Young women who have sexual relationships with older men often are dealing with inequitable power dynamics, little capacity to negotiate safe sex or to refuse sex, and—therefore —a greater risk of acquiring HIV. In sub-Saharan Africa, adolescent girls and young women are disproportionately affected by HIV, which has led to a heightened emphasis on understanding the characteristics of their male sexual partners. It also points attention to the fact that men are less often reached with HIV testing, care, and continued treatment—the 90-90-90 HIV care cascade.
The DREAMS Partnership (DREAMS stands for Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe), is an initiative of the United States President’s Emergency Plan for AIDS Relief that aims to reduce new HIV infections among adolescent girls and young women from 15 to 24-years-old. It chose eSwatini (formerly Swaziland) as a priority country due to the high HIV prevalence and vulnerability among teenage girls and young women there.
Recently, MEASURE Evaluation — funded by USAID — conducted a study of adolescent girls and young women and their male sexual partners in eSwatini to obtain locally relevant, usable data, including on the characteristics of high-risk male partners, where these men can be reached, and structural factors and vulnerabilities that may underlie their risk behaviors as well as potential preventive measures. Critical information included their uptake of HIV prevention and treatment services, such as timely HIV testing, medical circumcision, and antiretroviral therapy for those who are HIV-positive. The study was recently published in a PLOS One article: Who are the male partners of adolescent girls and young women in Swaziland? Analysis of survey data from community venues across 19 DREAMS districts.
The study employed a Priorities for Local AIDS Control (PLACE) approach, which is a sampling strategy to understand the local HIV epidemic by identifying where to reach those most likely to acquire and transmit HIV and assess service gaps among this group. The standard PLACE method was modified to focus recruitment on places where adolescent girls and young women and their partners meet and socialize.
The study found that sexual relations between adolescent girls and young women and their partners were characterized by high numbers of recent sexual partners, inconsistent condom use, and only modest uptake of preventive HIV services. In these relationships, researchers found, little discussion of HIV status took place (disclosing HIV status, whether negative, positive, or unknown was less likely when that partner was an adolescent girl, ages 15–19 years, versus older, ages 20 years or more). Men who had several young female partners were more likely to be HIV-positive. Further, these male sexual partners were found to be facing challenging life circumstances that may contribute to risk behaviors. Among these were relatively high unemployment, homelessness, having a lack of food, or being imprisoned.
Among a subsample of the 843 men surveyed, 568 men (83 percent of the sample) reported having at least one young female partner (ages 15–24) in the past 12 months—most of them (57 percent) reporting having two or more sexual partners in that period and 78 percent of those men saying most of their partners were younger (as opposed to their age or older). Only one-third of sexual partners of young women and teenage girls reported consistent condom use. Of men with young female partners,14 percent admitted they had physically abused their most recent partner and 4 percent said they had physically forced their most recent partner to have sex.
Four out of five (82 percent) male partners reported having been tested for HIV at least once and 42 percent said they had been tested within the last year. The most common reason cited for not getting tested was not wanting to know their status (41 percent) followed by not believing they are at risk (21 percent). More than a third (37 percent) of male partners reported being circumcised and, among those uncircumcised, 80 percent said they were not considering it. Six percent of male partners of young women and adolescent girls reported being HIV positive and, of those, 97 percent said they are currently taking antiretroviral therapy.
The study concluded that targeted initiatives to engage high-risk men in primary prevention interventions and in diagnostic and care services should continue so that outreach and prevention activities can better reach and meet the needs of these men and to reduce HIV vulnerability in eSwatini. Increasing their uptake of HIV testing and treatment should be considered along with structural factors and vulnerabilities—such as unemployment—that may underlie men’s risk and preventive behaviors.