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AbstractIntroduction: Transactional sex is a structural driver of HIV for women and girls in sub‐Saharan Africa. In transactional relationships, sexual and economic obligations intertwine and may have positive and negative effects on women's financial standing and social status. We conducted a clinic‐based survey with pregnant women in Swaziland using a locally validated transactional sex scale to measure the association between subjective social status, transactional sex, and HIV status, and to assess whether this association differed according to a woman's agency within her relationship.Methods: We recruited a convenience sample of 406 pregnant women at one rural and one urban public antenatal clinic in Swaziland and administered a behavioural survey that was linked to participant HIV status using clinic records. We then conducted a multigroup path analysis to test three hypotheses: (1) that more engagement in transactional sex is associated with decreased condom use and increased subjective social status; (2) that subjective social status mediates the relationship between transactional sex and HIV status; and (3) that these relationships are different across groups according to whether or not a woman reported any indicator of constrained agency within her relationship.Results: The amount and value of material goods received from a sexual partner was significantly and positively associated with higher subjective social status among all participants. As the amount of material goods received from a partner increased, women who reported no indicators of constrained agency were less likely to use condoms. Conversely, there was no relationship between transactional sex and condom use among women who reported any indicator of constrained relationship agency. Among women who reported any indicator of constrained agency, HIV was significantly associated with lower subjective social status.Conclusions: Relationship agency likely plays a key role in determining which mechanisms create HIV risk for women in transactional relationships. Interventions to mitigate these risks must address social forces that penalize women who engage in sexual relationships as well as structural drivers of gendered economic disparity that reduce women's agency within their sexual and romantic relationships.

BackgroundPsychological factors are often neglected in HIV research, although psychological distress is common in low‐ to middle‐income countries, such as South Africa. There is a need to deepen our understanding of the role of mental health factors in the HIV epidemic. We set out to investigate whether baseline depressive symptomatology was associated with risky sexual behaviour and relationship characteristics of men and women at baseline, as well as those found 12 months later.MethodsWe used prospective cohort data from a cluster randomized controlled trial of an HIV prevention intervention in the Eastern Cape Province of South Africa. Our subjects were 1002 female and 976 male volunteers aged 15 to 26. Logistic regression was used to model the cross‐sectional and prospective associations between baseline depressive symptomatology, risky sexual behaviors and relationship characteristics. The analysis adjusted for the clustering effect, study design, intervention and several confounding variables.ResultsPrevalence of depressive symptoms was 21.1% among women and 13.6% among men. At baseline, women with depressed symptoms were more likely to report lifetime intimate partner violence (AOR = 2.56, 95% CI 1.89‐3.46) and have dated an older partner (AOR = 1.37, 95% CI 1.03‐1.83). A year later, baseline depressive symptomatology was associated with transactional sex (AOR = 2.60, 95% CI 1.37, 4.92) and intimate partner violence (AOR = 1.67, 95% CI 1.18‐2.36) in the previous 12 months. Men with depressive symptoms were more likely to report ever having had transactional sex (AOR = 1.48, 95% CI 1.01‐2.17), intimate partner violence perpetration (AOR = 1.50, 95% CI 0.98‐2.28) and perpetration of rape (AOR = 1.81, 95% CI 1.14‐2.87). They were less likely to report correct condom use at last sex (AOR = 0.50, 95% CI 0.32‐0.78). A year later, baseline depressive symptomatology was associated with failure to use a condom at last sex among men (AOR = 0.60, 95% CI 0.40‐0.89).ConclusionsSymptoms of depression should be considered as potential markers of increased HIV risk and this association may be causal. HIV prevention needs to encompass promotion of adolescent mental health.

IntroductionAdolescents having unprotected heterosexual intercourse are at risk of HIV infection and unwanted pregnancy. However, there is little evidence to indicate whether pregnancy in early adolescence increases the risk of subsequent HIV infection. In this paper, we tested the hypothesis that adolescent pregnancy (aged 15 or younger) increases the risk of incident HIV infection in young South African women.MethodsWe assessed 1099 HIV‐negative women, aged 15–26 years, who were volunteer participants in a cluster‐randomized, controlled HIV prevention trial in the predominantly rural Eastern Cape province of South Africa. All of these young women had at least one additional HIV test over two years of follow‐up. Outcomes were HIV incidence rates per 100 person years and HIV incidence rate ratios (IRRs) estimated by Poisson multivariate models. Three pregnancy categories were created for the Poisson model: early adolescent pregnancy (a first pregnancy at age 15 years or younger); later adolescent pregnancy (a first pregnancy at age 16 to 19 years); and women who did not report an adolescent pregnancy. Models were adjusted for study design, age, education, time since first sexual experience, socio‐economic status, childhood trauma and herpes simplex virus type 2 infection.ResultsHIV incidence rates were 6.0 per 100 person years over two years of follow‐up. The adjusted IRR was 3.02 (95% CI 1.50–6.09) for a pregnancy occurring at age 15 or younger. Women with pregnancies occurring between 16 and 19 years of age did not have a higher incidence of HIV (IRR 1.08; 95% CI 0.64–1.84). Early adolescent pregnancies were associated with higher partner numbers and a greater age difference with partners.ConclusionsEarly adolescent pregnancies increase the incidence of HIV among South African women. The higher risk is associated with sexual risk behaviours such as higher partner numbers and a greater age difference with partners rather than a biological explanation of hormonal changes during pregnancy.