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By Neil
Andersson
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| High
school students attend a DramAidE forum
theatre performance at a high school in
Kwazulu Natal, a province in South Africa
with the highest HIV/AIDS prevalence. "Youth
who had endured forced sex were also more
likely to admit they would spread the virus
if infected" Photo credit: ©
2000 Patrick Coleman/CCP, Courtesy of Photoshare
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Forced Sex Widespread
The mechanical basis for a link between HIV infection
and forced sex is easy to understand: lacerations
increase transmission of the virus [1, 2, 3, 4].
Forced sex is common in South Africa. Even using
face-to-face interviews (a scenario in which many
people would be unwilling to share their experiences),
the Reproductive Health Research Unit (RHRU) 2003
study found 10% of females aged 15-24 years were
forced to have sex [5].
Anonymous self-administered questionnaires allow
more people to disclose. In 2002, CIET collected
data from 269,705 school-going youth at 1,400 schools
across the country. Overall 9% of male and female
school-goers aged 10-19 years said they had been
forced to have sex in the year prior to the study.
Under the age of 15 years, male school-goers were
more likely to report forced sex than were females
of the same age, possibly because unwanted pregnancies
reduce the number of abused girls in school. Rates
of abuse climbed rapidly with increasing age of
female school-goers, whereas it levelled out in
males [6].
Forced Sex and HIV
To be sure about the relevance of forced sex to
HIV infection, one would have to know the details
about the specific sexual contact when infection
happened. This is difficult for obvious reasons.
One type of circumstantial evidence is the female/male
difference in HIV rates. RHRU found HIV prevalence
rates much higher among women than men aged 15-24
years (16% compared with 5%). They noted a dramatic
increase in prevalence rates between 15 year olds
(4%) to 21 year olds (31%) [4]. These findings fit
with the Mandela/HSRC 2002 study [7].
Another line of evidence links beliefs about HIV
infection and sexual violence. One in every three
(33%) young respondents in the CIET study thought
he/she was HIV positive. Those suffering forced
sex were very much more likely to believe they were
HIV positive, yet less likely to be willing to go
for testing. And youth who believed they were HIV
positive were more likely to say they would spread
HIV intentionally (20% among those who believed
they were infected compared with 13% who did not).
Youth who had endured forced sex were also more
likely to admit they would spread the virus if infected
(odds ratio 2.39).
Forced sex is not the only cause of HIV infection;
but the attitudes and mindset that underline the
act of forced sex, the disrespect for the rights
of others (for example, failure to disclose one's
HIV status), all contribute to the spread of HIV.
Response to Messages
Sexual abuse may also affect the way survivors interpret
education attempting to reduce their risks [8].
With South African youth regularly exposed to dozens
of HIV risk awareness initiatives, planners need
to understand both their impact on individual risk
reduction and how a history of abuse might further
affect this.
Attractive Proposition
What would answer the question about a link between
forced sex and HIV? With the impossibility of monitoring
the exact nature of the sexual encounter where infection
occurs, the only way is through an intervention
study: reduce the rate of forced sex and the HIV
incidence should fall. Although not as easy to implement
as, for example, male circumcision [9], this approach
has the advantage of equity (circumcision only protects
men). In the worst of cases, if reducing forced
sex does not reduce HIV risks, the gain would still
be considerable. In the best of cases, we might
reduce forced sex and HIV risk. That should be an
attractive proposition.
Acknowledgement
The CIET study received financial support from the
International Development and Research Centre (grant
No 101477). Fieldwork in the Eastern Cape, KwaZulu-Natal
and Limpopo provinces received support from the
Joint United Nations programme "Involving youth
in HIV/AIDS prevention, care, and support",
funded by the United Nations Fund for International
Partnerships and administered by UNICEF.
References
1. Garcia-Moreno C, Watts CH. (2000). Violence against
women: its importance for HIV/AIDS prevention. AIDS
; 14 (suppl 3):S253-65
2. Wingood GM, DiClemente RJ. (1998). Rape among
African American women: sexual, psychological, and
social correlates predisposing survivors to risk
of STD/HIV. J Women Health . 7: 77-84.
3. Maman S, Campbell J, Sweat MD, Gielen A. (2000)
The intersections of HIV and violence: directions
for future research and interventions. Social
Science and Medicine. ,50: 459-78.
4. Dunkle KL, Jewkes RK, Brown HC, et al. (2004).
Gender-based violence, relationship power, and risk
of HIV infection in women attending antenatal clinics
in South Africa. The Lancet . 363: 1415-1421,
1 May.
5. Pettifor AE, Rees HV, Kleinschmidt I, et al.
(2005) Young people's sexual health in South Africa:
HIV prevalence and sexual behaviours from a nationally
representative household survey. AIDS.
19:1525-34.
6. Andersson N, Ho-Foster A, Matthis J, et al.
(2004) National cross sectional study of views on
sexual violence and risk of HIV infection and AIDS
among South African school pupils. BMJ ,329;952-4
.7. Nelson Mandela/HSRC study of HIV/AIDS. South
African national HIV prevalence, behavioural risks
and mass media. Household survey, 2002.
8. Noll JG, Trickett PK, Putnam FW. A prospective
investigation of the impact of childhood sexual
abuse on the development of sexuality. J Consult
Clin Psychol. 2003; 71(3): 575-86.
9. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou
J, Sitta R, et al. Randomized controlled intervention
trial of male circumcision for reduction of HIV
infection risk: The ANRS 1265 trial. PLoS Med
2(11): e298, 2005.
* Professor Neil Andersson is Scientific
Director of Centro de Investigación de Enfermedades
Tropicales (CIET), Universidad Autónoma de
Guerrero, Acapulco, Mexico and Ari Ho-Foster, Research
Associate, CIET Trust, South Africa
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