AIDS and Behavior

, Volume 19, Issue 7, pp 1305–1316 | Cite as

Risk Factors for HIV Acquisition in High Risk Women in a Generalised Epidemic Setting

  • Nivashnee NaickerEmail author
  • Ayesha B. M. Kharsany
  • Lise Werner
  • Francois van Loggerenberg
  • Koleka Mlisana
  • Nigel Garrett
  • Salim S. Abdool Karim
Original Paper


In South Africa young women bear a disproportionate burden of HIV infection however, risk factors for HIV acquisition are not fully understood in this setting. In a cohort of 245 women, we used proportional hazard regression analysis to examine the association of demographic, clinical and behavioural characteristics with HIV acquisition. The overall HIV incidence rate (IR) was 7.20 per 100 women years (wy), 95 % confidence interval (CI) 4.50–9.80. Women 18–24 years had the highest HIV incidence (IR 13.20 per 100 wy, 95 % CI 6.59–23.62) and were almost three times more likely to acquire HIV compared to women 25 years and older [adjusted Hazard Ratio (aHR) 2.61, 95 % CI 1.05–6.47]. Similarly, women in relationships with multiple sex partners had more than twice the risk of acquiring HIV when compared to women who had no partner or who had a husband or stable partner (aHR 2.47, 95 % CI 0.98–6.26). HIV prevention programmes must address young women’s vulnerability and sex partner reduction in this setting.


Risk factors HIV acquisition Women 



This work was supported by grants from the Comprehensive International Program of Research on AIDS (CIPRA) of the Division of AIDS (DAIDS), National Institute of Allergy and Infectious Disease (NIAID), National Institutes of Health (NIH), US Department of Health and Human Services (DHHS) [Grant number 5U19 AI051794] and the National Research Foundation, South Africa [Grant number UID 67385]. NN was partially sponsored by the University of KwaZulu-Natal for career development.The authors would like to acknowledge the CAPRISA 002 Study Team and the participants of the CAPRISA 002 Study without whom this work would not have been possible.


  1. 1.
  2. 2.
    Abdool Karim SS, Churchyard GJ, Abdool Karim Q, Lawn SD. HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet. 2009;374(9693):921–33.CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    National Department of Health. The 2012 National Antenatal Sentinel HIV and Herpes Simplex type-2 prevalence Survey, South Africa. Accessed July 14, 2014.
  4. 4.
    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.CrossRefPubMedGoogle Scholar
  5. 5.
    Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Zungu N, Labadarios D, Onoya D, et al. South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town: HSRC Press; 2014.Google Scholar
  6. 6.
    Abdool Karim Q, Kharsany ABM, Frohlich JA, Werner L, Mashego M, Mlotshwa M, et al. Stabilizing HIV prevalence masks high HIV incidence rates amongst rural and urban women in KwaZulu-Natal South Africa. Int J Epidemiol. 2011;40(4):922–30.CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Abdool Karim Q, Kharsany AB, Frohlich JA, Werner L, Mlotshwa M, Madlala BT, et al. HIV incidence in young girls in KwaZulu-Natal, South Africa-public health imperative for their inclusion in HIV biomedical intervention trials. AIDS Behav. 2012;16(7):1870–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Kelly K, Mkhwanazi N, Nkhwashu N, Rapiti R, Mashale R. (2012) HIV prevention situation analysis in KwaZulu-Natal, Mpumalanga and Gauteng provinces, South Africa. USAID Sexual HIV Prevention Programme in South Africa (SHIPP). Accessed March 20, 2013.
  9. 9.
    Abdool Karim Q, Sibeko S, Baxter C. Preventing HIV infection in women: a global health imperative. Clin Infect Dis. 2010;50(Suppl 3):S122–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Wand H, Ramjee G. Combined impact of sexual risk behaviors for HIV seroconversion among women in Durban, South Africa: implications for prevention policy and planning. AIDS Behav. 2011;15(2):479–86.CrossRefPubMedGoogle Scholar
  11. 11.
    Pettifor AE, Levandowski BA, MacPhail C, Padian NS, Cohen MS, Rees HV. Keep them in school: the importance of education as a protective factor against HIV infection among young South African women. Int J Epidemiol. 2008;37(6):1266–73.CrossRefPubMedCentralPubMedGoogle Scholar
  12. 12.
    Halperin DT. Why is HIV prevalence so severe in Southern Africa? South Afr J HIV Med. 2007;8(1):19–25.Google Scholar
  13. 13.
    Leclerc-Madlala S. Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS. 2008;22(Suppl 4):S17–25.CrossRefPubMedGoogle Scholar
  14. 14.
    Chimbindi NZ, McGrath N, Herbst K, San Tint K, Newell ML. Socio-demographic determinants of condom use among sexually active young adults in rural KwaZulu-Natal, South Africa. Open AIDS J. 2010;4:88–95.CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    van Loggerenberg F, Dieter AA, Sobieszczyk ME, Werner L, Grobler A, Mlisana K. HIV prevention in high-risk women in South Africa: condom use and the need for change. PLoS One. 2012;7(2):e30669.CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Salvana EMT. HIV and STIs: interactions in resource-limited settings. Accessed March 12, 2014.
  17. 17.
    McClelland RS, Lavreys L, Hassan WM, Mandaliya K, Ndinya-Achola JO, Baeten JM. Vaginal washing and increased risk of HIV-1 acquisition among African women: a 10-year prospective study. AIDS. 2006;20(2):269–73.CrossRefPubMedGoogle Scholar
  18. 18.
    Gray RH, Li X, Kigozi G, Serwadda D, Brahmbhatt H, Wabwire-Mangen F, et al. Increased risk of incident HIV during pregnancy in Rakai, Uganda: a prospective study. Lancet. 2005;366(9492):1182–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Myer L, Wright TC Jr, Denny L, Kuhn L. Nested case-control study of cervical mucosal lesions, ectopy, and incident HIV infection among women in Cape Town, South Africa. Sex Transm Dis. 2006;33(11):683–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Mlisana K, Naicker N, Werner L, Roberts L, van Loggerenberg F, Baxter C, et al. Symptomatic vaginal discharge is a poor predictor of sexually transmitted infections and genital tract inflammation in high-risk women in South Africa. J Infect Dis. 2012;206(1):6–14.CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    Polis CB, Curtis KM. Use of hormonal contraceptives and HIV acquisition in women: a systematic review of the epidemiological evidence. Lancet Infect Dis. 2013;13(9):797–808.CrossRefPubMedGoogle Scholar
  22. 22.
    WHO. Hormonal contraception and HIV Technical statement. Accessed July 18, 2014.
  23. 23.
    van Loggerenberg F, Mlisana K, Williamson C, Auld SC, Morris L, Gray CM, et al. Establishing a cohort at high risk of HIV infection in South Africa: challenges and experiences of the CAPRISA 002 acute infection study. PLoS One. 2008;3(4):e1954.CrossRefPubMedCentralPubMedGoogle Scholar
  24. 24.
    Abdool Karim SS, Mlisana K, Kharsany A, Williamson C, Baxter C, Karim Q. Utilizing nucleic acid amplification to identify acute HIV infection. AIDS. 2007;21(5):653–5.CrossRefGoogle Scholar
  25. 25.
    Kingsley LA, Detels R, Kaslow R, Polk BF, Rinaldo CR Jr, Chmiel J, et al. Risk factors for seroconversion to human immunodeficiency virus among male homosexuals. Results from the Multicenter AIDS Cohort Study. Lancet. 1987;1(8529):345–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Abdool Karim SS, Ramjee G. Anal sex and HIV transmission in women. Am J Public Health. 1998;88(8):1265–6.CrossRefGoogle Scholar
  27. 27.
    Heffron R, Donnell D, Rees H, Celum C, Mugo N, Were E, et al. Use of hormonal contraceptives and risk of HIV-1 transmission: a prospective cohort study. Lancet Infect Dis. 2012;12(1):19–26.CrossRefPubMedCentralPubMedGoogle Scholar
  28. 28.
    Hel Z, Stringer E, Mestecky J. Sex steroid hormones, hormonal contraception, and the immunobiology of human immunodeficiency virus-1 infection. Endocr Rev. 2010;31(1):79–97.CrossRefPubMedCentralPubMedGoogle Scholar
  29. 29.
    Ramjee G, Kapiga S, Weiss S, Peterson L, Leburg C, Kelly C, et al. The value of site preparedness studies for future implementation of phase 2/IIb/III HIV prevention trials: experience from the HPTN 055 study. J Acquir Immune Defic Syndr. 2008;47(1):93–100.CrossRefPubMedGoogle Scholar
  30. 30.
    Moodley D, Esterhuizen TM, Pather T, Chetty V, Ngaleka L. High HIV incidence during pregnancy: compelling reason for repeat HIV testing. AIDS. 2009;23(10):1255–9.CrossRefPubMedGoogle Scholar
  31. 31.
    Kumwenda N, Hoffman I, Chirenje M, Kelly C, Coletti A, Ristow A, et al. HIV incidence among women of reproductive age in Malawi and Zimbabwe. Sex Transm Dis. 2006;33(11):646–51.CrossRefPubMedGoogle Scholar
  32. 32.
    Bulterys M, Chao A, Habimana P, Dushimimana A, Nawrocki P, Saah A. Incident HIV-1 infection in a cohort of young women in Butare. Rwanda. AIDS. 1994;8(11):1585–91.PubMedGoogle Scholar
  33. 33.
    Harling G, Newell ML, Tanser F, Kawachi I, Subramanian SV, Barnighausen T. Do age-disparate relationships drive hiv incidence in young women? Evidence from a population cohort in rural KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr. 2014;66(4):443–51.CrossRefPubMedGoogle Scholar
  34. 34.
    Statistics South Africa. Mid-year population estimates 2014. Accessed August 04, 2014.
  35. 35.
    Chen L, Jha P, Stirling B, Sgaier SK, Daid T, Kaul R, et al. Sexual risk factors for HIV infection in early and advanced HIV epidemics in sub-Saharan Africa: systematic overview of 68 epidemiological studies. PLoS One. 2007;2(10):e1001.CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Zuma K, Gouws E, Williams B, Lurie M. Risk factors for HIV infection among women in Carletonville, South Africa: migration, demography and sexually transmitted diseases. Int J STD AIDS. 2003;14(12):814–7.CrossRefPubMedGoogle Scholar
  37. 37.
    Mavedzenge SN, Weiss HA, Montgomery ET, Blanchard K, de Bruyn G, Ramjee G, et al. Determinants of differential HIV incidence among women in three southern African locations. J Acquir Immune Defic Syndr. 2011;58(1):89–99.CrossRefPubMedGoogle Scholar
  38. 38.
    Statistics South Africa. Accessed September 07, 2014.
  39. 39.
    Morrison CS, Skoler-Karpoff S, Kwok C, Chen PL, van de Wijgert J, Gehret-Plagianos M, et al. Hormonal contraception and the risk of HIV acquisition among women in South Africa. AIDS. 2012;26(4):497–504.CrossRefPubMedGoogle Scholar
  40. 40.
    Sviri S, Khalaila R, Daher S, Bayya A, Linton DM, Stav I, et al. Increased Vitamin B12 levels are associated with mortality in critically ill medical patients. Clin Nutr. 2012;31(1):53–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Salles N, Herrmann F, Sakbani K, Rapin CH, Sieber C. High vitamin B12 level: a strong predictor of mortality in elderly inpatients. J Am Geriatr Soc. 2005;53(5):917–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Nelson RM, Lewis LL, Struble K, Wood SF. Ethical and regulatory considerations for the inclusion of adolescents in HIV biomedical prevention research. J Acquir Immune Defic Syndr. 2010;54(Suppl 1):S18–24.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Nivashnee Naicker
    • 1
    Email author
  • Ayesha B. M. Kharsany
    • 1
    • 2
  • Lise Werner
    • 1
  • Francois van Loggerenberg
    • 3
  • Koleka Mlisana
    • 2
    • 4
  • Nigel Garrett
    • 1
    • 5
  • Salim S. Abdool Karim
    • 1
    • 6
  1. 1.Centre for the AIDS Programme of Research in South Africa (CAPRISA), Doris Duke Medical Research Institute, Nelson R Mandela School of MedicineUniversity of KwaZulu-NatalDurbanSouth Africa
  2. 2.Department of Medical Microbiology, Nelson R. Mandela School of MedicineUniversity of KwaZulu-NatalDurbanSouth Africa
  3. 3.Centre for Tropical Medicine and Global HealthUniversity of OxfordOxfordUK
  4. 4.National Health Laboratory ServicesDurbanSouth Africa
  5. 5.Department of Infectious Diseases, Nelson R. Mandela School of MedicineUniversity of KwaZulu-NatalDurbanSouth Africa
  6. 6.Department of EpidemiologyColumbia UniversityNew YorkUSA

Personalised recommendations