Skip to main content
Springer Nature Link
Log in

In the Absence of Marriage: Long-Term Concurrent Partnerships, Pregnancy, and HIV Risk Dynamics Among South African Young Adults

  • Original Paper
  • Published:
AIDS and Behavior Aims and scope Submit manuscript

Abstract

In KwaZulu/Natal, South Africa, where HIV prevalence is among the world’s highest, a longitudinal qualitative study of partnership dynamics and HIV preventive behaviors was conducted. 47 young adults aged 18–24 participated in in-depth interviews, and 29 were re-interviewed 2 years later. Five analytical domains emerged: primary partnerships, love and romance; secondary partnerships; pregnancy/parenthood; condom use/prevention; and contextual influences, including schooling and future aspirations. Primary relationships were long-lasting, with most men and women in the same relationship at 2-year follow-up. Secondary, casual partnerships were common for men and women, although these were shorter and changed frequently. Love and marriage aspirations were not viewed as incompatible with secondary partners. Condom use increased over time in some primary relationships, but decreased in others, and was nearly universal with non-primary partners. Pregnancy, school drop-out, and economic need strongly influence young people’s lifecourse. These findings suggest the need to focus prevention efforts on the partnership context, including partner reduction, and structural factors that impede or enhance prevention success.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
$34.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or eBook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Canada)

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Garnett GP, Johnson AM. Coining a new term in epidemiology: concurrency and HIV. AIDS. 1997;11(5):681–3.

    Article  CAS  PubMed  Google Scholar 

  2. Morris M, Kretzschmar M. Concurrent partnerships and the spread of HIV. AIDS. 1995;11(5):641–8.

    Article  Google Scholar 

  3. Epstein H. AIDS and the irrational. BMJ. 2008;337:a2638.

    Article  PubMed  Google Scholar 

  4. Mah TL, Halperin D. Concurrent sexual partnerships and the HIV epidemics in Africa: evidence to move forward. AIDS Behav. 2008;12 [Epub ahead of print].

  5. Halperin D, Epstein H. Concurrent sexual partnerships help to explain Africa’s high HIV prevalence: implications for prevention. Lancet. 2004;364(9428):4–6.

    Article  PubMed  Google Scholar 

  6. Lurie M, Rosenthal S. Concurrent partnerships as a driver of the HIV epidemic in sub-Saharan Africa? The evidence is limited. AIDS Behav. 2010;14(1):17–24.

    Article  PubMed  Google Scholar 

  7. Mah T, Halperin D. The evidence for the role of concurrent partnerships in Africa’s HIV epidemics: a response to Lurie and Rosenthal. AIDS Behav. 2010;14(1):25–8.

    Article  Google Scholar 

  8. Morris M. Barking up the wrong evidence tree. Comment on Lurie and Rosenthal, “Concurrent partnerships as a driver of the HIV epidemic in sub-Saharan Africa? The evidence is limited”. AIDS Behav. 2010;14(1):31–3.

    Article  PubMed  Google Scholar 

  9. Epstein H. The mathematics of concurrent partnerships in Africa’s HIV epidemics: a response to Lurie and Rosenthal. AIDS Behav. 2010;14(1):29–30. doi:10.1007/s10461-009-9627-x.

    Article  PubMed  Google Scholar 

  10. Lurie MN, Rosenthal S. The concurrency hypothesis in sub-Saharan Africa: convincing empirical evidence is still lacking. Response to Mah and Halperin, Epstein, and Morris. AIDS Behav. 2010;14(1):34–7.

    Article  PubMed  Google Scholar 

  11. Nnko S, Boerma JT, Urassa M, Mwaluko G, Zaba B. Secretive females or swaggering males? An assessment of the quality of sexual partnership reporting in rural Tanzania. Soc Sci Med. 2004;59(2):299–310.

    Article  PubMed  Google Scholar 

  12. Harrison A, Cleland J, Frohlich J. Young people’s sexual partnerships in KwaZulu/Natal, South Africa: patterns, contextual influences and HIV risk. Stud Fam Plann. 2008;39(4):295–308.

    Article  PubMed  Google Scholar 

  13. Sandøy IF, Dzekedzeke K, Fylkesnes K. Prevalence and correlates of concurrent sexual partnerships in Zambia. AIDS Behav. 2010;14(1):59–71.

    Article  PubMed  Google Scholar 

  14. Reniers G, Watkins S. Ppolygyny and the spread of HIV in sub-Saharan Africa: a case of benign concurrency. AIDS. 2010;24(2):299–307.

    Article  PubMed  Google Scholar 

  15. Ferguson A, Pere M, Morris C, Ngugi E, Moses S. Sexual patterning and condom use among a group of HIV vulnerable men in Thika, Kenya. Sex Transm Infect. 2004;80(6):435–9.

    Article  CAS  PubMed  Google Scholar 

  16. Carter MJW, Kraft JM, Koppenhaver T, Galavotti C, Roels TH, Kilmarx PH, et al. ‘A bull cannot be contained in a single kraal’: concurrent sexual partnerships in Botswana. AIDS Behav. 2007;11(6):822–30.

    Article  PubMed  Google Scholar 

  17. LeClerc Madlala S. Cultural scripts for multiple and concurrent partnerships in southern Africa: why HIV prevention needs anthropology. Sex Health. 2009;6(2):103–10.

    Article  PubMed  Google Scholar 

  18. Helleringer S, Kohler HP, Kalilani-Phiri L. The association of HIV serodiscordance and partnership concurrency in Likoma Island, Malawi. AIDS. 2009;23(10):1285–7.

    Article  PubMed  Google Scholar 

  19. Gregson S, Nyamukapa CA, Garnett GP, Mason PR, Zhuwau T, Caraël M, et al. Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. Lancet. 2002;359(9321):1896–903.

    Article  PubMed  Google Scholar 

  20. MacPhail C, Williams B, Campbell C. Relative risk of HIV infection among young men and women in a southern African township. Int J STD AIDS. 2002;13(5):331–42.

    Article  CAS  PubMed  Google Scholar 

  21. Kelly R, Gray RH, Sewankambo NK, et al. Age differences in sexual partners and risk of HIV-1 infection in rural Uganda. J Acquir Immune Defic Syndr. 2003;32(4):446–51.

    Article  PubMed  Google Scholar 

  22. Pettifor AE, Rees HV, Kleinschmidt I, Steffenson AE, MacPhail C, Hlongwa-Madikizela L, et al. Young people’s sexual health in South Africa: HIV prevalence and sexual behaviors from a nationally representative household survey. AIDS. 2005;19(14):1525–34.

    Article  PubMed  Google Scholar 

  23. Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22(Suppl 4):S17–25.

    Article  PubMed  Google Scholar 

  24. Bongaarts J. Late marriage and the HIV epidemic in sub-Saharan Africa. Popul Stud. 2007;61(1):73–83.

    Article  Google Scholar 

  25. UNAIDS. 2008 report on the global AIDS epidemic. Geneva, Switzerland: UNAIDS; 2008.

    Google Scholar 

  26. Shisana O, Rehle T, Simbayi L, Mbelle N. South African Medical Research Council South African national HIV prevalence, HIV incidence, behaviour and communication survey. Cape Town: HSRC Press; 2005.

    Google Scholar 

  27. Hosegood V, McGrath N, Moultrie TA. Dispensing with marriage: marital and partnership trends in rural KwaZulu-Natal, South Africa 2000–2006. Demogr Res. 2009;20(13):279–312.

    Article  Google Scholar 

  28. Department of Health. Republic of South Africa, Measure DHS/ORC Macro, South Africa Demographic and Health Survey 2003: preliminary report. Pretoria: Department of Health; 2004.

  29. Mensch B, Singh S, Casterline J. Trends in the timing of first marriage among men and women in the developing world. New York: Population Council Working Paper No. 202; 2005.

  30. Hunter M. The changing political economy of sex in South Africa: the significance of unemployment and inequalities to the scale of the AIDS pandemic. Soc Sci Med. 2007;64(3):689–700.

    Article  PubMed  Google Scholar 

  31. Marks S. An epidemic waiting to happen? The spread of HIV/AIDS in South Africa in social and historical perspective. Afr Stud. 2002;61:13–26.

    Article  Google Scholar 

  32. Dunkle KL, Jewkes R, Nduna M, Jama N, Levin J, Sikweyiya Y, et al. Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: prevalence, predictors, and associations with gender-based violence. Soc Sci Med. 2007;65(6):1235–48.

    Article  PubMed  Google Scholar 

  33. Kapiga SH, Lugalla JL. Sexual behaviour patterns and condom use in Tanzania: results from the 1996 Demographic and Health Survey. AIDS Care. 2002;14(4):455–69.

    CAS  PubMed  Google Scholar 

  34. Harrison A. Hidden love: sexual ideologies and relationship ideals among rural South African adolescents in the context of HIV/AIDS. Cult Health Sex. 2008;10(2):175–89.

    Article  PubMed  Google Scholar 

  35. O’Sullivan LF, Harrison A, Morrell R, Monroe-Wise A, Kubeka M. Gender dynamics in the primary sexual relationships of young rural South Africans. Cult Health Sex. 2006;8(2):99–113.

    Article  PubMed  Google Scholar 

  36. Bhana D, Morrell R, Hearn J, Moletsane R. Power and identity: an introduction to sexualities in southern Africa. Sexualities. 2007;10:131–9.

    Article  Google Scholar 

  37. Susser I, Stein Z. Culture, sexuality and women’s agency in the prevention of HIV/AIDS in southern Africa. Am J Public Health. 2000;90(7):1042–8.

    Article  CAS  PubMed  Google Scholar 

  38. Jewkes RK, Levin JB, Penn-Kekana L. Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Soc Sci Med. 2003;56(1):125–34.

    Article  PubMed  Google Scholar 

  39. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet. 2004;363(9419):1415–21.

    Article  PubMed  Google Scholar 

  40. MacPhail C, Campbell C. ‘I think condoms are good, but aai, I hate those things’: condom use among adolescents and young people in a Southern African township. Soc Sci Med. 2002;52(11):331–45.

    Google Scholar 

  41. Harrison A, Xaba N, Kunene P. Understanding safe sex: gender narratives of HIV and pregnancy prevention by rural South African school-going youth. Reprod Health Matters. 2001;9(17):63–71.

    Article  CAS  PubMed  Google Scholar 

  42. Varga CA. Sexual decision-making and negotiation in the midst of AIDS: youth in KwaZulu/Natal, South Africa. Health Transit Rev. 1997;7(Suppl 3):45–67.

    Google Scholar 

  43. Worth D. Sexual decision-making and AIDS: why condom promotion among vulnerable women is likely to fail. Stud Fam Plann. 1989;20(6):297–307.

    Article  CAS  PubMed  Google Scholar 

  44. Samuelsen H. Love, lifestyles and the risk of AIDS: the moral worlds of young people in Bobo-Dioulasso, Burkina Faso. Cult Health Sex. 2006;8(3):211–24.

    Article  PubMed  Google Scholar 

  45. Luke N. Age and economic asymmetries in the sexual relationships of adolescent girls in sub-Saharan Africa. Stud Fam Plann. 2003;34(2):67–86.

    Article  PubMed  Google Scholar 

  46. Ginsburg GP. Rules, scripts and prototypes in personal relationships. In: Duck SW, editor. Handbook of personal relationships. Chichester: Wiley; 1988. p. 23–39.

    Google Scholar 

  47. Planalp S, Fitness J. Thinking/feeling about social and personal relationships. J Soc Pers Relat. 1999;16(6):731–50.

    Article  Google Scholar 

  48. Simon W, Gagnon JH. Sexual scripts: permanence and change. Arch Sex Behav. 1986;15(2):97–120.

    Article  CAS  PubMed  Google Scholar 

  49. Simon W, Gagnon JH. A sexual scripts approach. In: Greer JH, O’Donohue WT, editors. Theories of human sexuality. New York: Plenum; 1987. p. 363–83.

    Google Scholar 

  50. Amaro H. Love, sex, and power: considering women’s realities in HIV prevention. Am Psychol. 1995;50(6):437–47.

    Article  CAS  PubMed  Google Scholar 

  51. VanWesenbeeck I, Van Zessen G, Ingham R, Jaramazovic E, Stevens D. Factors and processes in heterosexual competence and risk: an integrated review of the evidence. Psychol Health. 1999;14(1):25–50.

    Article  Google Scholar 

  52. Statistics South Africa. Census 2001: primary tables KwaZulu-Natal: 1996 and 2001 compared. Pretoria: Statistics South Africa; 2004.

    Google Scholar 

  53. Department of Health. Republic of South Africa, National HIV sero-prevalence survey of women attending public antenatal clinics in South Africa. Summary report. Pretoria: Department of Health; 2008.

    Google Scholar 

  54. Hoffman S, O’Sullivan L, Harrison A, Dolezal C, Monroe-Wise A. HIV risk behaviors and the context of sexual coercion in young adults’ sexual interactions: results from a diary study in rural South Africa. Sex Transm Dis. 2006;33(1):52–8.

    Article  CAS  PubMed  Google Scholar 

  55. Bernard HR. Research methods in anthropology: qualitative and quantitative approaches. 4th ed. New York: Altamira Press; 2006.

    Google Scholar 

  56. QSR International. NVivo 7. Doncaster, Australia: QSR International Pty Ltd; 2007.

    Google Scholar 

  57. Kaufman CE, deWet T, Stadler J. Adolescent pregnancy and parenthood in South Africa. Stud Fam Plann. 2001;32(2):147–60.

    Article  CAS  PubMed  Google Scholar 

  58. Varga CA. How gender roles influence sexual and reproductive health among South African adolescents. Stud Fam Plann. 2003;34(3):160–72.

    Article  PubMed  Google Scholar 

  59. Stirling M, Rees H, Kasedde S, Hankins C. Introduction: addressing the vulnerability of young women and girls to stop the HIV epidemic in southern Africa. AIDS. 2008;22(S4):S1–3.

    Article  PubMed  Google Scholar 

  60. Pettifor AE, Hudgens MG, Levandowski BA, Rees HV, Cohen MS. Highly efficient HIV transmission to young women in South Africa. AIDS. 2007;21(7):861–5.

    Article  PubMed  Google Scholar 

  61. Callegari L, Harper CC, Van der Straten A, Kamba M, Chipato T, Padian NS. Consistent condom use in married Zimbabwean women after a condom intervention. Sex Transm Dis. 2008;35(6):624–30.

    Article  PubMed  Google Scholar 

  62. Moyo W, Levandowski BA, MacPhail C, Rees H, Pettifor A. Consistent condom use in South African youth’s most recent sexual relationships. AIDS Behav. 2008;12(3):431–40.

    Article  PubMed  Google Scholar 

  63. Anderson JE. Condom use and HIV risk among US adults. Am J Public Health. 2003;93(6):912–4.

    Article  PubMed  Google Scholar 

  64. Preston-Whyte EM, Zondi M. Assessing illegitimacy in South Africa. In: Burman S, Preston-Whyte E, editors. Questionable issue: illegitimacy in South Africa. Cape Town: Oxford University Press; 1992.

    Google Scholar 

  65. Grant MJ, Hallman K. Pregnancy-related school dropout and prior school performance in KwaZulu-Natal. Stud Fam Plann. 2008;39(4):369–82.

    Article  PubMed  Google Scholar 

  66. Laga M, Schwärtlander B, Pisani E, Sow PS, Caraël M. To stem HIV in Africa, prevent transmission to young women. AIDS. 2001;15(7):931–4.

    Article  CAS  PubMed  Google Scholar 

  67. Pettifor AE, MacPhail C, Rees H, Cohen M. HIV and sexual behavior among young people: the South African paradox. Sex Transm Dis. 2008;35(10):843–4.

    Article  PubMed  Google Scholar 

  68. Shelton JD, Halperin DT, Nantulya V, Potts M, Gayle HD, Holmes KK. Partner reduction is crucial for balanced ‘ABC’ approach to HIV prevention. BMJ. 2004;328(7444):891–3.

    Article  PubMed  Google Scholar 

  69. Stoneburner R, Low-Beer D. Sexual partner reductions explain human immunodeficiency virus declines in Uganda: comparative analyses of HIV and behavioural data in Uganda, Kenya, Malawi, and Zambia. Int J Epidemiol. 2004;33(3):624.

    Article  PubMed  Google Scholar 

  70. Harrison A, Smit J, Exner T, Hoffman S, Mantell J. Mpondombili project: gender inequalities and young people’s sexual health in rural South Africa. Sex Health Exch. 2004;(3/4):5–8.

  71. Pronyk P, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet. 2006;368(9551):1973–83.

    Article  PubMed  Google Scholar 

  72. Jewkes R, Nduna M, Levin J, Jama N, Kunkle K, Puren A, et al. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ. 2008;337:a506. doi:10.1136/bmj.a506.

  73. Maticka-Tyndale E, Gallant M, Brouillard-Coyle C, et al. The sexual scripts of Kenyan young people and HIV prevention. Cult Health Sex. 2005;7(1):27–41.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We gratefully acknowledge research support from NICHD Grant R01-HD41721 to Lucia F. O’Sullivan, Ph.D. We thank Muriel Kubeka, Project Coordinator, for research assistance and overall support to this project, as well as administrative support from the South African Medical Research Council.

Author information

Authors and Affiliations

  1. Population Studies and Training Center, Brown University, Box 1836, 68 Waterman St., Providence, RI, 02912, USA

    Abigail Harrison

  2. Department of Medicine, Warren Alpert School of Medicine, Brown University, Providence, RI, USA

    Abigail Harrison

  3. Department of Psychology, University of New Brunswick, Fredericton, NB, Canada

    Lucia F. O’Sullivan

Authors
  1. Abigail Harrison
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Lucia F. O’Sullivan
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Abigail Harrison.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOC 83 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Harrison, A., O’Sullivan, L.F. In the Absence of Marriage: Long-Term Concurrent Partnerships, Pregnancy, and HIV Risk Dynamics Among South African Young Adults. AIDS Behav 14, 991–1000 (2010). https://doi.org/10.1007/s10461-010-9687-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10461-010-9687-y

Keywords

Search

Navigation