Transactional Sex and HIV Risk: From Analysis to Action
January 8, 2019

Young women in sub-Saharan Africa are at a disproportionately high risk for HIV infection. Engagement in transactional sex may contribute to this increased HIV prevalence according to a new report published by UNAIDS with STRIVE, a research partner consortium which addresses the Structural Drivers of HIV/AIDS. The University of Maryland School of Public Health’s Dr. Kirsten Stoebenau is co-chair of a working group under STRIVE focused on understanding and mitigating the role of transactional sex in the ongoing high levels of HIV incidence among adolescent girls and young women in sub-Saharan Africa.

The joint STRIVE and UNAIDS report provides an analysis of young women’s engagement in transactional sex in sub-Saharan Africa and discusses policy options and principles of engagement around transactional sex in the context of HIV prevention.

“Both epidemiological evidence and intervention efforts have been hampered by confusion over the definition and approach to measuring transactional sex. We hope this report contributes to resolving some of that confusion, as well as enables effective combination intervention efforts that account for the structural drivers of transactional sex, along with interpersonal and individual-level approaches,” says Dr.  Kirsten Stoebenau, assistant research professor of behavioral and community health at the University of Maryland School of Public Health, who led the report in her capacity as co-chair of the STRIVE Working Group on Transactional Sex and HIV.

The researchers define transactional sex as “non-marital, non-commercial sexual relationships motivated by an implicit assumption that sex will be exchanged for material support or other benefits.” Unlike sex work, the exchange in transactional sex is implicit and often does not link directly to the act of sex. Most participants consider themselves partners or lovers and often share emotional intimacy.

Estimates for reported practice of transactional sex among young women in African countries can be as high as 52 percent, states the report. Widespread gender inequality in sub-Saharan Africa contributes to young women’s engagement in transactional sex. Determinants of participation include, “unequal customary and legal rights, uneven distribution of wealth and opportunities for its accumulation, and women’s lower levels of social and political power.” 

Engaging in transactional sex relationships increases young women’s risk of HIV. The report cites research led by the co-authors that shows young women who have practiced transactional sex are on average 50 percent more likely to be living with HIV than those who have never engaged in transactional sex. This is due to transactional sex’s association with HIV risk factors such as multiple sexual partners, intimate partner violence, abuse, alcohol consumption and varying levels of condom use.

The report reveals how the role of transactional sex in the spread of HIV has historically been overlooked. “Transactional sex likely accounts for a higher proportion of HIV cases than previously appreciated, because earlier work did not separate transactional sex from sex work or casual partnerships without transactions,” the researchers say. 

Even then, the researchers emphasize that transactional sex relationships are not inherently risky. They add that in order to be effective, HIV interventions should be based on a context-specific understanding of “the conditions and circumstances in which transactional sex imparts risk.”

To reduce the burden of new infections in young women, the authors call for greater emphasis on the role that transactional sex plays in HIV risk. They recommend that countries with high HIV prevalence address transactional sex directly within existing HIV prevention and intervention programs. 

The report, “Transactional Sex and HIV Risk: From Analysis to Action,” was authored by STRIVE researchers, Kirsten Stoebenau, Joyce Wamoyi, Annie Holmes, Nambusi Kyegombe, Meghna Ranganathan and Lori Heise.

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Transactional Sex and HIV Risk: From Analysis to Action

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Kirsten Stoebenau