Similar and Different Factors Associated with Transactional Sex with Main Partners and Casual Sexual Partners in Young Women in Urban Informal Settlements in South Africa Andrew Gibbs1, Nolwazi Ntini1, Thobani Khumalo1, Laura Washington3, Mpume Mbatha3, Esnat Chirwa2, Samantha Willan2, Yandisa Sikweyiya2, Nwabisa Jama-Shai2, Rachel Jewkes2 1 – Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban 2 – Gender and Health Research Unit, South African Medical Research Council 3 – Project Empower, Durban

Transactional sex, HIV & informal settlements Transactional sex is a complicated, global issue shaped by love, globalisation, poverty (Leclerc- Madlala, 2003; Hunter, 2010) Studies show transactional sex is a risk factor for HIV- acquisition for women in South Africa (Dunkle et al., 2004; Jewkes et al., 2012) Transactional sex with a casual/khwapheni is associated with HIV-risk but not transactional sex with a main partner (Jewkes et al., 2012) Urban informal settlements growing rapidly – in South Africa HIV-prevalence is double that of formal settlements (Rehle et al., 2007) In all sexual relationships there are implicit and explicit exchanges of goods and services for sex, whether overt or covert. Where it is more overt, we may want to call this transactional sex. In Africa, 61.7% of urban dwellers live in informal settlements and, in terms of numbers, this is expected to have increased from 400 million to 1.2 billion by 2050 (UN Habitat, 2015), resulting in multiple health, employment, sanitation and educational challenges.

Methods Women Mean/%(95% CI) Age 24.4(23.5-25.3) Education Primary or less 9.4(6.3-13.7) Secondary (but not completed) 55.9(49.6-62.1) Completed secondary 34.7(27.7-42.4) Mean earnings past month (Rand) R165(106-225) Experience any physical/sexual IPV past 12m 65.3(60.4-70.0) Experience non-partner sexual violence past 12m 32.8(27.1-39.1) Transactional sex with main partner past 12m 61.1(52.1-69.5) Transactional sex khwapheni or once-off past 12m 49.1(41.9-56.2) Both forms of transactional sex in the past 12m 41.9(34.3-50.0) Cross-sectional survey, women (n=320) in 16 clusters of control arm Stepping Stones and Creating Futures RCT Two types: transactional sex main partner & transactional sex khwapheni/casual partner or once-off To give a quick summary of methods and basic characteristics of participants. This data comes from a cross-sectional survey of 320 women in 16 clusters, that formed the control arm clusters of the Stepping Stones and Creating Futures RCT, which seeks to reduce IPV in urban informal settlements around Durban. Our primary outcomes in this analysis are transactional sex with a main partner, and transactional sex with a kwapheni or once-off sexual partner. Used scales for transactional sex that had previously been developed and widely used in South Africa. We built separate regression models for factors associated with each form of transactional sex, accounting for the clustering of data. in each model we added all variables that were significant in descriptive analysis, before conducting backwards elimination by consecutively removing variables that are not making a statistically significant contribution to the model and then providing model re-estimates for remaining predictors. The backward method is recommended because it is less likely to incur Type II error (Bingham & Fry, 2010). Basic characteristics of the participants are shown

Results Transactional sex with main partner past 12m aOR p-value Controlling behaviours (>=more) 1.07 p<0.05 Experience economic violence past 12m 2.29 p<0.01 Experience of non-partner sexual violence past 12m 1.86 Alcohol use (AUDIT) 1.1 p=0.001 Transactional sex with casual or once-off partner past 12m aOR p-value Hunger Low base Mid 2.32 p=0.055 High 3.91 P=0.004 Experience economic violence past 12m 1.79 p<0.05 Experience of non-partner sexual violence past 12m 2.34 p=0.005 Drug use past 12m 3.52 p<0.0001 The results suggest that the factors associated with transactional sex are pretty similar. We see in both multivariate models that experiencing economic violence from a partner in the past 12m, experiencing non-partner sexual violence in the past 12m and using substances (alcohol/drugs) are associated with both forms of transactional sex. Transactional sex with a main partner was associated with the partner being more controlling, while with a casual/once-off hunger. This does suggest that while they are similar they are also somewhat different, specifically: Transactional sex with a causal or once-off partner may have stronger roots in poverty/hunger than transactional sex with a main partner Transactional sex with a main partner is more strongly shaped by the male partner’s characteristic, of controlling behaviours

Andrew Gibbs, gibbs@ukzn.ac.za DONORS