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HIV risk behaviour research challenges stereotypical 'sugar daddy' image

The male partners of adolescent girls and young women in Eswatini (formerly Swaziland) and South Africa report substantial HIV risk behaviours, but the data also challenge the stereotypical image of a ‘sugar daddy’, say researchers at the University of North Carolina at Chapel Hill in the US. The men were only a few years older than their partners and many described challenging life circumstances such as unemployment, homelessness and violence, reports Aidsmap.

A parallel, qualitative study from Uganda by researchers at the Population Council, HIV and AIDS Programme in Washington and Epicentre AIDS Risk Management in Paarl, South Africa, describes a somewhat different situation, with men often acting as economic providers in relationships of a relatively long duration. These three studies were recently published and presented at the International AIDS Conference (AIDS 2018) in Amsterdam.

In many African countries, rates of new HIV infections among females aged 15-24 are much higher than among their male peers. Unequal power dynamics in sexual relationships with male partners, especially older partners, contribute to this vulnerability. However older male partners have often been seen as a “hidden” or “hard to reach” population. Until now, most researchers have asked women about their partners, rather than conducting research directly with men.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) therefore created the DREAMS partnership. It aims to reduce HIV infections among adolescent girls and young women in 10 Sub-Saharan African countries with interventions that go beyond the health sector, addressing structural factors such as poverty, education and gender inequality.

The partnership includes research to better understand the characteristics of older male partners and identify settings in which they can be reached. DREAMS will try to improve these men’s engagement with HIV services. A higher uptake of HIV testing in men, and antiretroviral therapy for the HIV-positive, may lower their risk of passing HIV on to young women.

Eswatini is a landlocked country in Southern Africa, formerly known as Swaziland, in which 15% of adolescent girls and young women are living with HIV. DREAMS’ study in Eswatini took a quantitative approach. In 19 rural, peri-urban and urban districts across the country, the researchers worked with community informants to identify 182 venues where men meet and socialise with adolescent girls and young women. These were predominantly drinking spots, kiosks, stores, bars and clubs, although other sites such as parks and churches were also included. Only men aged 20-34 were surveyed, on the basis of other work that suggests they are the age group mostly likely to have younger female partners and to be involved in HIV transmission.

The researchers interviewed 843 men in order to identify 568 men who reported having at least one female partner aged 15-24 in the past year. Over half of this group reported having two or more sexual partners in the past year. Relatively few men told interviewers that they were living with HIV (6%), but men who had at least three partners aged 15-24 in the past year were more likely to be HIV-positive (adjusted odds ratio 3.2).

The vast majority (88%) of the men described their marital status as single and their average age was 25.7 years. The majority of men (71%) had female partners no more than four years younger than them. In 14%, their partners' average age was 5-9 years younger but only 1% reported having partner ten years younger than them or more. Even for men aged 30-34, only 3% reported an age gap of ten years or more.

Only 36% had consistently used a condom with their current partner and 57% had talked about HIV status with this partner. Men whose current partner was under the age of 20 were less likely to talk about HIV status than men who had older partners (adjusted odds ratio 0.6).

Only half of the men were currently employed. They were engaged in a wide range of occupations, including industry, transport and government.

A substantial minority reported precarious living conditions – 15% had slept outside due to homelessness in the past year, 13% had been jailed in the past year and 8% had experienced a lack of food in the last month. “Challenging life circumstances suggest structural factors may underlie some risk behaviours,” comment the authors.

A similar survey was done in two informal settlements in Durban, South Africa. Here, recruitment took place both in venues where men meet younger women (such as drinking establishments and taxi ranks) and in HIV services.

The demographic profile of the 962 respondents was comparable to that in Swaziland, in terms of age, marital status and employment – 71% reported having multiple partners in the past year (of any age); 24% had five or more partners; 75% had at least one female partner aged 15-24 in the past year; and 54% had both younger and older partners.

Just under half the relationships could be described as “transactional” – the men had given money, goods or services mainly to start or stay in the relationship. Such gifts could include drinks, meals and make-up, but for 12% of the men it was something much more substantial, such as paying their partner’s rent or school fees.

Men who were employed (p<0.01), small business owners (p< 0.01) or educated to technical college or university level (p<0.05) were more likely to have multiple partners, in accordance with the idea that more economically powerful men have more partners.
Men's vulnerabilities, as well as their power, also emerged as a theme, however. There was a link between traumatic events in childhood or adulthood and sexual risk behaviour.

In childhood, 77% had been beaten and 21% had seen or heard their mother being beaten. These experiences were associated with less consistent condom use (p<0.05) and having multiple partners (p<0.05). 42% were not raised by a biological parent and 37% had experienced a parent’s death during childhood. These experiences were associated with less consistent condom use (p<0.01) and more age-disparate relationships (p<0.05). As adults, 59% had witnessed an armed attack, 39% had been robbed at gunpoint or knifepoint and 41% had felt close to death. These experiences were associated with multiple sexual partnerships (p=0.001).

The third DREAMS study took a qualitative approach, using in-depth interviews with 94 men in Uganda. The study was done in a mix of rural and urban sites in three geographically and culturally diverse districts. As well as recruiting at community venues where men and younger women met, adolescent girls and young women were asked to refer their male partners to the study. The latter approach was expected to identify men in more stable partnerships.

The respondents had a different profile to the other two studies. While the mean age was 28, interviewees were up to 45 years of age, 80% of respondents were married or cohabiting, and 94% were employed.

Multiple sexual partnerships were seen as a very common practice, as one man described: “These days most men have more than one woman, most men say that you can’t keep eating one type of food all the time. In fact you can’t find a man with only one woman, it isn’t there.”

Men often sought to develop “side” relationships. They were seen as additional long-term partners whom the man would provide for economically. Many men referred to them as “wives”. “She is not at my home she is in a rental but it’s me who pays her rent, it’s me who is taking care of her in everything even though she is not at my place she still is like my wife now.”

When men did not have an additional partner, it was often because of the cost of doing so. They might however have short-term casual partners who they would meet at drinking establishments. These relationships were nearly always transactional in nature, usually starting with the man buying the girl or woman drinks, a meal or low-cost items like mobile phone credit.

Some interviewees explicitly described a preference for younger partners. As this 31 year-old described, they could be more easily controlled: “If you get a woman who is your age mate, somehow these women tend not to be submissive… yet for a young girl, because of the age difference, she will find it very easy to listen to you, she will treat you with respect because she knows you are older than her and perhaps more experienced.”

Men described a pattern of establishing relationships with younger females. Most men had married in their early twenties, usually to a woman three to five years younger than themselves, and generally saw marriage as an important life event. Within a few years after marrying, however, many men described taking on one or more side partners. This might occur during a period of separation from the first wife due to a conflict or residential relocation.

As men got older, they might also have a series of short-term casual partnerships, almost always with adolescent girls and young women. A few of these might develop into longer term ‘side’ relationships.

The researchers comment that these complex and fluid patterns – including temporary separations of long-term partnerships, ‘side’ partnerships being initiated and casual partnerships sometimes becoming more formalised – will complicate public health strategies to reach these men.

Abstract 1
Background: Adolescent girls and young women (AGYW, ages 15–24) are at high risk of HIV in Swaziland. Understanding more about their male sexual partners can inform HIV prevention efforts for both.
Methods: Using the PLACE methodology across all 19 DREAMS implementation districts, 843 men ages 20–34 were surveyed between December 2016-February 2017. Surveys were conducted at 182 venues identified by community informants as places where AGYW and men meet/socialize. Descriptive and multivariate analyses examined characteristics and risk behaviors of male partners of AGYW.
Results: Men’s average age was 25.7. Sixty-three percent reported female partners ages 15–19, and 70% reported partners ages 20–24 in the last year; of those, 12% and 11% respectively had five or more such partners. Among the 568 male partners of AGYW, 36% reported consistent condom use with their current/last partner. Forty-two percent reported testing for HIV in the last year; 6% were HIV-positive, and of those, 97% were currently on treatment. One-third (37%) reported being circumcised; among uncircumcised, 81% were not considering it. In multivariate analyses, men who reported three or more AGYW partners in the last year were more likely to be HIV-positive (aOR 3.2, 95% CI 1.1,8.8). Men were also less likely to disclose their HIV status to adolescent versus older partners (aOR 0.6, 95% CI 0.4,0.9) and partners more than 5 years younger than themselves (aOR 0.6, 95% CI 0.4,0.9). Results also revealed relatively high unemployment and mobility, substantial financial responsibilities, and periodic homelessness.
Conclusions: Most men identified through community venues reported relationships with AGYW, and these relationships demonstrated substantial HIV risk. Challenging life circumstances suggest structural factors may underlie some risk behaviors. Engaging men in HIV prevention and targeted health services is critical, and informant-identified community venues are promising intervention sites to reach high-risk male partners of AGYW.

Zahra Reynolds, Ann Gottert, Erin Luben, Bheki Mamba, Patrick Shabangu, Nsindiso Dlamini, Muhle Dlamini, Sanyukta Mathur, Julie Pulerwitz

Abstract 2
Background: Adolescent girls and young women (AGYW, ages 15-24) are at high risk of HIV in South Africa. Context-specific data on characteristics, HIV risk and health-seeking behaviors of male partners of AGYW are sorely needed to develop more effective HIV programs.
Methods: We surveyed 962 men ages 20-40 recruited at community "hot spot" venues (n=649) and HIV service sites (n=313) in two informal settlements in Durban, from May-September 2017. We present descriptive and regression analyses of men"s characteristics and their partnership and service-use experiences.
Results: Men"s average age was 28, 15% were married/cohabiting, and 61% were employed. Over two-thirds (71%) reported two or more sexual partners in the last year; 24% had five or more. Overall, 75% had AGYW partner(s); 54% had both AGYW partners and partners age 25+. Men"s last three partners were 3.4 years younger on average; 8% had partners 10+ years younger. Thirty-two percent reported consistent condom use with their last partner; 14% with each of their last three non-marital partners. Sixty-four percent reported HIV testing in the last year. Among HIV-positive men (n=84), 87% were on treatment, and 24% knew that they were virally suppressed. In multivariate analyses controlling for demographic characteristics, men with more sexual partners in the last year were more likely to have a technical college/university education (p< 0.05), be employed (p=0.01), and be small business owners/entrepreneurs (p< 0.01). Taxi drivers had more age disparate partners (p< 0.001) as well as more partners ages 15-19 in the last year (p< 0.05), and were less likely to have tested for HIV (p< 0.05). Formally employed men were about half as likely to be virally suppressed as informally or unemployed men (p< 0.05).
Conclusions: Men in informal settlements in Durban are at very high risk of both acquiring HIV and transmitting to AGYW due to high numbers of partners, overlapping partnerships of AGYW and older women, inconsistent condom use, suboptimal testing, and low viral load suppression. Engaging men in primary HIV prevention and targeted health services is critical, and in Durban, focusing on reaching men at workplaces, technical colleges/universities, taxi ranks and self-owned businesses may yield the greatest results.

A Gottert, S. Mathur, C Cawood, J Pulerwitz

Abstract 3
Background: There is often limited focus on the vulnerabilities men face in their lives – either as key public health issues or as they link to HIV transmission. We examined such vulnerabilities and their association with HIV risk behaviors among men in Durban, South Africa.
Methods: We surveyed 962 men ages 20-40 recruited at community "hot spot" venues (n=649) and at HIV service sites (n=313) in two informal settlements in Durban, from May-September 2017. Adult experiences of violence and of deprivation, and childhood experiences of abuse and of parental absence, were each measured with sets of 2-4 items. Alcohol abuse was measured by the AUDIT-C; depression by the PHQ4 scale (alpha=0.81).
Results: Respondents" average age was 28; 15% were married/cohabiting. On average respondents had 3.7 sexual partners in the last year, and 14% used condoms consistently with their last three non-marital partners. About 40% had ever witnessed an armed attack, been robbed at knifepoint/gunpoint, and had felt close to death. Before age 18, 77% had been beaten physically at home (14% "very often"), 21% had seen/heard their mother being beaten by her husband/boyfriend, 42% were not raised by at least one biological parent, and 37% had lost a parent. Half (52%) abuse alcohol, and 30% were moderately or severely depressed. In multivariate analyses, adult experiences of violence (p=0.001) and of deprivation (p=0.001), and childhood experiences of abuse (p< 0.05), were each associated with having multiple sexual partners in the last year. Childhood experiences of abuse and of parental absence were associated with less consistent condom use (p< 0.05 and p< 0.01, respectively). Parental absence was also associated with having more age-disparate partners (p< 0.05). Men who abused alcohol had more partners in the last year (p< 0.001) and more highly age-disparate partners (p< 0.01). Depression was also associated with having more partners (p< 0.05).
Conclusions: Men in Durban are experiencing serious vulnerabilities including depression, alcohol abuse, and childhood and adult experiences of deprivation and violence. Each of these factors had direct effects on key HIV risk behaviors. Interventions should focus on reducing such vulnerabilities, to promote wellbeing and to curtail the HIV epidemic.

A Gottert, S Mathur, C Cawood, J Pulerwitz

Abstract 4
Background: Substantial concern exists about the high risk of sexually transmitted HIV to adolescent girls and young women (AGYW, ages 15–24) in Eastern and Southern Africa. Yet limited research has been conducted with AGYW’s male sexual partners regarding their perspectives on relationships and strategies for mitigating HIV risk. We sought to fill this gap in order to inform the DREAMS Partnership and similar HIV prevention programs in Uganda.
Methods: We conducted 94 in-depth interviews, from April-June 2017, with male partners of AGYW in three districts: Gulu, Mukono, and Sembabule. Men were recruited at community venues identified as potential transmission areas, and via female partners enrolled in DREAMS. Analyses focused on men’s current and recent partnerships and HIV service use.
Results: Most respondents (80%) were married and 28 years old on average. Men saw partner concurrency as pervasive, and half described their own current multiple partners. Having married in their early 20s, over time most men continued to seek out AGYW as new partners, regardless of their own age. Relationships were highly fluid, with casual short-term partnerships becoming more formalized, and more formalized partnerships characterized by periods of separation and outside partnerships. Nearly all men reported recent HIV testing and described testing at distinct relationship points (e.g., when deciding to continue a relationship/get married, or when reuniting with a partner after a separation). Testing often stemmed from distrust of partner behavior, and an HIV-negative status served to validate respondents’ current relationship practices.
Conclusions: Across the three regions in Uganda, findings with partners of AGYW confirm earlier reports in Uganda of multiple concurrent partnerships, and demonstrate substantial HIV testing. Yet they also unearth the degree to which these partnerships are fluid (switching between casual and/or more long-term partnerships), which complicates potential HIV prevention strategies. Context-specific findings around these partnerships and risk are critical to further tailor HIV prevention programs.

Ann Gottert, Julie Pulerwitz, Godfrey Siu, Anne Katahoire, Jerry Okal, Florence Ayebare, Nrupa Jani, Pamela Keilig, Sanyukta Mathur

[link url=""]Aidsmap material[/link]
[link url=""]PLOS One analysis[/link]
[link url=""]AIDS 2018 abstract 1[/link]
[link url=""]AIDS 2018 abstract 2[/link]
[link url=""]PLOS One abstract[/link]

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