The Journal of Primary Prevention

, Volume 35, Issue 4, pp 255–265

Exploring the Relationships Among Food Insecurity, Alcohol Use, and Sexual Risk Taking Among Men and Women Living in South African Townships

  • Lisa A. Eaton
  • Demetria N. Cain
  • Eileen V. Pitpitan
  • Kate B. Carey
  • Michael P. Carey
  • Vuyelwa Mehlomakulu
  • Leickness C. Simbayi
  • Kelvin Mwaba
  • Seth C. Kalichman
Original Paper


South African townships have among the highest rates of HIV infection in the world. Considerable research on understanding the high rates of HIV transmission in this country has identified alcohol use as a critical factor in driving the HIV epidemic. Although the relationship between alcohol use and sexual risk-taking is well documented, less is known about how other factors, such as food insecurity, might be important in understanding alcohol’s role in sexual risk-taking. Furthermore, prior research has highlighted how patterns of alcohol use and sexual risk-taking tend to vary by gender. We examined how food insecurity is related to both alcohol use and sexual risk-taking. We administered anonymous community surveys to men (n = 1,137) and women (n = 458) residing within four contiguous Black African townships outside of Cape Town, South Africa. In multivariate linear regression, we found that food insecurity was related to having higher numbers of male sex partners and condom-protected sex acts among women only. These relationships, however, were fully mediated by women’s alcohol use. Among men, we found that food insecurity was negatively related to unprotected sex; that is, men with greater food security reported more unprotected sex acts. Unlike the results found among women, this relationship was not mediated by alcohol use. Food insecurity appears to be an important factor in understanding patterns of sexual risk-taking in regards to gender and alcohol use, and may serve as an important point of intervention for reducing HIV transmission rates.


Community assessment Regression Mediation Gender 


  1. Altman, M., Hart, T., & Jacobs, P. (2009). Food security in South Africa. Pretoria: Human Sciences Research Council: Center for Poverty, Employment and Growth.Google Scholar
  2. Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182.PubMedCrossRefGoogle Scholar
  3. Bennett, G. A., Withers, J., Thomas, P. W., Higgins, D. S., Bailey, J., Parry, L., et al. (2005). A randomised trial of early warning signs relapse prevention training in the treatment of alcohol dependence. Addictive Behavior, 30(6), 1111–1124. doi:10.1016/j.addbeh.2004.10.008.CrossRefGoogle Scholar
  4. Coates, J., Swindale, A., & Bilinsky, P. (2007). Household Food Insecurity Access Scale (HFIAS) for measurement of food access: Indicator guide. Washington, DC: Food and Nutrition Technical Support, USAID.Google Scholar
  5. Duval Smith, A. (2011). South Africa to cut unemployment to 15% by 2020 in Asian-inspired plan. The guardian.
  6. Fihlani, P. (2010). Anger, not hope, in a South African township.
  7. Grant, B. F., Dawson, D. A., Stinson, F. S., Chou, P. S., Kay, W., & Pickering, R. (2003). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV): Reliability of alcohol consumption, tobacco use, family history of depression and psychiatric diagnostic modules in a general population sample. Drug and Alcohol Dependence, 71(1), 7–16.PubMedCrossRefGoogle Scholar
  8. Gruenewald, P. J., Russell, M., Light, J., Lipton, R., Searles, J., Johnson, F., et al. (2002). One drink to a lifetime of drinking: Temporal structures of drinking patterns. Alcoholism, Clinical and Experimental Research, 26(6), 916–925.PubMedCrossRefGoogle Scholar
  9. IBM Corp. (2012). IBM SPSS statistics for windows, version 21.0. Armonk, NY: IBM.Google Scholar
  10. Jewkes, R., Abrahams, N., Mathews, S., Seedat, M., Van Niekerk, A., Suffla, S., et al. (2009). Preventing rape and violence in South Africa: Call for leadership in a new agenda for action. MRC Policy Brief.Google Scholar
  11. Jewkes, R., & Morrell, R. (2010). Gender and sexuality: Emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. Journal of the International AIDS Society, 13, 6. doi:10.1186/1758-2652-13-6.PubMedCentralPubMedGoogle Scholar
  12. Kalichman, S. C., Simbayi, L. C., Jooste, S., & Cain, D. (2007). Frequency, quantity, and contextual use of alcohol among sexually transmitted infection clinic patients in Cape Town, South Africa. [Comparative Study Research Support, N.I.H., Extramural]. American Journal of Drug and Alcohol Abuse, 33(5), 687–698. doi:10.1080/00952990701522716.PubMedCrossRefGoogle Scholar
  13. Kalichman, S. C., Simbayi, L., Jooste, S., Vermaak, R., & Cain, D. (2008a). Sensation seeking and alcohol use predict HIV transmission risks: Prospective study of sexually transmitted infection clinic patients, Cape Town, South Africa. Addictive Behaviors, 33(12), 1630–1633. doi:10.1016/j.addbeh.2008.07.020.PubMedCrossRefGoogle Scholar
  14. Kalichman, S. C., Simbayi, L. C., Kaufman, M., Cain, D., Cherry, C., Jooste, S., et al. (2005). Gender attitudes, sexual violence, and HIV/AIDS risks among men and women in Cape Town, South Africa. [Research Support, N.I.H., Extramural Research Support, Non-U.S. Gov’t]. Journal of Sex Research, 42(4), 299–305. doi:10.1080/00224490509552285.PubMedCrossRefGoogle Scholar
  15. Kalichman, S. C., Simbayi, L. C., Vermaak, R., Jooste, S., & Cain, D. (2008b). HIV/AIDS risks among men and women who drink at informal alcohol serving establishments (Shebeens) in Cape Town, South Africa. Prevention Science, 9(1), 55–62. doi:10.1007/s11121-008-0085-x.PubMedCrossRefGoogle Scholar
  16. Kalichman, S. C., Watt, M., Sikkema, K., Skinner, D., & Pieterse, D. (2012). Food insufficiency, substance use, and sexual risks for HIV/AIDS in informal drinking establishments, Cape Town, South Africa. Journal of Urban Health. doi:10.1007/s11524-012-9686-6.
  17. Kanyamurwa, J. M., & Ampek, G. T. (2007). Gender differentiation in community responses to AIDS in rural Uganda. AIDS Care, 19(Suppl 1), S64–S72. doi:10.1080/09540120601114683.PubMedCrossRefGoogle Scholar
  18. Korsten, M. (1989). Alcoholism and pancreatitis: Does nutrition play a role? Alcohol Health and Research World, 13(3), 232–237.Google Scholar
  19. Labadarios, D., McHiza, Z. J., Steyn, N. P., Gericke, G., Maunder, E. M., Davids, Y. D., et al. (2011). Food security in South Africa: A review of national surveys. Bulletin of the World Health Organization, 89(12), 891–899. doi:10.2471/BLT.11.089243BLT.11.089243.PubMedCentralPubMedCrossRefGoogle Scholar
  20. Le Marcis, F., & Ebrahim-Vally, R. (2005). People living with HIV and AIDS in everyday conditions of township life in South Africa: Between structural constraint and individual tactics. SAHARA Journal, 2(1), 217–235.PubMedCrossRefGoogle Scholar
  21. Morojele, N. K., Kachieng’a, M. A., Mokoko, E., Nkoko, M. A., Parry, C. D., Nkowane, A. M., et al. (2006). Alcohol use and sexual behaviour among risky drinkers and bar and shebeen patrons in Gauteng province. South Africa. Social Science Medicine, 62(1), 217–227. doi:10.1016/j.socscimed.2005.05.031.CrossRefGoogle Scholar
  22. Napper, L. E., Fisher, D. G., Reynolds, G. L., & Johnson, M. E. (2010). HIV risk behavior self-report reliability at different recall periods. AIDS and Behavior, 14(1), 152–161. doi:10.1007/s10461-009-9575-5.PubMedCentralPubMedCrossRefGoogle Scholar
  23. Parry, C. D. H. (2010). Alcohol policy in South Africa: A review of policy development processes between 1994 and 2009. Addiction, 105(8), 1340–1345. doi:10.1111/j.1360-0443.2010.03003.x.PubMedCrossRefGoogle Scholar
  24. Parry, C. D., Patra, J., & Rehm, J. (2011). Alcohol consumption and non-communicable diseases: Epidemiology and policy implications. Addiction, 106(10), 1718–1724. doi:10.1111/j.1360-0443.2011.03605.x.PubMedCentralPubMedCrossRefGoogle Scholar
  25. Parry, C. D. H., Pluddemann, A., Steyn, K., Bradshaw, D., Norman, R., & Laubscher, R. (2005). Alcohol use in South Africa: Findings from the first Demographic and Health Survey (1998). Journal of Studies on Alcohol, 66(1), 91–97.PubMedGoogle Scholar
  26. Parry, C., Rehm, J., Poznyak, V., & Room, R. (2009). Alcohol and infectious diseases: An overlooked causal linkage? Addiction, 104(3), 331–332. doi:10.1111/j.1360-0443.2008.02500.x.PubMedCrossRefGoogle Scholar
  27. Pitpitan, E. V., Kalichman, S. C., Eaton, L. A., Cain, D., Sikkema, K. J., Watt, M. H., et al. (2012a). Co-occurring psychosocial problems and HIV risk among women attending drinking venues in a South African Township: A syndemic approach. Annals of Behavioral Medicine,. doi:10.1007/s12160-012-9420-3.PubMedCentralPubMedGoogle Scholar
  28. Pitpitan, E. V., Kalichman, S. C., Eaton, L. A., Sikkema, K. J., Watt, M. H., & Skinner, D. (2012b). Gender-based violence and HIV sexual risk behavior: Alcohol use and mental health problems as mediators among women in drinking venues, Cape Town. Social Science and Medicine, 75(8), 1417–1425. doi:10.1016/j.socscimed.2012.06.020.PubMedCentralPubMedCrossRefGoogle Scholar
  29. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891.PubMedCrossRefGoogle Scholar
  30. Rehm, J., Rehn, N., Room, R., Monteiro, M., Gmel, G., Jernigan, D., et al. (2003). The global distribution of average volume of alcohol consumption and patterns of drinking. European Addiction Research, 9(4), 147–156. doi:10.1159/00007222172221.PubMedCrossRefGoogle Scholar
  31. Rollins, N. (2007). Food insecurity—A risk factor for HIV infection. PLoS Medicine, 4(10), 1576–1577. doi:10.1371/journal.pmed.0040301.PubMedCrossRefGoogle Scholar
  32. Romeo, J., Warnberg, J., Diaz, L. E., Gonzalez-Gross, M., & Marcos, A. (2007). Effects of moderate beer consumption on first-line immunity of healthy adults. [Comparative Study Research Support, Non-U.S. Gov’t]. Journal of Physiology and Biochemistry, 63(2), 153–159.PubMedCrossRefGoogle Scholar
  33. Schneider, M., Norman, R., Parry, C., Bradshaw, D., & Pluddemann, A. (2007). Estimating the burden of disease attributable to alcohol use in South Africa in 2000. South African Medical Journal, 97(8 Pt 2), 664–672.PubMedGoogle Scholar
  34. Scott-Sheldon, L. A., Carey, M. P., Carey, K. B., Cain, D., Harel, O., Mehlomakulu, V., et al. (2012). Patterns of alcohol use and sexual behaviors among current drinkers in Cape Town. South Africa. Addictive Behavior, 37(4), 492–497. doi:10.1016/j.addbeh.2012.01.002.CrossRefGoogle Scholar
  35. Shisana, O., Rehle, T., Simbayi, L., Parker, W., Bhana, A., Zuma, K., et al. (2005). South African national HIV prevalence, incidence, behaviour and communication survey 2005. Cape Town: Human Sciences Research Council Press.Google Scholar
  36. Shisana, O., Rice, K., Zungu, N., & Zuma, K. (2010). Gender and poverty in South Africa in the era of HIV/AIDS: A quantitative study [Research Support, Non-U.S. Gov’t Research Support, U.S. Gov’t, P.H.S.]. Journal of Women’s Health (Larchmt), 19(1), 39–46. doi:10.1089/jwh.2008.1200.CrossRefGoogle Scholar
  37. Singer, M., & Clair, S. (2003). Syndemics and public health: Reconceptualizing disease in bio-social context. Medical Anthropology Quarterly, 2003(17), 423–441.CrossRefGoogle Scholar
  38. Suliman, S., Seedat, S., Williams, D. R., & Stein, D. J. (2010). Predictors of transitions across stages of alcohol use and alcohol-use disorders in South Africa. Journal of Studies on Alcohol and Drugs, 71(5), 695–703.PubMedCentralPubMedGoogle Scholar
  39. Tsai, A. C., Hung, K. J., & Weiser, S. D. (2012). Is food insecurity associated with HIV risk? Cross-sectional evidence from sexually active women in Brazil. PLoS Medicine, 9(4), e1001203. doi:10.1371/journal.pmed.1001203.PubMedCentralPubMedCrossRefGoogle Scholar
  40. Watt, M. H., Aunon, F. M., Skinner, D., Sikkema, K. J., Kalichman, S. C., & Pieterse, D. (2012). “Because he has bought for her, he wants to sleep with her”: Alcohol as a currency for sexual exchange in South African drinking venues [Research Support, N.I.H., Extramural]. Social Science Medicine, 74(7), 1005–1012. doi:10.1016/j.socscimed.2011.12.022.PubMedCentralPubMedCrossRefGoogle Scholar
  41. Watzl, B., & Watson, R. R. (1992). Role of alcohol abuse in nutritional immunosuppression [Research Support, U.S. Gov’t, P.H.S.Review]. Journal of Nutrition, 122(3 Suppl), 733–737.PubMedGoogle Scholar
  42. Weir, S. S., Morroni, C., Coetzee, N., Spencer, J., & Boerma, J. T. (2002). A pilot study of a rapid assessment method to identify places for AIDS prevention in Cape Town. South Africa. Sexually Transmitted Infections, 78(Suppl 1), i106–i113.CrossRefGoogle Scholar
  43. Weiser, S. D., Leiter, K., Bangsberg, D. R., Butler, L. M., Percy-de Korte, F., Hlanze, Z., et al. (2007). Food insufficiency is associated with high-risk sexual behavior among women in Botswana and Swaziland. PLoS Medicine, 4(10), 1589–1597 (discussion 1598). doi:10.1371/journal.pmed.0040260.
  44. Weiser, S. D., Young, S. L., Cohen, C. R., Kushel, M. B., Tsai, A. C., Tien, P. C., et al. (2011). Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. American Journal of Clinical Nutrition, 94(6), 1729S–1739S. doi:10.3945/ajcn.111.012070.PubMedCentralPubMedCrossRefGoogle Scholar
  45. WHO. (2010). UNAIDS/World Health Organization (2010). AIDS epidemic update. Geneva: Word Health Organization.Google Scholar
  46. Wood, K., & Jewkes, R. (1997). Violence, rape, and sexual coercion: Everyday love in a South African township. Gender and Development, 5(2), 41–46.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Lisa A. Eaton
    • 1
  • Demetria N. Cain
    • 1
  • Eileen V. Pitpitan
    • 1
  • Kate B. Carey
    • 2
  • Michael P. Carey
    • 3
  • Vuyelwa Mehlomakulu
    • 4
  • Leickness C. Simbayi
    • 4
    • 5
  • Kelvin Mwaba
    • 6
  • Seth C. Kalichman
    • 1
  1. 1.Center for Health, Intervention and PreventionUniversity of ConnecticutStorrsUSA
  2. 2.Brown UniversityProvidenceUSA
  3. 3.The Miriam HospitalProvidenceUSA
  4. 4.Human Sciences Research CouncilCape TownSouth Africa
  5. 5.University of Cape TownCape TownSouth Africa
  6. 6.University of the Western CapeCape TownSouth Africa

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