The main findings from this study highlight both expected and unexpected features of sexual partnerships among young men and women in the high HIV prevalence setting of KwaZulu/Natal, South Africa. Slightly more than one-third of sexually active young men reported having engaged in high risk multiple partnering over the preceding three year period, with nearly 40 percent reporting a current, overlapping partnership. Women’s participation in high risk partnering ranged from one-quarter of women with a partner five or more years older to more than 40 percent who perceived that their partner had other partners. Gender differences were striking: over 90 percent of women reported one or no partner in the past three years, more than twice the level for men, and there were few reports of young women with much older partners. Although women reported very few concurrent partnerships, they were aware of their male partners’ other partnerships, which placed them within higher risk sexual networks resulting from concurrent partnering patterns, and their serial partnering patterns sometimes included overlap between partners. While these findings are broadly similar to other studies of sexual partnering patterns in sub-Saharan Africa, the picture of the underlying dynamics of young people’s relationships that emerges from them is somewhat unexpected.
The majority of respondents characterized their partnerships as ‘regular’, and few purely casual encounters were reported by men or women. These definitions, however, were fluid and did not always conform to expectation. Contact between partners was infrequent, even in ‘regular’ partnerships, and especially for women. At the same time, relationships with secondary, as well as primary, partners were of long duration, on average more than a year for both men and women. Other South African studies have produced similar findings, using a variety of terms to capture this fluidity, including ‘regular casual’ or ‘visiting’ partners (Pettifor et al., 2005
). In this study, the qualitative findings further expand the range of relationship types beyond standard survey definitions, and also extend the understanding of these relationships beyond the usual dichotomy of ‘serious’ versus ‘casual’. Both young men and women favor relationships characterized by seriousness and a degree of commitment, even in the teen years, and young women, in particular, experience pressure to meet these normative expectations. Relationships that do not fit within these narrow social boundaries are conducted secretly, with consequences for sexual risk (Harrison, 2008
). It is within this moral dimension that young people contest normative understandings of sexuality and relationships (Samuelson, 2006
). However, this emphasis on committing to a ‘serious’ partner does not preclude multiple relationships, which may happen either sequentially or concurrently, or both, depending on circumstance.
Perhaps most importantly, the qualitative findings illustrate the complex and dynamic interrelationships between partnership type, duration, mobility, and distance. The rural youth in this study describe widespread sexual and romantic networks, which are sustained by high levels of mobility and frequent movement in and out of the rural areas. These relationships, conducted over time and distance, form the basis for overlapping, or concurrent, partnering patterns. There has been little emphasis, to date, on the temporal and spatial dimensions of young people’s partnerships and sexual risk, although the links between migration and HIV are well understood (Lurie et al., 2003
), as is the economic basis for sexual networking (Luke and Kurz, 2002
; Kaufman and Stavrou, 2004
; Dunkle et al., 2004b
; Dunkle, 2007
; Hunter, 2007
; Poulin, 2007
). In this study, the triangulation of data from multiple sources, primarily the partnership matrix and qualitative interviews, provide insight into how and why these patterns occur, as well as important gender differences. For instance, young men had multiple, and therefore overlapping, relationships within the same time period. In contrast, the young women were more likely to have multiple serial relationships, with overlap occurring frequently in the context of partner change, often at the start of a new relationship.
Findings from the multivariate analyses offer insight into a fourth, contextual dimension of young people’s sexual partnerships. The findings that young women who were not schooling or had low levels of community group participation were more likely to be in a high risk partnership support other studies that have found low social capital or ‘social connectedness’ to increase sexual risk (Campbell, Williams and Gilgen, 2002
; Kaufman et al., 2004
; Hallman, 2004
). Schooling, in particular, is an important marker of social capital or well-being in young people (Gregson et al., 2002a
; Lloyd and Hewett, 2003
; Hallman and Grant, 2004
). Higher participation in schooling or other social institutions is likely to reflect relative levels of personal empowerment, with these women more able to negotiate safer relationships and, quite possibly, to choose lower risk partners. In contrast, there was a protective effect for women affiliated with more conservative religious institutions, who were less likely to report that their partner had other partners. Most likely, these women – and presumably their partners – exhibited more conservative social norms overall, and may thus have been less likely to report that their partners had other partners. Overall, for women, social vulnerability appears to be an important mediator of sexual risk, and one that can possibly be countered by participation in social institutions such as schooling, community activities, or churches, which may lead to greater empowerment and self-efficacy. In contrast, for men, early socialization and sexual experiences appear to influence multiple partnering, highlighting the need to look more deeply at psychosocial mediators of risk (Mpofu et al., 2006
This study is subject to several important limitations. The findings reflect the behaviors and beliefs of a relatively small sample from one specific geographic area. The data are cross-sectional, meaning that our understanding of changes in partnerships are inferred from retrospective reports, rather than measured over time. In addition, this analysis excludes non-sexually active youth, and out-of-school youth in the qualitative sample, an unfortunate omission given the greater understanding of ‘high risk’ youth that such participants might have provided. Even more importantly, the large imbalance in the ratio between male and female survey respondents raises the possibility of selectivity bias in the male sample. Overall, however, the patterns reported here are similar to other surveys of sexual behavior conducted both in this area (Kaufman et al., 2004
; Welz et al., 2007
) as well as more broadly across South Africa (Pettifor et al., 2005
). Further, the mixed methods approach employed in this study permitted triangulation of data, including the comparison and validation of different data sources. Self-reported sexual behavior is widely recognized to have biases (Gregson et al., 2002b
; Hewett, Mensch and Erulkar, 2004
), which are often rooted in gender considerations, with men likely to exaggerate their number of sexual partners, and women likely to underreport both current and lifetime partners (Nnko et al., 2004
). Women may also be more likely to report a concluded partnership as ongoing, or a relationship as ‘serious’ or ‘permanent’, or among teenage women, to omit reporting of a sexual partner at all. In this study, straightforward comparisons between men and women are difficult due to the pronounced gender asymmetry in reported behaviors as well as the subjective, gender-influenced classifications of partners. While differences in sexual behavior between men and women are widely recognized (Nnko et al., 2004
; Wellings et al., 2006
), these differences may, to some extent, reflect normative beliefs regarding sexuality rather than actual behavior. Finally, although an examination of condom use or other preventive behaviors is beyond the scope of this analysis, it is important to consider how the various partnership types and patterns reported here may influence HIV preventive behaviors.
Substantively, these issues affect this analysis in several important ways. The discrepancies between women’s accounts of partner numbers in the survey and qualitative data suggest under-reporting of partner numbers, and possibly relationship duration as well. The qualitative data provide a more detailed understanding of women’s relationships, particularly their overlapping sequential pattern. However, reports of multiple partners were often uncovered through careful examination of inconsistencies in women’s reports of their sexual life histories, as much as direct reporting on number of partners and other characteristics. Ultimately, longitudinal data are required to fully understand these patterns, and such studies should be undertaken with the aim of prospectively following young people in partnerships over time.
In conclusion, we find that although the partnerships of young people in KwaZulu/Natal, South Africa are long-lasting and frequently characterized as ‘regular’ or ‘serious’, this apparent stability is deceptive. Young people’s relationships occur over distance and time, factors that enhance the complexity of sexual networks through the creation of greater opportunies for concurrency, often through a simultaneous pattern of sequential and overlapping relationships. These partnering patterns, in turn, enhance HIV risk. At the same time, women reported relatively few partners overall, consistent with other studies, but only a small proportion of men and women reported large partner age differences. Importantly, such findings offer new challenges for HIV prevention interventions, many of which focus only marginally on the partnership context of risk. Important messages include the idea of ‘safe partnering ’ for young people, beyond advice to ‘be faithful’ and including explanation of the risks associated with concurrent partnering. Women, in particular, are fully aware of the risks associated with their main partner’s additional partnerships, but may not understand how their own partnering patterns place them at risk. Finally, given mounting evidence that contextual factors exert the strongest influence on HIV risk – as in the case of schooling and community group participation in this study – increasing attention should be turned toward complementary strategies aimed at reducing structural and psychosocial vulnerabilities.