HIV Prevention and Sexual Relationships: A Qualitative Analysis of Sexual Histories

HIV Prevention and Sexual Relationships: A Qualitative Analysis of Sexual Histories National workshops: Johannesburg, Durban, Cape Town. November 2006 Benjamin Makhubele and Pumla Ntlabati Centre for AIDS Development, Research and Evaluation www.cadre.org.za

Objectives • Numerous quantitative studies and epidemiological analyses have illustrated very high HIV infection risks associated with partner turnover and concurrent sexual partnerships • The dynamics of sexual partnerships are not well understood • This small-scale qualitative study set out to explore- Individual histories of sexual relationships- Rationale for sexual relationships- Patterns in sexual relationships- Regulatory aspects of sexual relationships- Implications for and perceptions of HIV risk- Aspects of AIDS-related communication • Overall goal is to explore dynamics of sexual partnerships with a view to guiding HIV prevention communication

Methods • 14 in-depth interviews were conducted with 14 individuals aged 18-29 in two sites – Johannesburg and Grahamstown • Both males and females were interviewed, and locales for sampling respondents were high school (4); university residence (4) as well as categories of employment – employed (2) and unemployed (4) • Interviews transcribed and analysed • Preliminary findings presented here

Findings:Sexual debut (1) • Sexual debut was often unplanned, and included manipulation of contexts where debut could be initiated “When I got there he told me that he wanted to see his sister who lived nearby. Only to find that there was no one in that house” (female, 21) “I was there looking for my friend, right... So I was just sitting with her, one thing led to another and we ended up having sex” (male, 18) “…When I got out he asked me to accompany him to the shops…It never dawned on me that something was going to happen” (female, 22) “On our way home… we lagged behind…Then [he] said we should go to his house and that we won’t be long and I went along. And in his home we sat on top of his bed and kissed then we slept together. It was my first time and it was painful” (female, 21).

Findings:Sexual debut (2) • A number of respondents referred to debut occurring with people they were not in a relationship with “The first girl, it was like we weren’t going out. It was just something that happened that day. It was like okay we did it after that day but it was not really a consolidated relationship” (male, 18) “The first person I slept was not my girlfriend. She was my friend’s girlfriend” (male, 23). • Forced debut also occurred I was forced to ‘do’ sex with some girl. It was actually her older sister and her friends. … they just said that we must ‘do’ sex and I refused, the girl also refused. They were older girls, and they were saying that we must do it or else they would report that we had done it anyway. We then went ahead and did it.” (male, 24) • Where debut was planned, it included some preparation including obtaining contraceptives

Findings:Sexual debut – peer pressure • Public ridicule was provided as an example of peer pressure at school “… these HIV/AIDS programmes were going to schools, they also came to my school. But then they told us when they went to this other school… they asked who’s a virgin, you know, then they said this other girl put her hand up, the whole school was like laughing at her. You know, like, really laughing at her …” (female, 18) “They will say that she is still very rural, she does not have style, she does not know anything…They do not look at you nicely …they would wonder why you are not doing it. You will end up telling yourself to do it as well” (female, 22) “…the guys, they were asking about it all the time and it got to a point where they accused me of lying to them when I said we had not had sex. Some of them were also in relationships at this stage, and I think I started feeling the pressure to press on for sex.” (male, 24)

Findings:Sexual debut – Resisting peer pressure For some, strategies of resistance were applied… • Support of friends: “Well, I don’t feel pressured whatsoever because I’ve got two friends who haven’t done it at all, so I don’t feel pressured because I feel part of those others” (female, 18) • Direct knowledge of risks – a cousin had a pregnancy terminated at age 15… “So that motivated me to abstain because I did not want to find myself in the same situation, you see” (female, 28) • Ambivalence about sex and ‘self esteem’ “I feel good that there’s no guy… the guy tells you let’s go and do this and so I just want to… build my self esteem without a guy” (female, 18)

Findings:Initiation of sex in relationships • Many respondents reported that sex was initiated early on in the relationship “She came to me and said she likes me. I responded. I had not realized she wanted to leave with me, I thought she just liked me… I got up and she was waiting for me, we left together. I did not sleep at home that day”. (male, 20) “I’d say it’s usually after about three days or so, then the guy will let you know that they will come and pick you up. You may go to a movie first and later to his place”. (female, 28) “Maybe two weeks, but definitely not a month… A month is too long to wait. I take two weeks or three.” (female, 21) • Peers played a mentoring role in sex by sharing experiences, helping to arrange private venues for sex and helping to prevent parental scrutiny

Findings:Lifetime numbers of partners * Total number much higher as product of one-night stands that could not be estimated

Findings:Rationale for relationships • Some respondents noted that they were in relationships for the sake of being in a relationship • Motivations for sexual relationships included– love– ‘fun’– belonging to a group– status– access to money, resources– proving oneself– passing the time • Commitment was not seen as a strongly motivating factor within relationships • There was acceptance of having a sexual relationship with a person already in another relationship • Relationships don’t formally end, and previous relationships may be resumed over time

Findings:Economic factors as motivators • Sexual availability and money were seen as interlinked “She has about seven different cars visiting her. And she says she does it for transport, so if she wants to go some place and one car is busy she has access to another. As well as money, so she can get money. She has men who get paid on the 15th , 20th , 30th” (male, 20) “Yes, for both men and women this is always a factor, that’s why you get young boys going after older women” (female, 28)

Findings:Partner turnover – proving oneself • Sexual achievement is viewed as linked to ‘proving’ oneself… “You know sometimes there is this thing of wanting to prove yourself. Like if you are a gang, a group a friends, even if you can tell yourself that you do not do such and such, your friends will always make you do otherwise… You end up thinking that your ideas were wayward as compared to what they suggest to you.” (male, 26) “…it is now a hobby to him to have many girls…So he continually wants to prove himself” (male, 20) “[Older males] used to taunt us about having one relationship. You were regarded as isishumane [a guy who is not making it in the love department] and they would tell us how they used to be ‘players’ in their time. We also wanted the honour of being regarded highly by them and earning the respect of your peers” (male, 24)

Findings:Partner turnover – unfaithfulness • Connected to the idea of men being ‘naturally’ promiscuous “Sometimes I think that men were born to be like that as well. Because it is just impossible to have one girlfriend. It simply does not happen. It is something that is impossible” (male, 26). “It is common with boys… I think boys can’t seem to stick to one person” (female, 21) • But can also be linked to revenge… “I cheated on him because I wanted revenge for what he had done to me. My friends and I went to a party in East London and there we decided to have new boyfriends. Although it was supposed to be a temporary arrangement, mine lasted longer until my boyfriend here found out that I was doing something like that”. (female, 28)

Findings:Partner turnover – insecurity • Having ‘spare’ or other partners is linked to feelings of insecurity “I guess people have spare boyfriends because I mean most people they are afraid to be alone… It’s their fear to be alone. To think hey, the boyfriend decides that he doesn’t want to have sex so she can go and cry on the other boyfriend’s shoulder.” (female, 18) “Or it also happens like maybe she’s going out with this boyfriend for like a reason, a different reason, and she’s going with the other one for a different reason”. (female, 18) “They say that if I concentrate on one person and that person disappoints me I would feel like committing suicide. But if you have several, if one tells you stories you do not have to worry yourself. You just go to the next one. Things like that”. (male, 23) Interviewer: And if you really love the person, do you still need to have backup? Respondent: Yes because you won’t always agree on everything, and having others leaves room for those tough times.” (male, 24)

Findings:Turnover/concurrency – disincentives • Disapproval by family members and being caught out by partners are disincentives to having many and/or other partners. “They could even chase me from home. It is totally wrong to be sexually involved with more than one person. It is not like they are generally against being sexually involved. It is the number of people I am involved with that will be of major concern to them”. (male, 23) For some this results in secrecy: “For instance, I hide because I respect the elders I live around. They don’t see me they’ve never seen me going to a boyfriend or coming back in the morning”. (female, 21) • Some respondents spoke about conflict amongst concurrent partners – “He had too many girlfriends and I kept getting into fights”. (female, 28)

Findings:Turnover/concurrency – resistance • Risks of AIDS and pregnancy were seen as rationale for not having a partner at all (secondary abstinence) “I think I’ve somehow had it with men, and I had invested a lot in the relationship so at this point I don’t see myself getting involved. I’ve also seen people getting involved with new partners and getting infected…My decision is also affected by the fact that my aunt has lost three of her children to AIDS. In three consecutive years”. (female, 28) • Withstanding peer pressure is linked to survival “There are friends who will lead you astray… you have to learn to stand up for yourself and not get talked into any nonsense” (female, 28)

Findings:Casual sex – alcohol • Alcohol influences casual sex and disincentivises condom use “When we were drunk we would not use condoms but when we were sober, I would consider the risk and I would insist that we use them”. (female, 28) “There was a party there and we were drinking. I met a guy there who was very interested in me but he was very ugly. But there more I drank, it seemed as though this guy was getting more interesting and I was beginning to like him. He kissed me and I kissed him back… I went home with him and we slept together, but we used a condom. Then in the morning I was ashamed…”. (female 28). “I do have a friend who behaves like that… she has this man the one week and another the next…it’s like she only gets her men from drinking places. We always ask her why she has never met a man in town, for instance, but only gets them in one way only”. (female, 28).

Findings:Partner concurrency • Different locales influence opportunity linked to ‘need’ “There is one that I am involved with here. The thing is that the one in Vryheid – I am unable to see her when I want to because of the distance between us. And I cannot afford to have her come to visit me. That is where I ended up having a local girlfriend. I do understand that a person must try and control himself, but it is not possible to do so for a long time” (male, 23) If I have one in PE, another in Queenstown and another in Butterworth, then I can manage having multiple relationships. You fall in love with different people by being at different places at certain times and you only pursue that relationship when you are with them, you see (male, 19) “I had a girlfriend at school, I had a girlfriend in Soweto, I had a girlfriend here in Hillbrow. Different places you see. To make sure that they never meet.” (male, 18)

Conclusions (1) • Social norms (‘peer pressure’) amongst young people place value on early sexual debut and on sexual experience • Sexual debut is often unplanned, and does not necessarily occur within an established relationship • Sexual initiation in relationships is reported to occur very early after the relationship is established – within a few weeks • Higher levels of partner turnover and concurrency are reported freely by males, but less so by females • Numbers of sexual partners and experiences of sexual relationships vary considerably between individuals • Some individuals are highly promiscuous, whilst others are less so. The overall pattern is for higher levels of partner turnover and concurrency to occur amongst males – but not exclusively

Conclusions (2) • In spite of the severe AIDS epidemic – which includes widespread knowledge of people dying of AIDS – there is very little understanding or internalisation of the risks of having many sexual partners or concurrent partners • Whilst discincentives to partner concurrency and turnover exist (via parents, fear of being caught, fear of AIDS), these are largely de-emphasised at the individual level • Infidelity is generally perceived as acceptable • Respondents generally used condoms inconsistently, but considered themselves to be regular condom users • Lack of condom use in conjunction with alcohol consumption was acknowledged but not necessarily addressed

Implications • There is very little clear knowledge or internalisation of the risks of sexual partner turnover in the context of a severe HIV epidemic • There is an urgent need for communication interventions to prioritise promotion of– delayed sexual debut– limiting lifetime number of sexual partners– avoiding casual sexual encounters– avoiding concurrent sexual partnerships • The necessity of consistent condom use needs to be communicated • Normative changes also need to be addressed. In particular, the severity of the epidemic needs to be linked the high risk of starting sex early and having a high partner turnover

HIV Prevention and Sexual Relationships: A Qualitative Analysis of Sexual Histories