AIDS and Behavior

, Volume 21, Issue 3, pp 665–677 | Cite as

Economic Resources and HIV Preventive Behaviors Among School-Enrolled Young Women in Rural South Africa (HPTN 068)

  • Larissa JenningsEmail author
  • Audrey Pettifor
  • Erica Hamilton
  • Tiarney D. Ritchwood
  • F. Xavier Gómez-Olivé
  • Catherine MacPhail
  • James Hughes
  • Amanda Selin
  • Kathleen Kahn
  • The HPTN 068 Study Team
Original Paper


Individual economic resources may have greater influence on school-enrolled young women’s sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women’s sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13–20 years (n = 2533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR 1.56, 95 % CI 1.28–1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR 2.38, 95 % CI 1.58–3.58) and periodic sexual abstinence to avoid HIV (OR 1.71, 95 % CI 1.07–2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR 1.94, 95 % CI 1.08–3.46), discussing HIV testing (OR 2.15, 95 % CI 1.13–4.06), and discussing condom use (OR 1.99, 95 % CI 1.04–3.80). Having a bank account was associated with condom use (OR 1.49, 95 % CI 1.01–2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women’s individual economic resources may complement future prevention initiatives.


Economic resources Assets HIV Women Risk behaviors South Africa Prevention 



The authors wish to thank the study participants, community stakeholders, and staff from the HPTN 068 South African study site; the MRC/Wits Rural Public Health and Health Transitions Unit (Agincourt), School of Public Health at University of the Witwatersrand in South Africa; and the HPTN collaborators at the University of North Carolina (UNC) Gillings School of Public Health and the Johns Hopkins Bloomberg School of Public Health, and the HPTN Scholars Program leaders.


This study was funded by Award Numbers UM1 AI068619 (HPTN Leadership and Operations Center), UM1AI068617 (HPTN Statistical and Data Management Center), and UM1AI068613 (HPTN Laboratory Center) from the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health and the National Institute on Drug Abuse of the National Institutes of Health. The Wellcome Trust, United Kingdom, provided vital core funding for the Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit including the Agincourt Health and Socio-Demographic Surveillance System (Grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z). The primary author’s work on this manuscript was supported through resources from the HPTN Scholars Program (Grant UM1 AI068619: NIAID, NIMH, NIDA) and through services provided by the Johns Hopkins University Center for AIDS Research (Grant 1P30AI094189: NIAID, NCI, NICHD, NHLBI, NIDA, NIMH, NIA). The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Research Involving Human Participants and/or Animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.


  1. 1.
    Jukes M, Simmons S, Bundy D. Education and vulnerability: the role of schools in protecting young women and girls from HIV in southern Africa. AIDS. 2008;22(suppl 4):S41–56.CrossRefPubMedGoogle Scholar
  2. 2.
    UNAIDS Report on the Global AIDS Epidemic 2013. Global Report. November 2013. p. 1–116.Google Scholar
  3. 3.
    MacPhail C, Adato M, Kahn K, Selin A, Twine R, Khoza S, Rosenberg M, Nguyen N, Becker E, Pettifor A. Acceptability and feasibility of cash transfers for HIV prevention among adolescent South African Women. AIDS Behav. 2013;17:2301–12.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Pettifor A, Rees H, Kleinschmidt I, Steffenson A, MacPhail C, Hlongwa-Madikizela L, et al. Young people’s sexual health in South Africa: HIV prevalence and sexual behaviours from a nationally representative household survey. AIDS. 2005;19:1525–34.CrossRefPubMedGoogle Scholar
  5. 5.
    Bärnighausen T, Hoosegood V, Timaeus I, Newell M. The socioeconomic determinants of HIV incidence: evidence from a longitudinal, population-based study in rural South Africa. AIDS. 2007;21(suppl 7):s29–38.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Davidoff-Gore A, Luke N, Wawire S. Dimensions of poverty and inconsistent condom use among youth in urban Kenya. AIDS Care. 2011;23(10):1282–90.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Arnold MP, Fisher HR, McFarland W. Socioeconomic position and HIV risk-relevant behavior among lower-income heterosexuals in San Francisco. AIDS Behav. 2011;15:499–506.CrossRefPubMedGoogle Scholar
  8. 8.
    Krueger LE, Wood RW, Diehr PH, Maxwell CL. Poverty and HIV seropositivity: the poor are more likely to be infected. AIDS. 1990;4:811–4.CrossRefPubMedGoogle Scholar
  9. 9.
    Holtgrave DR, Crosby RA. Social capital, poverty, and income inequality as predictors of gonorrhoea, syphilis, chlamydia and AIDS case rates in the United States. Sex Transm Infect. 2003;79:62–4.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Piot P, Greener R, Russell S. Squaring the circle: AIDS, poverty, and human development. PLoS Med. 2007;4(10):e314.CrossRefPubMedCentralGoogle Scholar
  11. 11.
    Parkhurst JO. Understanding the correlations between wealth, poverty and human immunodeficiency virus infection in African countries. Bull World Health Organ. 2010;88(7):519–26.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Fox AM. The HIV-poverty thesis re-examined: poverty, wealth or inequality as a social determinant of HIV infection in sub-Saharan Africa? J Biosoc Sci. 2012;44(4):459–80.CrossRefPubMedGoogle Scholar
  13. 13.
    Davey-Rothwell MA, Linas BS, Latkin C. Sources of personal income and HIV risk among sexually active women. AIDS Educ Prev. 2012;24(5):422–30.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Kim J, Pronyk P, Barnett T, Watts C. Exploring the role of economic empowerment in HIV prevention. AIDS. 2008;22(Suppl 4):S57–71.CrossRefPubMedGoogle Scholar
  15. 15.
    Pinkham S, Malinowska-Sempruch K. Women, harm reduction and HIV. Reprod Health Matters. 2008;16(31):168–81.CrossRefPubMedGoogle Scholar
  16. 16.
    Logan TK, Cole J, Leukefeld C. Women, sex, and HIV: social and contextual factors, meta-analysis of published interventions, and implications for practice and research. Psychol Bull. 2002;128(6):851–85.CrossRefPubMedGoogle Scholar
  17. 17.
    Greig FE, Koopman C. Multilevel analysis of women’s empowerment and HIV prevention: quantitative survey results from a preliminary study in Botswana. AIDS Behav. 2003;7(2):195–208.CrossRefPubMedGoogle Scholar
  18. 18.
    Blankenship KM, Friedmann SR, Dworkin S, Mantell JE. Structural interventions: concepts, challenges and opportunities for research. J Urban Health. 2006;83(1):59–72.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Biello KB, Sipsma HL, Ickovics JR, Kershaw T. Economic dependence and unprotected sex: the role of sexual assertiveness among young urban mothers. J Urban Health. 2010;87(3):416–25.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Pettifor A, Macphail C, Anderson AD. Maman ‘If I buy the Kellogg’s then he should [buy] the milk’: young women’s perspectives on relationship dynamics, gender power and HIV risk in Johannesburg, South Africa. Cult Health Sex. 2012;14(5):477–90.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Katz IT, Ybarra ML, Wyatt MA, Kiwanuka JP, Bangsberg DR, Ware NC. Socio-cultural and economic antecedents of adolescent sexual decision-making and HIV-risk in rural Uganda. AIDS Care. 2013;25(2):258–64.CrossRefPubMedGoogle Scholar
  22. 22.
    Bandali S. Exchange of sex for resources: HIV risk and gender norms in Cabo Delgado, Mozambique. Cult Health Sex. 2011;13(5):575–88.CrossRefPubMedGoogle Scholar
  23. 23.
    Moser C, Dani AA, editors. Assets, livelihoods, and social policy. Washington, DC: World Bank; 2008.Google Scholar
  24. 24.
    Chatterji M, Murray N, London D, Anglewicz P. The factors influencing transactional sex among young men and women in 12 sub-Saharan African countries. Soc Biol. 2005;52:56–72.PubMedGoogle Scholar
  25. 25.
    Kaufman CE, Stavrou SE. Bus fare please: the economies of sex and gifts among young people in urban South Africa. Culture, Health, & Sexuality. 2004;6:377–91.CrossRefGoogle Scholar
  26. 26.
    Reed E, Gupta J, Biradavolu M, Devireddy V, Blankenship KM. The context of economic insecurity and its relation to violence and risk factors for HIV among female sex workers in Andhra Pradesh, India. Public Health Reports. 2010;125(Suppl 4):81–9.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Kamndaya M, Thomas L, Vearey J, Sartorius B, Kazembe L. Material deprivation affects high sexual risk behavior among young people in urban slums, South Africa. J Urban Health. 2014;91(3):581–91.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Allen CF, Simon Y, Edwards J, Simeon DT. Factors associated with condom use: economic security and positive prevention among people living with HIV/AIDS in the Caribbean. AIDS Care. 2010;22(11):1386–94.CrossRefPubMedGoogle Scholar
  29. 29.
    Ssewamala FM, Han CK, Neilands TB, Ismayilova L, Sperber E. Effect of economic assets on sexual risk-taking intentions among orphaned adolescents in Uganda. Am J Public Health. 2010;100(3):483–8.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Languille DB, Hughes L, Murphy GT, Rigby JA. Socio-economic factors and adolescent sexual activity and behaviour in Nova Scotia. Can J Public Health. 2005;96(4):313–8.Google Scholar
  31. 31.
    Soldan VA, deGraft-Johnson JE, Bisika T, Tsui AO. Social, economic and demographic characteristics of sexual risk behaviors among men in rural Malawi: a district-level study. Afr J Reprod Health. 2007;11(2):33–46.CrossRefPubMedGoogle Scholar
  32. 32.
    Ssewamala FM, Ismayilova L, McKay M, Sperber E, Bannon W, Alicea S. Gender and the effects of an economic empowerment program on attitudes toward sexual risk-taking among AIDS-orphaned adolescent youth in Uganda. J Adolesc Health. 2010;2009(46):372–8.CrossRefGoogle Scholar
  33. 33.
    de Walque D, Dow WH, Nathan R, Abdul R, Abilahi F, Gong E, Isdahl Z, Jamison J, Jullu B, Krishnan S, Majura A, Miguel E, Moncada J, Mtenga S, Mwanyangala MA, Packel L, Schachter J, Shirima K, Medlin CA. Incentivizing safe sex: a randomized trial of conditional cash transfers for HIV and sexually transmitted infection prevention in rural Tanzania. BMJ Open. 2012;2:e000747.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Oman RF, Vesely SK, Aspy CB, Tolma EL, Gavin L, Bensyl DM, Mueller T, Fluhr JD. A longitudinal study of youth assets, neighborhood conditions, and youth sexual behaviors. J Adolesc Health. 2013;52(6):779–85.CrossRefPubMedGoogle Scholar
  35. 35.
    Mueller T, Gavin L, Oman R, Vesely S, Aspy C, Tolma E, Rodine S. Youth assets and sexual risk behaviors: differences between male and female adolescents. Health Educ Behav. 2010;37(3):343–56.CrossRefPubMedGoogle Scholar
  36. 36.
    Hargreaves J, Morrison L, Kim J, Bonell C, Porter J, Watts C, et al. The association between school attendance, HIV infection and sexual behaviour among young people in rural South Africa. J Epidemiol Community Health. 2008;62:113–9.CrossRefPubMedGoogle Scholar
  37. 37.
    Sherraden M. Stakeholding: notes on a theory of welfare based on assets. Soc Serv Rev. 1990;64:580–601.CrossRefGoogle Scholar
  38. 38.
    Yadama GN, Sherraden M. Effects of assets on attitudes and behaviors: advance test of a social policy proposal. Soc Work Res. 1996;20(1):3–11.Google Scholar
  39. 39.
    Dworkin SL, Blankenship K. Microfinance and HIV/AIDS prevention: assessing its promise and limitations. AIDS Behav. 2009;13(3):462–9.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Stratford D, Mizuno Y, Williams K, Courtenay-Quirk C, O’Leary A. Addressing poverty as risk for disease: recommendations from CDC’s consultation on microenterprise as HIV prevention. Public Health Rep. 2008;123(1):9.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    MacLachlan E, Neema S, Luyirika E, Ssali F, Juncker M, Rwabukwali C, Harvey M, Duncan T. Women, economic hardship and the path of survival: HIV/AIDS risk behavior among women receiving HIV/AIDS treatment in Uganda. AIDS Care. 2009;21(3):355–67.CrossRefPubMedGoogle Scholar
  42. 42.
    Nyanzi B, Nyanzi S, Wolff B, Whitworth J. Money, men and markets: economic and sexual empowerment of market women in southwestern Uganda. Cult Health Sex. 2006;7(1):13–26.CrossRefGoogle Scholar
  43. 43.
    Mumah JN, Jackson-Smith D. Why are the benefits of increased resources not impacting the risk of HIV infection for high SES women in Cameroon? PLoS One. 2014;9(6):e100507.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Hargreaves JR, Davey C, Fearon E, Hensen B, Krishnaratne S. Trends in socioeconomic inequalities in HIV prevalence among young people in seven countries in Eastern and Southern Africa. PLoS One. 2015;10(3):e0121775.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Pettifor A, Levandowski B, MacPhail C, Padian N, Cohen M, Rees H. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    HIV Prevention Trials Network (HPTN) 068 Protocol Versions 3.0, 2.0 and 1.0. Effects of cash transfer for the prevention of HIV in young South African women. HPTN 068 Quick Links. Study Documents. Accessed 4/16/2015 at URL:
  47. 47.
    Kahn K, Collinson MA, Gómez-Olivé FX, Kabudula CW, Mee P, Mokoena O, Shabangu M, Tibane J, Twine R, Afolabi S, Clark BD, Khosa A, Khosa S, Silaule B, Wagner R, Garenne M, Clark SJ, Tollman SM. Profile: Agincourt health and socio-Demographic Surveillance System (Agincourt HDSS). Int J Epidemiol. 2012;41:988–1001.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Kahn K, Tollman SM, Collinson MA, Clark SJ, Twine R, Clark BD, Shabangu M, Gómez-Olivé FX, Mokoena O, Garenne ML. Research into health, population and social transitions in rural South Africa: data and methods of the Agincourt Health and Demographic Surveillance System. Scand J Public Health Suppl. 2007;69:8–20.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Collinson M. Striving against diversity: the dynamics of migration, health and poverty in rural South Africa. Glob Health Action. 2010;. doi: 10.3402/gha.v3i0.5080.Google Scholar
  50. 50.
    Gómez-Olivé FX, Angotti N, Houle B, Klipstein-Grobusch K, Kabudula C, Menken J, Williams J, Tollman S, Clark SJ. Prevalence of HIV among those 15 and older in rural South Africa. AIDS Care. 2013;25(9):1122–8.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    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.CrossRefPubMedGoogle Scholar
  52. 52.
    Dunkle KL, Wingood GM, Camp CM, Diclemente RJ. Economically motivated relationships and transactional sex among unmarried African American and white women: results from a U.S. national telephone survey. Public Health Rep. 2010;125(Suppl 4):90–100.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Baird SJ, Garfein RS, McIntosh CT, Ozler B. Effect of a cash transfer programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: a cluster randomised trial. Lancet. 2012;379(9823):1320–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Peralta L, Deeds BG, Hipszer S, Ghalib K. Barriers and facilitators to adolescent HIV testing. AIDS Patient Care STDS. 2007;21(6):400–8.CrossRefPubMedGoogle Scholar
  55. 55.
    Schwarcz S, Richards TA, Frank H, Wenzeld C, Hsua LC, Chin CJ, Murphy J, Dilley J. Identifying barriers to HIV testing: personal and contextual factors associated with late HIV testing. AIDS Care. 2011;23(7):892–900.CrossRefPubMedGoogle Scholar
  56. 56.
    Wand H, Ramjee G. The relationship between age of coital debut and HIV seroprevalence among women in Durban, South Africa: a cohort study. BMJ Open. 2012;2(1):e000285.CrossRefPubMedPubMedCentralGoogle Scholar
  57. 57.
    Stöckl H, Kalra N, Jacobi J, Watts C. Is early sexual debut a risk factor for HIV infection among women in Sub-Saharan Africa? A systematic review. Am J Reprod Immunol. 2013;69(s1):27–40.CrossRefPubMedGoogle Scholar
  58. 58.
    Pettifor AE, van der Straten A, Dunbar MS, Shiboski SC, Padian NS. Early age of first sex: a risk factor for HIV infection among women in Zimbabwe. AIDS. 2004;18(10):1435–42.CrossRefPubMedGoogle Scholar
  59. 59.
    Krishnan S, Dunbar MS, Minnis AM, Medlin CA, Gerdts CE, Padian NS. Poverty, gender inequities, and women’s risk of human immunodeficiency virus/AIDS. Ann N Y Acad Sci. 2008;1136:101–10.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Larissa Jennings
    • 1
    Email author
  • Audrey Pettifor
    • 2
    • 5
  • Erica Hamilton
    • 3
  • Tiarney D. Ritchwood
    • 4
  • F. Xavier Gómez-Olivé
    • 5
    • 6
  • Catherine MacPhail
    • 5
    • 7
    • 8
  • James Hughes
    • 9
    • 10
  • Amanda Selin
    • 2
  • Kathleen Kahn
    • 5
    • 6
    • 11
  • The HPTN 068 Study Team
  1. 1.Department of International Health, Social and Behavioral Interventions ProgramJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  2. 2.Department of EpidemiologyUniversity of North Carolina, Gillings School of Global Public HealthChapel HillUSA
  3. 3.FHI360, Science FacilitationDurhamUSA
  4. 4.Department of Public Health SciencesMedical University of South CarolinaCharlestonUSA
  5. 5.Medical Research Council Wits Rural Public Health and Health Transitions Research Unit, Agincourt, School of Public Health, Faculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
  6. 6.INDEPTH NetworkAccraGhana
  7. 7.School of HealthUniversity of New EnglandArmidaleAustralia
  8. 8.Wits Reproductive Health and HIV InstituteUniversity of the WitwatersrandJohannesburgSouth Africa
  9. 9.Fred Hutchinson Cancer Research CenterStatistical Center for HIV/AIDS Research & Prevention (SCHARP)SeattleUSA
  10. 10.Department of BiostatisticsUniversity of WashingtonSeattleUSA
  11. 11.Centre for Global Health ResearchUmeå UniversityUmeåSweden

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