HIV Prevention for Young Adults
in South Africa:
Addressing Risk in the AIDS Epicentre
Lucia F. O’Sullivan, PhD
Associate Professor, Department of Psychology
Canada Research Chair in Adolescents’ Sexual Health Behaviour
University of New Brunswick
Presentation, Sexual Health Awareness Week
Centre for History of Medicine
Warwick University
November 25 2009
Young people under age 30 are among the highest HIV prevalence in the world. Surveys
indicate a rapid increase in condom use among South African youth between 1995-2005
(Dinkelman et al., 2007; HSRC, 2009; Pettifor et al., 2004). Recent data show 87.4% of 15-24
year old men report condom use at last sex, and 73.1% of women (Human Sciences Research
Council; HSRC, 2009). What is unclear, however, is why there are continued high levels of HIV
infection and high levels of pregnancy (one third have a child before 25 years of age) given such
high levels of condom use. Our research was designed to explore relationship dynamics and
the influence of gender on efforts to prevent HIV, particularly through the use of condoms and
partner reduction strategies.
We conducted a series of qualitative interviews among young people residing in rural northern
KwaZulu/Natal province. This area is a fairly homogenous culture, with Zulu being the main
cultural and linguistic group. It is characterized by a long history of inequality and
marginalization, social isolation and high levels of poverty. Annual per capita income is less
than $1000 USD. The inhabitants rely on labor migration, which disrupts family life and
relationships. They also tend to be socially conservative and strongly religious.
We conducted in-depth interviews with 47 young adults (18-24 years) in established
relationships (23 men and 24 women), then completed 29 follow-up interviews after two years
(10 men and 19 women), for a total of 76 interviews. The sample was school-going youth in
final two years of secondary school. We conducted classroom-based recruitment, using
purposive sampling. We analyzed the data using thematic coding and comparative matrices to
construct the relationship narratives. We used NVivo to manage the data and analysis.
We found that young South Africans primary relationships tended to be of long duration. The
average duration was 3.9 years for women and 2.4 for men. Most relationships were ongoing
at the time of the second interview, and thus total duration is likely far longer. Romance and
long-term aspirations, such as marriage, characterized participants’ feelings about their
relationships despite historically low rates of marriage among adults and young adults. Of
interest, secondary partnerships were very common among both the young women and men.
These concurrent relationships were also relatively long-lasting. The average duration was 1.4
years among the women and 0.7 months among the men. However, there were notable
differences in the ways in which women and men described these relationships. Men tended to
note that having secondary partners was a common and accepted practice among men.
Women described these relationships in the context of need—both emotional and economic.
Both also described the context of uncertainty—often being separated from their primary
partners by distance and enduring long periods of separation. Secondary partnerships, thus,
represented a form of security for many of these young people.
As expected, and in contrast to national health surveys, we found relatively low rates of
consistent condom use. At follow-up, 5 of the 10 men and 5 of the 19 women indicated that
they always used condoms. Condom used varied as a function of partnership type. Little
condom use was noted with primary partnerships, which was characterized by love and ‘trust,’
whereas secondary partnerships were perceived as far more casual (despite often being longlasting). There tended to be much more consistent use of condoms in these contexts.
We saw little acknowledgement of the importance of partner reduction as a form of protection
from HIV infection, although perhaps a growing view that partner reduction was ultimately
important. Given the low rates of condom use overall, 15 of the 24 young women had a child at
the two-year follow-up interview. Pregnancy is accepted within long-term relationships only if
not necessarily encouraged, desired, or intended.
In sum, intervention research needs to target this high risk sub-group. Despite reporting high
levels of condom use in national health surveys, interviews reveal relatively low rates, especially
in established relationships. Continued high rates of infection and pregnancy lend validity to
our findings. Future research must address fertility intentions and values, contraceptive
trajectories, and relationship values and decision-making.
This research was funded by a grant from NICHD R01-HD41721 (to Lucia F. O’Sullivan, Ph.D.).
These findings are summarized in a forthcoming article by Abigail Harrison, Ph.D. and Lucia F.
O’Sullivan, Ph.D., (in press). In the Absence of Marriage: Long-term Concurrent Partnerships,
Pregnancy, and HIV Risk Dynamics among South African Young Adults. AIDS & Behavior.