In the Absence of Marriage: Long-Term Concurrent Partnerships, Pregnancy, and HIV Risk Dynamics Among South African Young Adults
First Online: 31 March 2010 DOI:
10.1007/s10461-010-9687-y Cite this article as: Harrison, A. & O’Sullivan, L.F. AIDS Behav (2010) 14: 991. doi:10.1007/s10461-010-9687-y 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.
Keywords Concurrent partnerships Youth South Africa HIV risk Longitudinal Electronic supplementary material
The online version of this article (doi:
) contains supplementary material, which is available to authorized users. 10.1007/s10461-010-9687-y References
Garnett GP, Johnson AM. Coining a new term in epidemiology: concurrency and HIV. AIDS. 1997;11(5):681–3.
Morris M, Kretzschmar M. Concurrent partnerships and the spread of HIV. AIDS. 1995;11(5):641–8.
Epstein H. AIDS and the irrational. BMJ. 2008;337:a2638.
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].
Halperin D, Epstein H. Concurrent sexual partnerships help to explain Africa’s high HIV prevalence: implications for prevention. Lancet. 2004;364(9428):4–6.
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.
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.
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.
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:
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.
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.
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.
Sandøy IF, Dzekedzeke K, Fylkesnes K. Prevalence and correlates of concurrent sexual partnerships in Zambia. AIDS Behav. 2010;14(1):59–71.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22(Suppl 4):S17–25.
Bongaarts J. Late marriage and the HIV epidemic in sub-Saharan Africa. Popul Stud. 2007;61(1):73–83.
UNAIDS. 2008 report on the global AIDS epidemic. Geneva, Switzerland: UNAIDS; 2008.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Bhana D, Morrell R, Hearn J, Moletsane R. Power and identity: an introduction to sexualities in southern Africa. Sexualities. 2007;10:131–9.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Ginsburg GP. Rules, scripts and prototypes in personal relationships. In: Duck SW, editor. Handbook of personal relationships. Chichester: Wiley; 1988. p. 23–39.
Planalp S, Fitness J. Thinking/feeling about social and personal relationships. J Soc Pers Relat. 1999;16(6):731–50.
Simon W, Gagnon JH. Sexual scripts: permanence and change. Arch Sex Behav. 1986;15(2):97–120.
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.
Amaro H. Love, sex, and power: considering women’s realities in HIV prevention. Am Psychol. 1995;50(6):437–47.
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.
Statistics South Africa. Census 2001: primary tables KwaZulu-Natal: 1996 and 2001 compared. Pretoria: Statistics South Africa; 2004.
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.
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.
Bernard HR. Research methods in anthropology: qualitative and quantitative approaches. 4th ed. New York: Altamira Press; 2006.
QSR International. NVivo 7. Doncaster, Australia: QSR International Pty Ltd; 2007.
Kaufman CE, deWet T, Stadler J. Adolescent pregnancy and parenthood in South Africa. Stud Fam Plann. 2001;32(2):147–60.
Varga CA. How gender roles influence sexual and reproductive health among South African adolescents. Stud Fam Plann. 2003;34(3):160–72.
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.
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.
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.
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.
Anderson JE. Condom use and HIV risk among US adults. Am J Public Health. 2003;93(6):912–4.
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.
Grant MJ, Hallman K. Pregnancy-related school dropout and prior school performance in KwaZulu-Natal. Stud Fam Plann. 2008;39(4):369–82.
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.
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.
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.
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.
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.
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.
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:
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.
CrossRef PubMed Copyright information
© Springer Science+Business Media, LLC 2010