Is the high HIV prevalence in Gert Sibande, South Africa driven by a high multiple sexual partnership (MSP) prevalence? 1,2 B A B A L O L A O S, 1,2 BELLO B, 1 N D L OV U N U N I V E R S I T Y O F T H E W I T WAT E R S R A N D, & 2 C E N T R E F O R S TAT I S T I C A L A N A LY S I S & R E S E A R C H ( C E S A R ) , JOHANNESBURG, SOUTH AFRICA 1 Gert Sibande District (GSD) South Africa (SA) According to the annual HIV prevalence, GSD HIV prevalence ranked from 3rd (40.5% - 2008) to 1st (46.1% - 2011) of 52 Districts in SA Consistently higher HIV prevalence in GSD than national and provincial HIV averages Mpumalanga Province MSP and Concurrent Partnerships (CSP) are
major determinants of HIV epidemic No study on MSPSibande and CSP carried out in Gert GSD Two-component generalised HIV epidemics A sexual epidemic necessarily depends on multiple partnering. Component 1: Rapid Multiple partnering (especially concurrency and largely acute infection) ~2/3 of new infections Component 2: Slow MSP and Concurrent Partnerships (CSP) are major determinants of HIV epidemic Long-term discordant partnerships ~1/3 of new infections
From: Shelton JD. A tale of two-component generalised HIV epidemics. The Lancet. 2010; 375:964-966 Main Objectives To estimate the prevalence of multiple and concurrent sexual partnerships (past 12 months) To identify the factors associated with MSP among adults (16-55 years) of GSD Study Design Secondary data analysis Cross-sectional, multistaged cluster sampling method Probability proportionate to size (PPS); that is, selfweighted sampling Multivariate logistic regression of a binomial distribution with results reported as adjusted odds ratios (AOR) and Gert Sibande District 7 Municipalities: 30 Enumeration Areas (EAs)/Primary Sampling Unit (PSU) 25 Households/Secondary Sampling Units (SSU) from each EA
From 750 households: 750 Respondents (Female=500) 592 sexually active adults, aged 16 55 (Female=392) Measures and analysis Standardized scale of measurement Outcome measures 1) 2) MSP (past 12 months): two or more sexual partners, past 12 months CSP: occurs when sexual intercourse with one partner occurs between two acts of intercourse with another partner (UNAIDS 2009). Exposure variables Socio-demographics (age, education, employment status, socio-economic and marital status) Sexual behavioural (age at rst sex, condom use at last sex, transactional sex, sex under influence of alcohol) Types of Concurrent Partnerships Intermittent or occasional (coparents, location dependent relationships, little girlfriends) One-off (sex-worker,
casual encounter, takeaways, local bicycles) Expectation of affection, commitment and support Ongoing (main partner), (co-wife, mistress, small house) Jan Duration of partnership From: S. Leclerc-Madlala (2008) Age-disparate and intergeneration sex in southern Africa: the dynamics of hypervulnerability. AIDS, 22 (supp 4): 1-9. Dec Prevalence of MSP and CSP is higher among males 50 45 44 40 35 Percentage 30 25 22
20 20 15 11 10 8 5 3 0 Male Female 12-Month MSP***(p<0.001) CSP***(p<0.001) Total Factors of MSP and CSP Males Females Young people Socio-economic Never married Transactional sex status
Never married Age at rst sex (<16) Condom use at last sex Sex under the Condom use at last sex Sex under the influence of alcohol Prevalence of MSP and CSP is highest among young people 70 60 57 50 47 Percentage 43 43 40 33 30 20
20 16 13 14 10 12 12 10 9 9 7 6 5 1 Age group 0 16-19 20-24 25-29 Male MSP* (p<0.05)
Female MSP 30-34 35-44 CSP* (p<0.05) 45-55 Multivariate Models (MSP only) Three multivariate sex-differentiated models were built. Variables signicant at p<0.05 were retained in the nal models which contained: Two socio-demographic and three sexual behavioural factors in males One socio-demographic and three sexual behavioural factors in females Multivariate Models 1 Socio-demographic (Males: N=200) MULTIVARIATE VARIABLES AOR ( 95% CI) Socio-demographic (Females: N=392) VARIABLES
AOR Age group 16 20 25 30 35 45 19 24 29 34 44 55 Socio-economic status High Intermediate Low 3.8 (1.2 5.2 (2.0 3.5 (1.2
3.2 (1.3 2.4 (0.6 Ref 12.2)* - 13.5)*** 10.2)* 7.2)* 2.7) Ref 2.6 (1.5 4.6)*** 1.3 (0.6 2.7) MULTIVARIATE ( 95% CI) Marital status Ever married Never *p 0.05 Ref 8.5 (1.1 64.0)* **p 0.01 ***p 0.001 AOR: Adjusted odds ratios, adjusting for other variables in the model married Multivariate Models 2 Sexual behavioural
(Males: N=200) VARIABLES MULTIVARIATE AOR 10.7 (2.4 33.8)*** 11.8 (3.4 40.3)*** Transactional No Yes Ref 4.9 (1.3 18.2)* Sex while drunk Non drinkers No MULTIVARIATE AOR ( 95% CI) Condom use at last sex Ref Recent sex VARIABLES
( 95% CI) Age at first sex <16 16 19 20+ Sexual behavioural (Females: N=392) Ref 1.3 (0.6 2.8) No Yes Ref 2.1 (1.1 3.9)* Recent Transactional sex No Yes Ref 3.2 (1.0 9.5)* Sex while drunk Non drinkers No Yes *p 0.05 **p 0.01
Ref 1.3 (0.6 -3.0) 4.8 (2.3 9.8)*** ***p 0.001 AOR: Adjusted odds ratios, adjusting for other variables in the model Full Multivariate Model (Adjusted for sociodemographic and sexual behavioural) Males: N=200 VARIABLES MULTIVARIATE AOR VARIABLES MULTIVARIATE ( 95% CI) Age group 20 24 3.0 (1.0 -9.3)* 45 55 Ref Socio-economic status High
Ref Intermediate 3.1 (1.7 5.6)*** Age at first sex <16 16 19 Females: N=392 9.0 (2.7 30.1)*** 9.7 (2.3 41.4)** AOR ( 95% CI) Marital status Ever married Ref Never married 10.9 (1.3 90.3)* Condom use at last sex No Ref
Yes 2.4 (1.1 5.6)* Recent Transactional sex No Ref Yes 12.0 (3.9 37.1)*** 20+ Ref Recent Transactional sex No Ref Yes 4.5 (1.3 15.2)* Sex while drunk Non drinkers Ref Yes 4.5 (1.9 9.7) *** *p 0.05
Sex while drunk Non drinkers Ref No Yes 2.1 (1.0 -4.2)* 9.3 (4.4 19.6)*** **p 0.01 ***p 0.001 AOR: Adjusted odds ratio adjusting for other variables in the model What does this research tell us? There is a high prevalence of MSP and CSP among adults of Gert Sibande District compared to levels reported in the SABSSM surveys in South Africa Similar high levels of MSP and CSP were associated with high HIV prevalence in various studies Age, socio-economic factors among males and having never been married among females remained as signicant underlying correlates of MSP after adjusting for proximate sexual behavioural factors Age at rst sex in males, condom use at last sex among females as well as sex under the influence of alcohol and transactional sex in both males and females remained as signicant independent sexual behavioural factors of MSP How does the ndings influence policies and interventions? More work is needed in Gert Sibande to address
MSP and CSP. Emphasis on the need for a multi-sectoral approach to address both the structural and contextual risk factors. Sexually active adults, young people and the unmarried, should be strategically targeted. Interventions targeting places where alcohol is served must be built into HIV prevention programmes to address the HIV risk related to alcohol use. Conclusions and reflections MSP is high in Gert Sibande District High MSP might explain the high HIV prevalence in GSD. Well tailored interventions are needed in Gert Sibande to address enabling factors Understanding of the factors at work in GSD might be a good point in helping to address the epidemic in THAN K YOU
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