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Try out PMC Labs and tell us what you think. Learn More. Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing of studies have suggested that the practice of transactional sex may in part explain women's heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesized.
We set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarize the findings through a meta-analysis.
The search strategy included 8 databases, hand searches in 10 journals, and searches across 17 websites and portals for organizations as informed by expert colleagues. A systematic review of cross-sectional and longitudinal studies was carried out for studies on women and men who engage in transactional sex published up through Random effects meta-analysis was used to further examine the relationship between transactional sex and prevalent HIV infection across a subset of studies with the same exposure period.
Analyses were conducted separately for men and women. Nineteen papers from 16 studies met our inclusion criteria.
Of these 16 studies, 14 provided data on women and 10 on men. Out of 10 studies involving men, only 2 indicate a positive association between HIV and transactional sex in unadjusted or adjusted models. Transactional sex is associated with HIV among women, whereas findings for men were inconclusive. Given that only two studies used a longitudinal approach, there remains a need for better measurement of the practice of transactional sex and additional longitudinal studies to establish the Women seeking sex Hidden Valley pathways between transactional sex and HIV.
Although the HIV epidemic is generalized in sub-Saharan Africa, there is heterogeneity in where and among whom HIV infections occur, with certain localities and populations being consistently more vulnerable to infection than others [ 12 ]. For example, HIV prevalence among young women remains more than twice as high as in young men throughout sub-Saharan Africa [ 1 ]. Among those living with HIV, AIDS is now the leading cause of death among adolescents in Africa and the second most common cause of death among adolescents globally [ 23 ]. Given young women's continued disproportionate risk of HIV, prevention of HIV in adolescent girls and young women is a long-standing priority.
The disproportionately high HIV incidence in young women compared to young men has been attributed to social and economic aspects of gender inequality and to specific factors such as age disparate sexual relationships [ 45 ], poor negotiating power with respect to condom use [ 5 — 8 ] and intimate partner violence [ 910 ]. A growing body of literature speculates that transactional sex—defined here as non-marital, noncommercial sexual relationships motivated by the implicit assumption that sex will be exchanged for material benefit or status [ 11 ]—may play a role in young women's disproportionate risk and explain the feminization of the epidemic [ 212 ].
Numerous in-depth studies conducted across the region confirm [ 11 ] first that transactional sex relationships are non-commercial ; participants describe themselves as boyfriends and girlfriends, or lovers, not as clients and sex workers. Second, the exchange embedded in these relationships is implicit ; it is not formally negotiated and may not immediately follow a sexual act. Finally, many of these relationships include shared emotional intimacy.
Despite growing evidence, there has not yet been an attempt to synthesize the strength of the association between transactional sex and HIV. We therefore conducted a systematic review and meta-analysis to determine the extent to which transactional sex is a risk factor for HIV in sub-Saharan Africa. This systematic review of the relationship between transactional sex and HIV is a part of a larger comprehensive review assessing the state of knowledge on transactional sex in sub-Saharan Africa including its conceptualization, definition and measurement as well as its association with HIV and related risk behaviours [ 11 ].
The comprehensive search strategy was broad to accommodate these multiple aims and includes studies conducted through Both quantitative and qualitative studies were included. No time or types of article restrictions were applied to the search. The from the searches were downloaded to the EndNote program where duplicates were eliminated. Within this broader search strategy, we developed specific criteria reviewed below that applied to the systematic review of the association between transactional sex and HIV.
The broader literature review, discussions with experts and our own contributions to the field informed our definition of transactional sex, as stated above. This definition served as the basis for the following inclusion criteria for the systematic review: transactional sex was examined in populations other than sex workers, bar workers, men who have sex with men or drug users; Women seeking sex Hidden Valley transactional sex was measured as distinct from sex work.
We restricted our review to studies conducted within sub-Saharan Africa. In as much as possible, we made efforts to include studies that captured transactional sex, not sex work. Our central objective was to measure the association between transactional sex and HIV. We only included studies with a biological measure of HIV. Both HIV prevalence and incidence measures were included from observational and intervention studies.
Quantitative data extracted included characteristics of the study population, sample size, study location, measures and prevalence of transactional sex, and HIV prevalence or incidence. Furthermore, unadjusted and adjusted associations between HIV and transactional sex were extracted, and papers were subdivided by sex and age groups young people only, e.
We sex-disaggregate our findings as men and women have different roles in transactional sex that may correspond to differences in HIV risk. Random effects meta-analysis was used to examine the relationship between transactional sex and prevalent HIV infection across studies.
The meta-analysis was performed separately for men and women. Only studies that included sex-disaggregated measures of ever having engaged in transactional sex were included in the analysis to reduce heterogeneity of exposure. We therefore excluded studies from the meta-analysis that measured transactional sex in the last 12 months, 4 weeks or with a recent sexual partner. The decision to focus the meta-analysis on prevalent HIV infection was taken as only one study identified in the systematic review measured incident HIV infection. Where the age-adjusted OR was not reported in a paper, attempts were made to obtain it from the study authors.
Sensitivity analyses were performed, respectively, excluding a study with a population that differed from other included studies 15—year-olds attending reproductive health clinics in an urban slum, rather than a population-based sample and studies in which the OR was not adjusted for age. The study selection process studies on transactional sex and HIV is summarized in the flow diagram in Figure 1. In brief, 15, records were identified for screening, of which were unique. We assessed full-text articles for eligibility, from which 19 papers representing 16 studies met the inclusion criteria. Studies that met eligibility criteria for inclusion in the systematic review are summarized in Table 1.
The sample sizes ranged from to 11, In total, 14 studies 15 papers provide data on women, and 7 of these studies focused specifically on Women seeking sex Hidden Valley women age range 13—26 years. Ten studies provide data on men, four of which provide data exclusively on young men. Three studies provided measures of association that were not sex disaggregated [ 16 — 18 ].
Overall, 14 studies 17 papers were cross-sectional or repeated cross-sectional and provide HIV prevalence measures, whereas two cohort studies provided HIV incidence measures. The majority of the studies set out to determine factors associated with HIV infection. In these studies, transactional sex was included as a predictor, but it was not the focus of the analysis. However, in three studies, the primary objective was to assess the role of transactional sex on HIV [ 19 — 21 ].
Of these three studies, one study used incident measures and was better able to assess the causal role of transactional sex in HIV risk [ 20 ]. The studies originate from a total of five different countries within southern and eastern Africa. Details of studies included in a systematic review of the association between transactional sex and HIV for men and women in sub-Saharan Africa.
Among the 11 papers from South Africa, five provide data from two data sources. Three of these papers report on findings from the Stepping Stones Trial in rural South Africa, and two report baseline findings for each sex [ 1022 ]; and the final reports endline findings for women [ 20 ]; another two papers report findings from the same study of pregnant women in antenatal clinics in urban, South Africa [ 919 ]. We did not include more than one study from the same data source in our sex-disaggregated meta-analyses. Most of the studies were Women seeking sex Hidden Valley, apart from four HIV behavioural intervention-based studies [ 1020 — 24 ].
Nine studies draw from general population groups, whereas seven were conducted with specific populations: three studies of women attending reproductive health clinics in urban settings [ 9192526 ]; one study of adults in an urban homeless clinic [ 16 ]; one urban convenience sample [ 27 ]; one study of men with multiple young partners from a peri-urban township [ 28 ]; one of fishermen [ 29 ]; and one study of urban, uncircumcised sexually experienced men [ 23 ]. Five studies conducted among women [ 1017202126 ] and four among men [ 1722 — 24 ] met the inclusion criteria for the meta-analyses.
The measurement of transactional sex varied across the studies see Table 1. We included this study despite it poorly distinguishing transactional sex from sex work because it provided a measure of association among adolescent girls in a context outside of South Africa. However, given our concern about whether this measure adequately distinguished transactional sex from sex work, we run meta-analyses with and without this study [ 26 ].
The exposure period also varied across studies. In six studies, the exposure period varied e. In the majority of cases, studies compare HIV rates between those who reported having practiced transactional sex with those who did not report transactional sex. However, a minority of studies present a comparison of transactional sex prevalence between respondents who are HIV positive compared to those who are HIV negative. It is important to note that three studies provide measures of association that are not sex disaggregated [ 16 — 18 ].
Measures of association between transactional sex and HIV among women in a systematic review of studies from sub-Saharan Africa.
Measures of the association between transactional sex and HIV among men from a systematic review of studies from sub-Saharan Africa. Four studies report a ificant unadjusted OR or test of association with reported p -value between transactional sex and HIV. Four studies report from multivariate analyses. Although there are some distinctions see Table 2most studies controlled for age — particularly important for valid estimation with very young women — some measure of socio-economic status, a series of related sexual behaviours e.
Of these, one study with a highly ificant unadjusted OR lost ificance in the adjusted model [ 26 ]. The remaining three studies including one study not disaggregated by sex report a ificant adjusted OR, indicating that those who had practiced transactional sex had nearly two to more than three times the risk of being HIV positive [ 10172021 ].
Among the six mixed age group studies, the prevalence of transactional sex ranged from 4.Women seeking sex Hidden Valley
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