AIDS and Behavior

, Volume 22, Issue 11, pp 3468–3479 | Cite as

Motivated Reasoning and HIV Risk? Views on Relationships, Trust, and Risk from Young Women in Cape Town, South Africa, and Implications for Oral PrEP

  • Miriam HartmannEmail author
  • Margaret McConnell
  • Linda-Gail Bekker
  • Connie Celum
  • Thola Bennie
  • Jabulisile Zuma
  • Ariane van der Straten
Original Paper


In high prevalence environments relationship characteristics are likely to be associated with HIV risk, yet evidence indicates general underestimation of risk. Furthermore uncertainty about partner‘s risk may challenge PrEP demand among young African women. We conducted quantitative and qualitative interviews with women before and after HIV discussions with partners, to explore how partner’s behavior affected risk perceptions and interest in PrEP. Twenty-three women were interviewed once; twelve had a follow-up interview after speaking to their partners. Fourteen women were willing to have their partner contacted; yet two men participated. Several themes related to relationships and risk were identified. These highlighted that young women’s romantic feelings and expectations influenced their perceptions of risk within their relationships, consistent with the concept of motivated reasoning. Findings emphasize challenges in using risk to promote HIV prevention among young women. Framing PrEP in a positive empowering way that avoids linking it to relationship risk may ultimately encourage greater uptake.


HIV risk HIV prevention Female-initiated methods Pre-exposure prophylaxis 



We would like to pay tribute to the women and men who participated in this study, their participation made this study possible. The contributions of Jonah Leslie are acknowledged as critical in the analysis of this study. This study was supported by the National Institutes of Health (1R01MH107251). Writing of this manuscript was supported in part by internal funds from RTI International. The content is solely the responsibility of the authors and does not necessarily represent the official views of the authors’ employers or funders.


This study was funded by the National Institutes of Health (grant number 1R01MH107251).

Compliance with Ethical Standards

Conflict of interest

All 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.

Informed Consent

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


  1. 1.
    Medicines Control Council approves fixed -dose combination of tenofovir disoproxyl fumarate and emtricitabine for pre-exposure prophylaxis of HIV [press release]. Pretoria: Registrar of Medicines, Medicines Control Council 2015.Google Scholar
  2. 2.
    Recommendations on the Use of PrEP for All Populations, PEPFAR Scientific Advisory Board (SAB). PrEP Expert Working Group (EWG); 2015.Google Scholar
  3. 3.
    WHO. WHO Expands Recommendation on Oral Pre-Exposure Prophylaxis of HIV Infection (PrEP). Geneva: WHO; 2015.Google Scholar
  4. 4.
    Baeten JM, Palanee-Phillips T, Brown ER, Schwartz K, Soto-Torres LE, Govender V, et al. Use of a vaginal ring containing dapivirine for HIV-1 prevention in women. N Engl J Med. 2016;375(22):2121–32.CrossRefGoogle Scholar
  5. 5.
    Marrazzo JM, Ramjee G, Richardson BA, Gomez K, Mgodi N, Nair G, et al. Tenofovir-based preexposure prophylaxis for HIV Infection among African women. N Engl J Med. 2015;372(6):509–18.CrossRefGoogle Scholar
  6. 6.
    Van Damme L, Corneli A, Ahmed K, Agot K, Lombaard J, Kapiga S, et al. Preexposure prophylaxis for HIV infection among African women. N Engl J Med. 2012;367(5):411–22.CrossRefGoogle Scholar
  7. 7.
    UNAIDS. Global Report: UNAIDS report on the global AIDS epidemic, Geneva. Switzerland: Joint United Nations Programme on HIV/AIDS (UNAIDS); 2013. p. 2013.Google Scholar
  8. 8.
    UNAIDS. The Gap Report. Geneva, Switzerland; 2014.Google Scholar
  9. 9.
    Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Zungu N, et al. South African National HIV Prevalence, Incidence and Behavior Survey, 2012. Cape Town: Human Sciences Research Council (HSRC); 2014.Google Scholar
  10. 10.
    Germain A. Integrating gender into HIV/AIDS programmes in the health sector: tool to improve responsiveness to women’s needs. Bull World Health Organization. 2009;87(11):883.CrossRefGoogle Scholar
  11. 11.
    Wingood GM, DiClemente RJ. Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Educ Behav. 2000;27(5):539–65.CrossRefGoogle Scholar
  12. 12.
    Amico KR, Mansoor LE, Corneli A, Torjesen K, van der Straten A. Adherence support approaches in biomedical HIV prevention trials: experiences, insights and future directions from four multisite prevention trials. AIDS Behav. 2013;17(6):2143–55.CrossRefGoogle Scholar
  13. 13.
    van der Straten A, Stadler J, Montgomery E, Hartmann M, Magazi B, Mathebula F, et al. Women’s experiences with oral and vaginal pre-exposure prophylaxis: the VOICE-C qualitative study in Johannesburg, South Africa. PLoS ONE. 2014;9(2):e89118.CrossRefGoogle Scholar
  14. 14.
    Ware NC, Wyatt MA, Haberer JE, Baeten JM, Kintu A, Psaros C, et al. What’s love got to do with it? Explaining adherence to oral antiretroviral pre-exposure prophylaxis (PrEP) for HIV serodiscordant couples. J Acquir Immune Defic Syndr (1999). 2012;59(5):463–8.CrossRefGoogle Scholar
  15. 15.
    Celum CL, Delany-Moretlwe S, McConnell M, Van Rooyen H, Bekker L-G, Kurth A, et al. Rethinking HIV prevention to prepare for oral PrEP implementation for young African women. J Int AIDS Soc. 2015;18(4):20227.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Giedd JN, Blumenthal J, Jeffries NO, Castellanos FX, Liu H, Zijdenbos A, et al. Brain development during childhood and adolescence: a longitudinal MRI study. Nat Neurosci. 1999;2(10):861–3.CrossRefGoogle Scholar
  17. 17.
    Johnson SB, Blum RW, Giedd JN. Adolescent maturity and the brain: the promise and pitfalls of neuroscience research in adolescent health policy. J Adolesc Health. 2009;45(3):216–21.CrossRefGoogle Scholar
  18. 18.
    Epley N, Gilovich T. The mechanics of motivated reasoning. J Econ Perspect. 2016;30:133–40.CrossRefGoogle Scholar
  19. 19.
    Middelkoop K, Bekker L-G, Myer L, Whitelaw A, Grant A, Kaplan G, et al. Antiretroviral program associated with reduction in untreated prevalent tuberculosis in a South African township. Am J Respir Crit Care Med. 2010;182(8):1080–5.CrossRefGoogle Scholar
  20. 20.
    Dolley C. No end in sight for Masi protests. IOL News. 2015 25 October 2015;Sect. Crime & Courts.Google Scholar
  21. 21.
    Dohmen T, Falk A, Huffman D, Sunde U, Schupp J, Wagner GG. Individual risk attitudes: measurement, determinants, and behavioral consequences. J Eur Econ Assoc. 2011;9(3):522–50.CrossRefGoogle Scholar
  22. 22.
    Corneli A, Field S, Namey E, Agot K, Ahmed K, Odhiambo J, et al. Preparing for the rollout of pre-exposure prophylaxis (PrEP): a vignette survey to identify intended sexual behaviors among women in Kenya and South Africa if using PrEP. PLoS ONE. 2015;10(6):e0129177.CrossRefGoogle Scholar
  23. 23.
    Gourlay A, Mshana G, Birdthistle I, Bulugu G, Zaba B, Urassa M. Using vignettes in qualitative research to explore barriers and facilitating factors to the uptake of prevention of mother-to-child transmission services in rural Tanzania: a critical analysis. BMC Med Res Methodol. 2014;14(1):21.CrossRefGoogle Scholar
  24. 24.
    Tsai AC, Kakuhikire B, Perkins JM, Vorechovska D, McDonough AQ, Ogburn EL, et al. Measuring personal beliefs and perceived norms about intimate partner violence: population-based survey experiment in rural Uganda. PLoS Med. 2017;14(5):e1002303.CrossRefGoogle Scholar
  25. 25.
    Slovic P, Finucane M, Peters E, MacGregor DG. Heuristics and biases. In: Gilovich T, Griffin D, Kahneman D, editors. The psychology of intuitive judgment. New York: Cambridge University Press; 2002.Google Scholar
  26. 26.
    Pronin E, Gilovich T, Ross L. Objectivity in the eye of the beholder: divergent perceptions of bias in self versus others. Psychol Rev. 2004;111(3):781–99.CrossRefGoogle Scholar
  27. 27.
    Hunter M. Masculinities and multiple-sexual partners in KwaZulu Natal: the making and unmaking of Isoka. Transformations. 2005;54:123–53.CrossRefGoogle Scholar
  28. 28.
    Morrell R. The times of change: men and masculinity in South Africa. In: Morrell R, editor. In changing men in Southern Africa. Pietermaritzburg: University of Natal Press; 2001. p. 3–56.Google Scholar
  29. 29.
    O’Sullivan LF, Harrison A, Morrell R, Monroe-Wise A, Kubeka M. Gender dynamics in the primary sexual relationships of young rural South African women and men. Culture. 2006;8(2):99–113.Google Scholar
  30. 30.
    Shefer T, Crawford M, Strebel A, Simbayi L, Dwadwa-Henda N, Cloete A, et al. Gender, power and resistance to change among two communities in the Western Cape, South Africa. Fem Psychol. 2008;18(2):157–82.CrossRefGoogle Scholar
  31. 31.
    Strebel A, Crawford M, Shefer T, Cloete A, Henda N, Kaufman MR, et al. Social constructions of gender roles, gender-based violence and HIV/AIDS in two communities of the Western Cape, South Africa. Sahara J. 2006;3(3):516–28.CrossRefGoogle Scholar
  32. 32.
    Pettifor A, MacPhail C, Anderson A, Maman S. ‘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. Culture. 2012;14(5):477–90.Google Scholar
  33. 33.
    Jewkes R, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. 2010;376:41–8.CrossRefGoogle Scholar
  34. 34.
    Pulerwitz J, Gortmaker S, DeJong W. Measuring relationship power in HIV/STD Research. Sex Roles. 2000;432(7/8):637–60.CrossRefGoogle Scholar
  35. 35.
    Fox AM, Jackson SS, Hansen NB, Gasa N, Crewe M, Sikkema KJ. In their own voices a qualitative study of women’s risk for intimate partner violence and HIV in South Africa. Violence Against Women. 2007;13(6):583–602.CrossRefGoogle Scholar
  36. 36.
    Harrison A, Xaba N, Kunene P. Understanding safe sex: gender narratives of HIV and pregnancy prevention by rural South African school-going youth. Reproduct Health Matters. 2001;9(17):63–71.CrossRefGoogle Scholar
  37. 37.
    Bryan A, Kagee A, Broaddus MR. Condom use among South African adolescents: developing and testing theoretical models of intentions and behavior. AIDS Behav. 2006;10(4):387.CrossRefGoogle Scholar
  38. 38.
    Sayles JN, Pettifor A, Wong MD, MacPhail C, Lee S-J, Hendriksen E, et al. Factors associated with self-efficacy for condom use and sexual negotiation among South African youth. J Acquir Immune Deficiency Syndromes (1999). 2006;43(2):226.CrossRefGoogle Scholar
  39. 39.
    Hensen BTS, Lewis JJ, et al. Systematic review of strategies to increase men’s HIV-testing in sub-Saharan Africa. AIDS. 2014;28(14):2133–45.CrossRefGoogle Scholar
  40. 40.
    Musheke MNH, Gari S, et al. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa. BMC Public Health. 2013;13(1):220.CrossRefGoogle Scholar
  41. 41.
    Barker G, Ricardo C, Nascimento M. Engaging men and boys in changing gender-based inequity in health: evidence from programme interventions. Geneva: World Health Organization; 2007.Google Scholar
  42. 42.
    Ricardo C, Eads M, Barker G. Engaging boys and young men in the prevention of sexual violence: a systematic and global review of evaluated interventions. Cape Town/Rio de Janeiro: Sexual Violence Research Initiative/Instituto Promundo; 2011.Google Scholar
  43. 43.
    Montgomery ET, van der Straten A, Chidanyika A, Chipato T, Jaffar S, Padian N. The importance of male partner involvement for women’s acceptability and adherence to female-initiated HIV prevention methods in Zimbabwe. AIDS Behav. 2011;15(5):959–69.CrossRefGoogle Scholar
  44. 44.
    Mngadi KT, Maarschalk S, Grobler AC, Mansoor LE, Frohlich JA, Madlala B, et al. Disclosure of microbicide gel use to sexual partners: influence on adherence in the CAPRISA 004 trial. AIDS Behav. 2014;18(5):849–54.CrossRefGoogle Scholar
  45. 45.
    Corneli A, Wang M, Agot K, Ahmed K, Lombaard J, Van Damme L, et al. Perception of HIV risk and adherence to a daily, investigational pill for HIV prevention in FEM-PrEP. JAIDS J Acquir Immune Deficiency Syndromes. 2014;67(5):555–63.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Miriam Hartmann
    • 1
    Email author
  • Margaret McConnell
    • 2
  • Linda-Gail Bekker
    • 3
  • Connie Celum
    • 4
  • Thola Bennie
    • 3
  • Jabulisile Zuma
    • 3
  • Ariane van der Straten
    • 1
    • 5
  1. 1.Women’s Global Health Imperative, RTI InternationalSan FranciscoUSA
  2. 2.Department of Global Health and PopulationHarvard UniversityBostonUSA
  3. 3.The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
  4. 4.Department of Global HealthUniversity of WashingtonSeattleUSA
  5. 5.Center for AIDS Prevention Studies, Department of MedicineUCSFSan FranciscoUSA

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