Young people
A tale of two countries: rethinking sexual risk for HIV among young people in South Africa and the United States
Pettifor AE, Levandowski BA, Macphail C, Miller WC, Tabor J, Ford C, Stein CR, Rees H, Cohen M. J Adolesc Health. 2011 Sep;49(3):237-243.e1.
Pettifor and colleagues compared the sexual behaviours of young people in South Africa and the United States of America with the aim to better understand the potential role of sexual behaviour in HIV transmission in these two countries that have strikingly different HIV epidemics. Nationally representative, population-based surveys of young people aged 18-24 years from South Africa (n = 7548) and the USA (n = 13,451) were used for the present study. The prevalence of HIV was 10.2% in South Africa and <1% in the USA. Young women and men in the USA reported an earlier age of first sex than those in South Africa (mean age of coital debut for women: USA [16.5], South Africa [17.4]; for men: USA [16.4], SA [16.7]). The median number of lifetime partners is higher in the USA than in South Africa: women: USA (4), South Africa (2); men: USA (4), South Africa (3). The use of condom at last sex is reported to be lower in the USA than in South Africa: women: USA (36.1%), South Africa (45.4%); men: USA (48%), South Africa (58%). On average, young women in South Africa report greater age differences with their sex partners than young women in the USA. Young people in the USA report riskier sexual behaviours than young people in South Africa, despite the much higher prevalence of HIV infection in South Africa. Factors above and beyond sexual behaviour likely play a key role in the ongoing transmission of HIV in South African youth, and thus should be urgently uncovered to develop maximally effective prevention strategies.
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Editor’s note: This comparison of two nationally representative surveys of young people starkly underscores that behaviour is not the sole determinant of HIV risk. South African young people had their first sex at a later age, have fewer sexual partners, and practise more safer sex than their American counterparts. How can the more than 10-fold difference in HIV prevalence be explained? The first thought goes to larger age gaps between sexual partners. This means sexual mixing with older partners who can act as a bridge population to younger cohorts…. but there has to be more to it than that. In South Africa, male circumcision levels are far lower, herpes simplex 2 infection levels are higher, genital tract inflammation is higher, co-infections (tuberculosis, helminths) that can increase viral set points are more common, and the prevalence of the CCR5Δ32 coreceptor is lower. But social determinants, such as gender power imbalances, poverty, coerced sex and rape, lack of youth friendly services, and stigma are likely playing important roles. Although these surveys were conducted in 2003 (South Africa) and 2001-2 (USA) using somewhat different methodologies, the finding that ‘ordinary’ sexual behaviour can place young people, particularly young women, in South Africa at such high risk should galvanise leaders at all levels to call for urgent action. Advocates are calling out ‘where the hell is the gel’ and researchers are testing microfinance and conditional cash transfers, but it will take a paradigm shift at all levels to prioritise investment in protecting young people from what is a preventable, chronic, lifelong disease.
