex
Variable Overall Female Male Pvalue
Do you have a sexual partner?
No (n, %) 22/129 (17.05) 15/71 (21.13) 7/58 (12.07) .1736
Yes (n, %) 107/129 (82.95) 56/71 (78.87) 51/58 (87.93)
How many sexual partners do you currently have?
One (n, %) 65/107 (60.75) 40/56 (71.43) 25/51 (49.02) .0177
More than 1 (n, %) 42/107 (39.25) 16/56 (28.57) 26/51 (50.98)
Median (IQR) 1.00 (1.00−2) 1.00 (1.00−2) 2.00 (1.00−3) .0071
Mean (SD) 1.75 (1.49) 1.49 (1.34) 2.04 (1.60) .0553
Min, Max (0−10) (0−10) (1−10)
What types of partners are they?
One night stand (n, %) 16/107 (14.95) 4/56 (7.14) 12/51 (23.53) .0176
Dating (n, %) 91/107 (85.05) 53/56 (94.64) 38/51 (74.51) .0035
Living together (n, %) 4/107 (3.74) 2/56 (3.57) 2/51 (3.92) .9240
Other (n, %) 5/107 (4.67) 3/56 (5.36) 2/51 (3.92) .7253
Refuse to answer (n, %) 1/107 (0.93) 0/56 (0.00) 1/51 (1.96) -
Frequency of new/different partners?
Weekly (n, %) 12/107 (11.21) 3/56 (5.36) 9/51 (17.65) .0442
Monthly (n, %) 35/107 (32.71) 14/56 (25.00) 21/51 (41.18) .0749
Yearly (n, %) 57/107 (53.27) 36/56 (64.29) 21/51 (41.18) .0167
Never (n, %) 2/107 (1.87) 2/56 (3.57) 0/51 (0.00) -
Refuse to answer (n, %) 1/107 (0.93) 1/56 (1.79) 0/51 (0.00) -
Do you typically use condoms with these partners?
Yes (n, %) 77/107 (71.96) 30/56 (53.57) 47/51 (92.16) <.0001
No (n, %) 30/107 (28.04) 26/56 (46.43) 4/51 (7.84)
How often do you have sexual penetrative intercourse?
Regularly (n, %) 48/107 (44.86) 25/56 (44.64) 23/51 (45.10) .9933
On occasion (n, %) 55/107 (51.40) 29/56 (51.79) 26/51 (50.98)
Unusually (n, %) 4/107 (3.74) 2/56 (3.57) 2/51 (3.92)
When was the last time you had sex?
Within 1 wk (n, %) 58/107 (54.21) 29/56 (51.79) 29/51 (56.86) .6888
Within 1 mo (n, %) 33/107 (30.84) 20/56 (35.71) 13/51 (25.49)
Within 1−3 mo (n, %) 10/107 (9.35) 5/56 (8.93) 5/51 (9.80)
Within 3−6 mo (n, %) 4/107 (3.74) 1/56 (1.79) 3/51 (5.88)
Within 1 y (n, %) 2/107 (1.87) 1/56 (1.79) 1/51 (1.96)
With whom did you have sex? If group sex event, specify in 'Other'
One night stand (n, %) 8/107 (7.48) 0/56 (0.00) 8/51 (15.69) -
Dating partner (n, %) 92/107 (85.98) 54/56 (96.43) 38/51 (74.51) .0011
Living together (n, %) 2/107 (1.87) 1/56 (1.79) 1/51 (1.96) .9468
Other (n, %) 4/107 (3.74) 1/56 (1.79) 3/51 (5.88) .2645
Refuse to answer (n, %) 1/107 (0.93) 0/56 (0.00) 1/51 (1.96) -
How did you have sexual relations?
Oral (n, %) 35/107 (32.71) 20/56 (35.71) 15/51 (29.41) .4877
Vaginal (n, %) 93/107 (86.92) 55/56 (98.21) 38/51 (74.51) .0003
Anal (n, %) 19/107 (17.76) 5/56 (8.93) 14/51 (27.45) .0123
Did you use a condom with the last sexual encounter?
No (n, %) 39/107 (36.45) 31/56 (55.36) 8/51 (15.69) <.0001
Yes (n, %) 68/107 (63.55) 25/56 (44.64) 43/51 (84.31)
Youth Sexual Risk Behaviours During COVID-19 National Lockdown 5
Sex Med 2022;10:100487

was their drug of choice. Most participants who drank or used
drugs usually had penetrative sex during this time (56.0%,
n = 47/84).
DISCUSSION
This paper adds to the body of sexual and reproductive health
research by describing sexual risk behaviors and substance use
among youth aged 18−24 years in South Africa during the first
COVID-19 lockdown. The results show that, despite the risk of
contracting COVID-19, most participants reported having had sex
within the past 7 days at the time of data collection. A large number
of participants reported alcohol consumption, and more than half
had engaged in sex while under the influence of alcohol or drugs.
Having more than one partner significantly increases the chan-
ces of exposure to HIV, as does changing partners frequently.
43
More than half of the participants in this study reported engaging
in sex with their long-term partners during level 3 of the lockdown.
This was especially true for female participants, whereas their male
counterparts were more likely to change partners in less than a
year. Despite the COVID-19 lockdown restrictions, about 54% of
the participants in this study had sex and 87.9% (51/58) of those
had vaginal sex within a week of the time of data collection. While
our study cannot determine whether the participants’sexual
activity increased or decreased, it does reveal that a large number
reported engaging in sexual activity during level 3 of the lockdown.
Their actions may have been a consequence of feeling isolated and
lonely during levels 5 and 4, which severely restricted local and
international travel, and limited social contact to their immediate
family.
14
Recent studies report increased sexual activity during the
COVID-19 national lockdowns in the U.S., U.K. and south-east
Asian countries (Bangladesh, India and Nepal).
20−22
In some of
these studies, participants’feelings of isolation, anxiety and loneli-
ness during lockdown prompted sexual contact,
15
which fulfilled
their psychological needs, relieved negative emotions
16
and reaf-
firmed their sense of feeling loved.
Sexually active participants in this study reported a high rate
of condom use, especially for penetrative vaginal sex. More par-
ticipants reported using condoms during last sexual contact than
those who did not, and most confirmed that they typically use
condoms with their sexual partners. The 2017 National HIV
prevalence survey recorded increased condom use during last sex-
ual encounter among young people in South Africa.
44
While
these results are encouraging for HIV prevention efforts, incon-
sistent condom use remains a challenge, particularly among ado-
lescents and young women.
2,17,18
More than one-third of
participants (36%) in this study reported condomless sex during
last sexual contact, more than half of whom (55%) were female.
Table 3. Substance use by biological sex
Variable Overall Female Male Pvalue
Do you drink alcohol?
Yes (n, %) 89/129 (68.99) 47/71 (66.20) 42/58 (72.41) .4476
No (n, %) 40/129 (31.01) 24/71 (33.80) 16/58 (27.59)
How often do you use alcohol?
Daily (n, %) 2/89 (2.25) 0/47 (0.00) 2/42 (4.76) -
Weekly (n, %) 12/89 (13.48) 3/47 (6.38) 9/42 (21.43) .0380
Sometimes (n, %) 75/89 (84.27) 44/47 (93.62) 31/42 (73.81) .0104
How do you use alcohol?
Socially (n, %) 84/89 (94.38) 44/47 (93.62) 40/42 (95.24) .7402
Excessively (n, %) 5/89 (5.62) 3/47 (6.38) 2/42 (4.76)
Do you use drugs?
Often (weekly) (n, %) 2/129 (1.55) 0/71 (0.00) 2/58 (3.45) -
Sometimes (n, %) 5/129 (3.88) 1/71 (1.41) 4/58 (6.90) .1082
No (n, %) 122/129 (94.57) 70/71 (98.59) 52/58 (89.66) .0258
Which drugs do you use?
Marijuana (n, %) 7/7 (100.0) 1/1 (100.0) 6/6 (100.0) -
Do you usually have penetrative sexual intercourse with your partner(s)
when you have been drinking or using drugs?
Yes (n, %) 47/84 (55.95) 27/44 (61.36) 20/40 (50.00) .2947
No (n, %) 37/84 (44.05) 17/44 (38.64) 20/40 (50.00)
Have you ever suffered from depression or stress?
Yes (n, %) 53/129 (41.09) 36/71 (50.70) 17/58 (29.31) .0140
No (n, %) 76/129 (58.91) 35/71 (49.30) 41/58 (70.69)
Are you worried about getting / having HIV or AIDS?
Yes (n, %) 81/129 (62.79) 48/71 (67.61) 33/58 (56.90) .2107
No (n, %) 48/129 (37.21) 23/71 (32.39) 25/58 (43.10)
6Mulaudzi et al
Sex Med 2022;10:100487

This finding is not unique to this study in the South African con-
text. Previous studies in HIV prevention report high rates of con-
domless sex or inconsistent condom use in females due to their
socio-economic circumstances and imbalanced gender-power
dynamics in their sexual relationships.
2,17,19,20
Several similar
studies have found that adolescents and young women in cohab-
iting, stable or marital relationships are likely to report condom-
less sex, and if not, inconsistent condom use.
2,3
Most of the participants in the current study who were alco-
hol drinkers described their consumption as mostly social or
occasional drinking. This was despite the South African govern-
ment’s ban on the sale and consumption of alcohol in public pla-
ces as part of the COVID-19 lockdown regulations. In South
Africa, alcohol, marijuana, and tobacco are the three most fre-
quently reported substances used.
24,45,46
Alcohol consumption is
one of the many behaviors that put youth at higher risk of expo-
sure to HIV.
24,47
From the sample of participants who reported
substance use, some reported having penetrative sex with a part-
ner after using marijuana or consuming alcohol. Marijuana was
the only drug our study’s participants reported using. Drug and
substance abuse is a biobehavioral factor that is related to HIV
transmission and has been seen as a significant facilitator of the
HIV spread among MSM.
48
Sanchez et al (2020) suggested that
young participants in their study were more likely to have
increased their drug and alcohol use during COVID-19.
17
Male participants in our study were more likely to use alcohol,
which is a significant concern in the context of COVID-19 restric-
tions. A study on self-reported alcohol consumption in Belgium
showed that, from a sample of 2,871 adults, at least 75% had either
maintained or increased their alcohol use during the national lock-
down.
29
While the reasons for alcohol consumption varied, the pre-
dominant factors included the possibility of contamination by their
partner, and heightened levels of depression and anxiety. In South
Africa, the national lockdown may have added to people’spsycho-
logical stress because of their isolation and restricted movement,
and the fear of contracting the virus. These factors may have
prompted more people to use alcohol and substances to cope with
the pandemic, as suggested by numerous publications on the topic
during the COVID-19 lockdown.
28,29,49,50
Limitations
The main limitations of this study relate to the sample size
and sampling strategy. As the sample was not representative of
the population of young people in Soweto and South Africa, the
results cannot be generalized. However, the findings have rele-
vance for future research in HIV prevention for young people in
other settings in South Africa. Another limitation was that the
questions on sexual behavior and substance use were not tailored
specifically for the lockdown period. However, data on sexual
behavior is relevant as it was collected while the national lock-
down restrictions were still in place. Additionally, the survey con-
tained sensitive questions on participant’s sexual behavior which
may have resulted in social desirability bias. The self-reporting of
mental health, while giving participants privacy, may also have
made the study susceptible to invalid answers owing to misinter-
pretation or lack of clarity on questions.
CONCLUSION
Most of the youth reported sex and alcohol use despite the
social distancing restrictions due to the COVID-19 pandemic.
However, some participants reported that other sexual risk behav-
iors such as sex under the influence of substances and group sex
activities still occurred among youth in South Africa during this
time. Future studies may explore sexual risk behavior before, dur-
ing and after imposing the national lockdown to better understand
and mitigate the impact of pandemics such as COVID-19 on the
sexual behavior in young people in South Africa.
AVAILABILITY OF DATA AND MATERIALS
Data will be made available on request.
Ethics Approval and Consent to Participate
Audio recorded verbal consent was achieved from all partici-
pants. Ethical clearance was achieved from University of the Witwa-
tersrand Human and Research Ethics Committee (HREC-medical).
Consent for Publication
All participants agreed to the publication of the data provided.
Corresponding Author: Mamakiri Mulaudzi, Perinatal HIV
Research Unit (PHRU), School of Clinical Medicine, Faculty of
Health Sciences, University of the Witwatersrand, 26 Chris
Hani Road Diepkloof, Soweto, Johannesburg, 1864, South
Africa.; E-mail: mulaudzim@phru.co.za
Conflict of Interests: All authors declare that they have no compet-
ing interests.
Funding: Mamakiri Maluadzi received funding from the follow-
ing institutions: the Thuthuka PhD award through the National
Research Foundation (NRF) of South Africa; the National Insti-
tute for the Humanities and Social Sciences (NIHSS), in collabo-
ration with the South African Humanities Deans Association
(SAHUDA); the Soweto Matlosana Collaborating Centre for
HIV/AIDS and TB (SoMCHAT), through support from the
South African Medical Research Council; and the Canada-Africa
Prevention Trials Network (CAPTN). Dietrich’s work on this
manuscript was supported through a Thuthuka post-PhD award.
Opinions expressed and conclusions arrived at are those of the
authors and do not necessarily reflect those of the NIHSS,
SAHUDA, NRF, SoMCHAT, or CAPTN.
The work reported herein for Janan Dietrich was also made possi-
ble through partial funding by the South African Medical Research
Council (SAMRC) through its Division of Research Capacity
Development under the SAMRC Postdoctoral Programme from
Youth Sexual Risk Behaviours During COVID-19 National Lockdown 7
Sex Med 2022;10:100487

funding received from the South African National Treasury as well
as the CIPHER GROWING THE LEADERS OF TOMOR-
ROW grant from the International AIDS Society.
Thecontenthereofisthesoleresponsibilityoftheauthorsanddo
not necessarily represent the official views of the SAMRC, IAS or
the funders.
STATEMENT OF AUTHORSHIP
Mamakiri Mulaudzi: Conceptualization; Mamakiri
Mulaudzi: Validation; Kennedy Otwombe: Formal Analysis;
Khuthadzo Hlongwane: Formal Analysis; Mamakiri Mulaudzi:
Writing −Original Draft; Campion Zharima: Review & Edit-
ing; Peace Kiguwa: Supervision; Janan J. Dietrich: Supervision
All authors approved the final version of the manuscript for
submission for publication.
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