Discussion This study is one of the few providing insight into sexual behaviour of women in rural South Africa and the first to assess women in a region with predominantly people of Sotho and Shangaan ethnic origin. We show differences in sexual behaviour for different ages, ethnicity and by HIV-status.
These differences together with the associations observed with condom use illustrate the complexity of sexual behaviour in this region. Also, they provide an entry point for further discussion towards the design of tailor-made prevention strategies for these different groups of women. The sample of women included in this evaluation is considered representative for ethnic composition, age and HIV status of women visiting PHC facilities in this area.
The relation between age and sexual behaviour is well documented and confirmed in this study. Younger women are known to engage in higher risk sexual behaviour which is reflected in our study by the higher number of concurrent sexual partners. In addition, potential lifestyle differences e. Recently, a study from Kenya showed considerable ethnic disparities in HIV prevalence arising from sexual behaviour [ 13 ].
The relevance of race black, white, and coloured as a determinant of sexual behaviour has been reported before, but information about ethnic groups in South Africa is limited [ 17 , 18 , 21 ]. A recent study presented characteristics of sexual behaviour by isiXhosa women but no data are available for women of Sotho and Shangaan origin [ 16 , 17 , 24 , 25 ].
Sotho women were more likely to report concurrent sexual partners whereas intravaginal cleansing, vaginal scarring and knowledge of HIV-status of the steady partner were more frequent among Shangaan women. This may reflect a bias in recruitment although there was no specific selection and participants were representative of those visiting a primary healthcare facility on a random day.
On the other hand, these differences may be an important observation to warrant further research which could, hypothetically, result in a design of prevention efforts to be implemented at the same facilities where our study population was recruited: Discussing safe sex and sexual practice may be taboo within relationships in this region and understanding the influence of cultural practices, social beliefs, financial dependency and local media is required to inform the design of intervention strategies [ 26 — 29 ].
The association of HIV-infected status and sexual behaviour is reasonably well-documented, but information from rural Africa and rural South Africa is limited. Our study shows that HIV-infected women reported a higher lifetime number of sexual partners, were more likely to use a condom during last sexual act, and to have a known HIV-infected partner whereas HIV negative women were more likely to use hormonal contraceptives and practice fellatio.
Having a circumcised partner was significantly more frequently reported by HIV-negative women. Most of these associations have been reported before [ 3 , 12 , 19 , 30 ]. The lower frequency of practising fellatio by HIV-infected women has been reported once before [ 20 ]. This could relate to a difference in age as HIV-infected women were older and young women were more likely to engage in fellatio or a change, e.
The findings in our study suggest an essential difference in sexual behaviour related to HIV-status, but the study design did not allow determining temporality of this relationship.
We determined factors associated with non- use of condoms to support the development of prevention tools [ 31 ]. These factors are well known in African populations where condom use within the marriage is unusual and pregnancy frequently associated with lower uptake of condom use [ 19 , 32 ]. While alcohol use before intercourse is a known factor of sexual risk behaviour, there was no difference between condom uptake between women using alcohol before intercourse or not [ 33 , 34 ].
Men in age-disparate relationships, i. Efforts aimed at reducing age mixing are complicated, but may decrease the risk of HIV and STIs among young women in a traditional setting such as ours [ 36 ]. This study has several limitations. First, this study design does not allow for assessment of temporality of the observed associations and the results should be interpreted with caution. Sexual behaviour is a complex entity and we can only provide some degree of insight. Most importantly, the groups compared in this analysis could provide insight into different target groups and entry points of prevention efforts.
Second, we used self-reported age, HIV-status and ethnic group. We tried to limit the effect of self-report by using strict criteria for classification of HIV-status. Third, reporting and desirability bias may have occurred although we tried to create as safe as possible environment.
This could play a role in particular when considering the positive association of condom use with HIV-positive status: Selection bias may have occurred and extrapolation of information should be done cautiously as we only included women visiting PHC facilities.
These women are of low socio-economic status, demonstrated by the high unemployment rate reported in our study compared to the average in this area, and cannot afford private healthcare.
However, the study was conducted at a representative sample of PHC facilities in the district, which provide prominent locations to implement preventions campaigns. Conclusions More information about heterosexual sexual behaviour in Africa is warranted to determine the relevance and potential impact of efforts aimed at modifying sexual behaviour for HIV and STI prevention.
Our further gratitude goes to the staff of the Anova Health Institute for their invaluable contribution, efforts and support. Furthermore, the funding body NVTG had no role in the design of the study, the collection, analysis and interpretation of data, and writing of the manuscript. Availability of data and materials The raw data collected in this study and supporting the conclusions in this manuscript will be made available in SPSS format by the corresponding author upon specific request.
LE carried out the cross-sectional study and helped to draft the manuscript. JAM participated in the design of the study and helped to draft the manuscript. NM carried out the cross-sectional study. GAJ helped to draft the manuscript. SO performed statistical analysis and helped to draft the manuscript. SAM participated in the design of the study and helped to draft the manuscript. HES participated in the design and coordination of the study and helped to draft the manuscript.
RPHP was responsible for planning of the study, participated in its design and coordination, and helped to draft the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interest.
Ethics approval and consent to participate Written informed consent was obtained from all study participants. This study was approved by the Human Ethics Research Committee of the University of the Witwatersrand reference number: Lisette van der Eem, Phone: The burden of disease attributable to sexually transmitted infections in South Africa in S Afr Med J. South African national HIV prevalence, incidence, behaviour and communication survey A turning tide among teenagers?
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