Understanding HIV Risk Behaviors Among Young Men in South Africa: A Syndemic Approach


Young men in South Africa experience several adverse socio-structural and psychosocial factors that may contribute HIV risk behaviors. This study applied a syndemic framework to explore whether these syndemic factors are interconnected and work in synergy to increase HIV risk behaviors. Five syndemic factors were assessed including: binge drinking, polydrug use, depressive symptoms, violence and food insecurity on two HIV risk behaviors: multiple sex partners and transactional sex. Participants were (N = 1233) young men aged 18–29 years from a township in Cape Town, South Africa. Bivariate logistic regression analysis demonstrated that many of the syndemic factors were related to one another. Pairwise interactions (on an additive scale) among the syndemic factors revealed significant positive interactions between binge drinking and violence on greater odds of reporting multiple sex partners (aOR = 5.10, 95% CI 3.10, 8.29; p = < .001) compared to reporting neither factor. Also, food insecurity and violence (aOR = 2.89, 95% CI 1.63, 5.11; p = < .001) as well as food insecurity and polydrug use (aOR = 2.73, 95% CI 1.54, 4.84; p = < .001) were significantly associated with greater odds of transactional sex compared to reporting neither factor. Our findings highlight a synergistic relationship between some adverse socio-structural and psychosocial factors on HIV risk behaviors. HIV prevention programs that address multiple syndemic factors simultaneously may achieve greater impact on HIV risk reduction.

This is a preview of subscription content, access via your institution.


  1. 1.

    Zuma K, Shisana O, Rehle TM, Simbayi LC, Jooste S, Zungu N, et al. New insights into HIV epidemic in South Africa: key findings from the National HIV Prevalence, Incidence and Behaviour Survey, 2012. Afr J AIDS Res. 2016;15(1):67–75.

    Article  Google Scholar 

  2. 2.

    Mahajan S. Economics of South African townships : special focus on Diepsloot [Internet]. The World Bank; 2014 Aug [cited 2017 Aug 2] pp. 1–297. Report No.: 89917. Retrieved from http://documents.worldbank.org/curated/en/217211468302413395/Economics-of-South-African-townships-special-focus-on-Diepsloot.

  3. 3.

    Dunkle KL, Jewkes RK, Nduna M, Levin J, Jama N, Khuzwayo N, et al. Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa. AIDS Lond Engl. 2006;20(16):2107–14.

    Article  Google Scholar 

  4. 4.

    Eaton LA, Cain DN, Pitpitan EV, Carey KB, Carey MP, Mehlomakulu V, et al. Exploring the relationships among food insecurity, alcohol use, and sexual risk taking among men and women living in South African townships. J Prim Prev. 2014;35(4):255–65.

    Article  Google Scholar 

  5. 5.

    Mufune P. Poverty and HIV/AIDS in Africa: specifying the connections. Soc Theory Health. 2015;13(1):1–29.

    Article  Google Scholar 

  6. 6.

    Tladi LS. Poverty and HIV/AIDS in South Africa: an empirical contribution. SAHARA-J J Soc Asp HIVAIDS. 2006;3(1):369–81.

    CAS  Article  Google Scholar 

  7. 7.

    Singer M. A dose of drugs, a touch of violence, a case of AIDS: conceptualizing the sava syndemic. Free Inq Creat Sociol. 1996;24(2):99–110.

    Google Scholar 

  8. 8.

    Salas-Wright CP, Olate R, Vaughn MG. Substance use, violence, and HIV risk behavior in El Salvador and the United States: cross-national profiles of the SAVA syndemic. Vict Offenders. 2015;10(1):95–116.

    Article  Google Scholar 

  9. 9.

    Pitpitan EV, Kalichman SC, Eaton LA, Cain D, Sikkema KJ, Watt MH, et al. Co-occurring psychosocial problems and HIV risk among women attending drinking venues in a South African township: a syndemic approach. Ann Behav Med Publ Soc Behav Med. 2013;45(2):153–62.

    Article  Google Scholar 

  10. 10.

    Stall R, Friedman M, Catania. Interacting epidemics and gay men’s health: a theory of syndemic production among urban gay men—oxford scholarship [Internet]. 2007 [cited 2017 Nov 12]. Retrieved from http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780195301533.001.0001/acprof-9780195301533-chapter-9.

  11. 11.

    Shields N, Nadasen K, Pierce L. The effects of community violence on children in Cape Town, South Africa. Child Abuse Negl. 2008;32(5):589–601.

    Article  Google Scholar 

  12. 12.

    Cluver LD, Orkin FM, Meinck F, Boyes ME, Sherr L. Structural drivers and social protection: mechanisms of HIV risk and HIV prevention for South African adolescents. J Int AIDS Soc [Internet]. 2016 Apr 15 [cited 2017 Oct 12];19(1). Retrieved from http://www.jiasociety.org/index.php/jias/article/view/20646.

    Article  Google Scholar 

  13. 13.

    Wilson K, Kelling G. The police and neighborhood safety: broken windows. Atlantic Monthly. 1982;3:29–38.

    Google Scholar 

  14. 14.

    Otwombe KN, Dietrich J, Sikkema KJ, Coetzee J, Hopkins KL, Laher F, et al. Exposure to and experiences of violence among adolescents in lower socio-economic groups in Johannesburg, South Africa. BMC Public Health [Internet]. 2015 May 1;15. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4419458/.

  15. 15.

    Parry CDH, Plüddemann A, Steyn K, Bradshaw D, Norman R, Laubscher R. Alcohol use in South Africa: findings from the first Demographic and Health Survey (1998). J Stud Alcohol. 2005;66(1):91–7.

    Article  Google Scholar 

  16. 16.

    Bello B, Moultrie H, Somji A, Chersich MF, Watts C, Delany-Moretlwe S. Alcohol use and sexual risk behaviour among men and women in inner-city Johannesburg, South Africa. BMC Public Health. 2017;1(17):4350.

    Google Scholar 

  17. 17.

    Given M. An exploratory study of the relationship between alcohol use and sexual risk behaviour among students at the University of Kwazulu-Natal. J AIDS Clin Res. 2015;6(1):1, 1–6.

  18. 18.

    Kaufman ZA, Braunschweig EN, Feeney J, Dringus S, Weiss H, Delany-Moretlwe S, et al. Sexual risk behavior, alcohol use, and social media use among secondary school students in informal settlements in Cape Town and Port Elizabeth, South Africa. AIDS Behav. 2014;18(9):1661–74.

    CAS  Article  Google Scholar 

  19. 19.

    Sandfort TGM, Knox JR, Alcala C, El-bassel N, Kuo I, Smith LR. Substance use and Hiv risk among men who have sex with men in Africa: a systematic review. Jaids J Acquir Immune Defic Syndr [Internet]. 2017 Oct 1 [cited 2017 Oct 12];76(2). Retrieved from https://insights.ovid.com/pubmed?pmid=28903126.

    Article  Google Scholar 

  20. 20.

    Floyd LJ, Hedden S, Lawson A, Salama C, Moleko AG, Latimer W. The association between poly-substance use, coping, and sex trade among black South African substance users. Subst Use Misuse. 2010;45(12):1971–87.

    Article  Google Scholar 

  21. 21.

    Kalichman SC, Simbayi LC, Kagee A, Toefy Y, Jooste S, Cain D, et al. Associations of poverty, substance use, and HIV transmission risk behaviors in three South African communities. Soc Sci Med 1982. 2006 Apr;62(7):1641–9.

    Article  Google Scholar 

  22. 22.

    Tibbits MK, Smith EA, Caldwell LL, Flisher AJ. Impact of HealthWise South Africa on polydrug use and high-risk sexual behavior. Health Educ Res. 2011;26(4):653–63.

    Article  Google Scholar 

  23. 23.

    Trenz RC, Scherer M, Duncan A, Harrell P, Moleko AG, Latimer W. Latent class analysis of polysubstance use, sexual risk behaviors, and infectious disease among South African Drug Users. Drug Alcohol Depend. 2013;132(3):441–8.

    Article  Google Scholar 

  24. 24.

    Hedden SL, Hulbert A, Cavanaugh CE, Parry CD, Moleko AG, Latimer WW. Alcohol, drug and sexual risk behavior correlates of recent transactional sex among female black south african drug users. J Subst Use. 2011;16(1):57–67.

    Article  Google Scholar 

  25. 25.

    Wechsberg WM, Myers B, Kline TL, Carney T, Browne FA, Novak SP. The relationship of alcohol and other drug use typologies to sex risk behaviors among vulnerable women in Cape Town, South Africa. J AIDS Clin Res [Internet]. 2012;Suppl 1(15). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3568528/.

  26. 26.

    Shisana O, Rehle T, Simbayi L, Parker W, Zuma K, Bhana A, et al. South African National HIV prevalence, HIV incidence, behaviour and Communication Survey, 2005 [Internet]. 2005 [cited 2017 Aug 2]. Retrieved from: http://www.hsrcpress.ac.za/product.php?productid=2134.

  27. 27.

    Bunyasi EW, Coetzee DJ. Relationship between socioeconomic status and HIV infection: findings from a survey in the Free State and Western Cape Provinces of South Africa. BMJ Open. 2017;7(11):e016232.

    Article  Google Scholar 

  28. 28.

    Pienaar K. Rethinking the poverty-disease nexus: the case of HIV/AIDS in South Africa. J Med Humanit. 2017;38(3):249–66.

    Article  Google Scholar 

  29. 29.

    Steinert JI, Cluver L, Melendez-Torres GJ, Herrero Romero R. Relationships between poverty and AIDS Illness in South Africa: an investigation of urban and rural households in KwaZulu-Natal. Glob Public Health. 2017;12(9):1183–99.

    Article  Google Scholar 

  30. 30.

    Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Transactional sex among women in Soweto, South Africa: prevalence, risk factors and association with HIV infection. Soc Sci Med 1982. 2004;59(8):1581–92.

    Article  Google Scholar 

  31. 31.

    Lion RR, Watt MH, Wechsberg WM, Meade CS. Gender and sex trading among active methamphetamine users in Cape Town, South Africa. Subst Use Misuse. 2017;52(6):773–84.

    Article  Google Scholar 

  32. 32.

    Kalichman SC, Watt M, Sikkema K, Skinner D, Pieterse D. Food insufficiency, substance use, and sexual risks for HIV/AIDS in informal drinking establishments, Cape Town, South Africa. J Urban Health Bull N Y Acad Med. 2012;89(6):939–51.

    Article  Google Scholar 

  33. 33.

    Pengpid S, Peltzer K, Skaal L. Mental health and HIV sexual risk behaviour among University of Limpopo students. South Afr J Psychiatr. 2013;19(2):6.

    Article  Google Scholar 

  34. 34.

    Sikkema KJ, Watt MH, Meade CS, Ranby KW, Kalichman SC, Skinner D, et al. Mental health and HIV sexual risk behavior among patrons of alcohol serving venues in Cape Town, South Africa. J Acquir Immune Defic Syndr 1999. 2011;57(3):230–7.

    Article  Google Scholar 

  35. 35.

    Rotheram-Borus MJ, Tomlinson M, Durkin A, Baird K, DeCelles J, Swendeman D. Feasibility of using soccer and job training to prevent drug abuse and HIV. AIDS Behav. 2016;20(9):1841–50.

    Article  Google Scholar 

  36. 36.

    Radloff LS. The CES-D scale a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.

    Article  Google Scholar 

  37. 37.

    Tsai AC, Venkataramani AS. Syndemics and health disparities: a methodological note. AIDS Behav. 2016;20(2):423–30.

    Article  Google Scholar 

  38. 38.

    Knol MJ, VanderWeele TJ, Groenwold RHH, Klungel OH, Rovers MM, Grobbee DE. Estimating measures of interaction on an additive scale for preventive exposures. Eur J Epidemiol. 2011;26(6):433–8.

    Article  Google Scholar 

  39. 39.

    Mimiaga MJ, OʼCleirigh C, Biello KB, Robertson AM, Safren SA, Coates TJ, et al. The effect of psychosocial syndemic production on 4-year HIV incidence and risk behavior in a large cohort of sexually active men who have sex with men. J Acquir Immune Defic Syndr 1999. 2015;68(3):329–36.

    Article  Google Scholar 

  40. 40.

    Mustanski B, Phillips G, Ryan DT, Swann G, Kuhns L, Garofalo R. Prospective effects of a syndemic on HIV and STI incidence and risk behaviors in a cohort of young men who have sex with men. AIDS Behav. 2017;21(3):845–57.

    Article  Google Scholar 

  41. 41.

    Nehl EJ, Klein H, Sterk CE, Elifson KW. Prediction of HIV sexual risk behaviors among disadvantaged african american adults using a syndemic conceptual framework. AIDS Behav. 2016;20(2):449–60.

    Article  Google Scholar 

  42. 42.

    Stall R, Mills TC, Williamson J, Hart T, Greenwood G, Paul J, et al. Association of Co-occurring psychosocial health problems and increased vulnerability to HIV/AIDS among urban men who have sex with men. Am J Public Health. 2003;93(6):939–42.

    Article  Google Scholar 

  43. 43.

    Wang Y, Wang Z, Jia M, Liang A, Yuan D, Sun Z, et al. Association between a syndemic of psychosocial problems and unprotected anal intercourse among men who have sex with men in Shanghai, China. BMC Infect Dis. 2017;17(1):46.

    Article  Google Scholar 

  44. 44.

    Hatcher AM, Colvin CJ, Ndlovu N, Dworkin SL. Intimate partner violence among rural South African men: alcohol use, sexual decision-making, and partner communication. Cult Health Sex. 2014;16(9):1023–39.

    Article  Google Scholar 

  45. 45.

    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(1–2):56–72.

    PubMed  Google Scholar 

  46. 46.

    Baral S, Adams D, Lebona J, Kaibe B, Letsie P, Tshehlo R, et al. A cross-sectional assessment of population demographics, HIV risks and human rights contexts among men who have sex with men in Lesotho. J Int AIDS Soc. 2011;4(14):36.

    Article  Google Scholar 

  47. 47.

    Lane T, Raymond HF, Dladla S, Rasethe J, Struthers H, McFarland W, et al. High HIV prevalence among men who have sex with men in Soweto, South Africa: results from the Soweto Men’s Study. AIDS Behav. 2011;15(3):626–34.

    Article  Google Scholar 

  48. 48.

    Hutton HE, Lyketsos CG, Zenilman JM, Thompson RE, Erbelding EJ. Depression and HIV risk behaviors among patients in a sexually transmitted disease clinic. Am J Psychiatr. 2004;161(5):912–4.

    Article  Google Scholar 

  49. 49.

    Shrier LA, Harris SK, Sternberg M, Beardslee WR. Associations of depression, self-esteem, and substance use with sexual risk among adolescents. Prev Med. 2001;33(3):179–89.

    CAS  Article  Google Scholar 

  50. 50.

    Meade CS, Lion RR, Cordero DM, Watt MH, Joska JA, Gouse H, et al. HIV risk behavior among methamphetamine users entering substance abuse treatment in Cape Town, South Africa. AIDS Behav. 2016;20(10):2387–97.

    Article  Google Scholar 

  51. 51.

    Nduna M, Jewkes RK, Dunkle KL, Shai NPJ, Colman I. Associations between depressive symptoms, sexual behaviour and relationship characteristics: a prospective cohort study of young women and men in the Eastern Cape, South Africa. J Int AIDS Soc. 2010;15(13):44.

    Article  Google Scholar 

  52. 52.

    Arfer KB, Tomlinson M, Mayekiso A, Bantjes J, van Heerden A, Rotheram-Borus MJ. Criterion validity of self-reports of alcohol, cannabis, and methamphetamine use among young men in Cape Town, South Africa. Int J Ment Health Addict. 2017;1:1–8.

    Google Scholar 

  53. 53.

    Pronyk PM, 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 Lond Engl. 2006;368(9551):1973–83.

    Article  Google Scholar 

  54. 54.

    Wechsberg WM, Luseno WK, Lam WKK, Parry CDH, Morojele NK. Substance use, sexual risk, and violence: HIV prevention intervention with sex workers in Pretoria. AIDS Behav. 2006;10(2):131.

    Article  Google Scholar 

  55. 55.

    Pettifor A, MacPhail C, Hughes JP, Selin A, Wang J, Gómez-Olivé FX, et al. The effect of a conditional cash transfer on HIV incidence in young women in rural South Africa (HPTN 068): a phase 3, randomised controlled trial. Lancet Glob Health. 2016;4(12):e978–88.

    Article  Google Scholar 

  56. 56.

    Wechsberg WM, Jewkes R, Novak SP, Kline T, Myers B, Browne FA, et al. A brief intervention for drug use, sexual risk behaviours and violence prevention with vulnerable women in South Africa: a randomised trial of the Women’s Health CoOp. BMJ Open. 2013;3(5):e002622.

    Article  Google Scholar 

  57. 57.

    Mills EJ, Beyrer C, Birungi J, Dybul MR. Engaging men in prevention and care for HIV/AIDS in Africa. PLOS Med. 2012;9(2):e1001167.

    Article  Google Scholar 

  58. 58.

    Jewkes R, Nduna M, Levin J, Jama N, Dunkle 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;7(337):a506.

    Article  Google Scholar 

  59. 59.

    Kalichman SC, Simbayi LC, Vermaak R, Cain D, Smith G, Mthebu J, et al. Randomized trial of a community-based alcohol-related HIV risk-reduction intervention for men and women in Cape Town South Africa. Ann Behav Med Publ Soc Behav Med. 2008;36(3):270–9.

    Article  Google Scholar 

  60. 60.

    Kalichman SC, Simbayi LC, Cloete A, Clayford M, Arnolds W, Mxoli M, et al. Integrated gender-based violence and HIV risk reduction intervention for South African men: results of a quasi-experimental field trial. Prev Sci. 2009;10(3):260–9.

    Article  Google Scholar 

  61. 61.

    Wechsberg WM, El-Bassel N, Carney T, Browne FA, Myers B, Zule WA. Adapting an evidence-based HIV behavioral intervention for South African couples. Subst Abuse Treat Prev Policy. 2015;24(10):6.

    Article  Google Scholar 

Download references


This project was supported by the National Institute on Drug Abuse (R34DA030311) and the National Research Foundation, South Africa. CNO is supported by the UCLA Postdoctoral Fellowship Training Program in Global HIV Prevention Research (T32MH080634; PIs: Currier and Gorbach). SS is supported by NIMH P30 058107—CHIPTS UCLA CFAR grant AI028697. MT is supported by the National Research Foundation, South Africa and is a Lead Investigator of the Centre of Excellence in Human Development, University Witwatersrand, South Africa.

Author information



Corresponding author

Correspondence to Chukwuemeka N. Okafor.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical Approval

The Institutional Review Boards at UCLA and Stellenbosch University approved all aspects of the study.

Informed Consent

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

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Okafor, C.N., Christodoulou, J., Bantjes, J. et al. Understanding HIV Risk Behaviors Among Young Men in South Africa: A Syndemic Approach. AIDS Behav 22, 3962–3970 (2018). https://doi.org/10.1007/s10461-018-2227-x

Download citation


  • HIV risk
  • HIV risk behaviors
  • Syndemics
  • Alcohol
  • South Africa