About the Author(s)


Jyotika Basdav Email symbol
Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology, Durban, South Africa

Poovendhree Reddy symbol
Department of Community Health Studies, Faculty of Health Sciences, Durban University of Technology, Durban, South Africa

Firoza Haffejee symbol
Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology, Durban, South Africa

Citation


Basdav J, Reddy P, Haffejee F. Identifying sexual behavioural choices when commencing pre-exposure prophylaxis: Findings from a public health facility in eThekwini, KwaZulu-Natal, South Africa. S Afr J HIV Med. 2026;27(1), a1758. https://doi.org/10.4102/sajhivmed.v27i1.1758

Original Research

Identifying sexual behavioural choices when commencing pre-exposure prophylaxis: Findings from a public health facility in eThekwini, KwaZulu-Natal, South Africa

Jyotika Basdav, Poovendhree Reddy, Firoza Haffejee

Received: 12 July 2025; Accepted: 06 Oct. 2025; Published: 04 Feb. 2026

Copyright: © 2026. The Authors. Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

Background: HIV/AIDS continues to be of concern, particularly in South Africa, where the current prevalence is 12.7%.

Objectives: This study aimed to explore sexual practices that increased HIV vulnerability among clinic users who chose to initiate pre-exposure prophylaxis (PrEP) in KwaZulu-Natal, South Africa.

Method: A quantitative approach was utilised to collect data at an urban clinic in eThekwini (n = 376). Data were analysed using SPSS v29.

Results: Participants were predominantly female (n = 331; 88%), single (n = 343; 91.5%), and heterosexual (n = 368; 98.1%). Sexual debut occurred at 18.4 ± 2.58 years. More men reported having concurrent sexual partners (n = 24; 54.5%). Transactional sex was more often reported by single women aged 18 years to 24 years. Age-disparate relationships were more common among those aged 18 years to 24 years. A significant association between early sexual debut and the number of lifetime partners was identified (P < 0.001).

Conclusion: Our findings indicate that the study population was aware of their increased HIV vulnerability and were willing to try preventive measures, such as PrEP, to protect against seroconversion. However, interventions are required to abate the cycle of transactional sex, age-disparate relationships, and early sexual debut, especially among young women aged 15 years to 24 years.

Keywords: sexual behavioural choices; pre-exposure prophylaxis initiation; self-perceived HIV risk; HIV risk profile; KwaZulu-Natal; South Africa.

What this study adds: The study identified that participants were aware of their self-perceived HIV risk and were willing to try PrEP. The driving factors for their high HIV risk were transactional sex, age-disparate relationships, and early sexual debut.

Introduction

Vulnerable populations, such as adolescent girls and young women, orphans, street children, serodiscordant couples, and migrant workers, are at high risk of contracting HIV, based on their sexual behavioural practices.1,2 In addition, there are a multitude of interlinking risk factors that increase one’s chance of acquiring HIV, including early sexual debut, multiple concurrent sexual partners, lack of condom use, sexually transmitted infections, and transactional sex. Early sexual debut (at 15 years or younger) was reported across both genders in South Africa,3,4,5,6,7 but is more frequent amongst boys aged 14 years or younger,3,8 and commonly reported among those residing in urban locations.9 However, non-consensual sex is reported by girls as young as 13 years, many of whom were coerced by older men,5 placing them at a greater risk of contracting HIV4 and sexually transmitted infections.5 Age-disparate relationships are defined as a sexual partner who was at least 5 years older than the participant, and this increases the chance of HIV acquisition because of the difficulty in negotiating safe sexual practices.6

These age-disparate relationships are often transactional in nature, with the female partner viewing the receipt of material items as an expression of love.10 These young women are at high risk of HIV acquisition as they do not have the ability to negotiate safe sexual activity.10,11,12 Moreover, multiple concurrent relationships of a transactional nature were reported among a cohort of young women in the North West province of South Africa,11 as this increased their chances of monetary and material gain.11,12

Other factors, such as education inequalities and informal housing, contribute to sexual behaviour resulting in high HIV transmission rates.13,14,15 Psychosocial factors, such as trauma exposure and lack of emotional support, negatively impact their attitudes towards relationships and sex. Lack of advice and support systems usually contributes to their views on relationships and sex.16 A study conducted on adolescent girls and young women in the South African provinces of KwaZulu-Natal and Gauteng found an association with depressive symptoms, substance use, and intimate partner violence that increased their risk of HIV acquisition.17 Another study conducted in Cape Town, South Africa, highlighted that women and girls from a lower socio-economic background were more likely to contract HIV compared to their male counterparts. Women and girls were less likely to use a condom or have multiple partners.15 Transactional sex is a key factor in HIV, as this results in age-disparate relationships and unequal gender dynamics in relationships. Men were seen as financial benefactors and, under these circumstances, the women and girls were unable to negotiate safe sexual practices. Furthermore, material and economic gains outweighed the risk of HIV. These factors underscore the need to empower women economically, to explore innovative ways to market HIV prevention methods, and to address cultural norms.

A study conducted by Madiba and Ngwenya18 in the Mpumalanga province of South Africa highlighted women’s fear of physical and sexual violence when they suggested condom use to their partners. These women feared that their partners would discuss these matters among family members, feared the relationship would end in divorce, and assumed they would be subjected to stigma. Men paid a bride price (lobola) and felt they were entitled to dictate sexual practices within the relationship. Under these circumstances, men were assumed to be dominant while women were submissive, especially because of their financial dependence on their partners.18

Existing interventions, such as condom use, male circumcision, harm reduction programmes for drug users, and elimination of mother-to-child transmission,19 are currently used as part of HIV prevention strategies; however, the HIV epidemic continues unabated in South Africa. In 2016, pre-exposure prophylaxis (PrEP), an oral tablet taken daily, was introduced for HIV prevention in high-risk populations. Pre-exposure prophylaxis can be used during high-risk exposure stages and phased off when no longer required,20 and can be used in conjunction with other biomedical interventions. Studies have highlighted the importance of PrEP initiation in populations with poor condom negotiation skills, transactional sex, concurrent sexual relationships, and serodiscordant relationships.21,22,23,24 The success of this prophylaxis will be determined by one’s awareness of their HIV risk exposure. However, a recent study reported very low awareness of PrEP among young people, and users of a primary healthcare clinic in KwaZulu-Natal.25 The current study was located in an urban clinic, where PrEP was integrated into existing sexual reproductive health services as part of the healthcare facility-based model. This study aimed to offer PrEP to those at risk of acquiring HIV, and explored the baseline sexual practices that increase HIV vulnerability of the participants who enrolled for PrEP at a KwaZulu-Natal primary healthcare clinic offering reproductive health services.

Research methods and design

This quantitative study was conducted at a primary healthcare clinic located in the central business district in eThekwini, KwaZulu-Natal, South Africa. Data were collected from January 2022 to April 2023, using purposive sampling. This type of sampling allows one to gain knowledge about a particular phenomenon. Greater preference is given to the knowledge aspect rather than the statistical outcome of the research. Purposive sampling is beneficial in explanatory studies, and allows the researcher to create theories or suggestions.26,27 The clinic provides sexual and reproductive health services. As part of the standard of practice, clients are advised on HIV prevention measures, post HIV testing, together with an invitation to commence PrEP. HIV counsellors and nurses assisted with identifying those who agreed to commence PrEP. A brief explanation of the study was provided. Those who agreed to participate were invited to answer a self-administered baseline questionnaire, which sought information on demographics, sexual history, PrEP knowledge, and reasons for initiating PrEP. Participants who were already using PrEP were excluded from the study.

In the current report, early sexual debut was defined as those who had sex for the first time at 15 years and younger. In an age-disparate relationship, the sexual partner was at least 5 years older than the participants. Transactional sex was defined as an exchange of material support for sex. Multiple concurrent partners referred to having two or more sexual partners at the same time.

The questionnaire took approximately 15 min to complete. The researcher or research assistant was present to answer any questions. The questionnaires were available in either English or isiZulu. The baseline questionnaire was completed in a closed clinic room to allow for privacy while completing the questionnaire due to the sensitive nature of some questions. Participants were allowed to withdraw at any point in the study. Verbal cues and body language were taken into consideration, as the study population was predominantly younger; this ensured the participants’ welfare was protected, especially if they did not voice their discomfort. In the current study, none of the participants displayed any signs of discomfort or voiced any questions they may have had. A distress protocol was in place for the relevant referrals for counselling and support groups; however, this was not utilised in the current study.

Prior to the main study, the questionnaires were piloted among PrEP users to ensure reliability and validity. An expert focus group, comprising the researchers, current PrEP users, and nurses (n = 6), assessed the validity of the questionnaire, after which minor changes were implemented. Cronbach’s alpha was calculated only for sections comprising grouped items that measured a single construct. These included the abuse sections (type of abuse, α = 0.618; frequency of abuse, α = 0.833), and the PrEP knowledge section (α = 0.612). Other sections of the questionnaire consisted largely of single-item or descriptive measures for which Cronbach’s alpha is not applicable. For further validation, we also computed the Kuder–Richardson 20 coefficient for the dichotomous knowledge items. The Kuder–Richardson 20 value was 0.51, which, while slightly lower than Cronbach’s alpha, is consistent with moderate internal consistency for exploratory research of this nature. A total of 376 questionnaires were completed and included in the analysis.

Data analysis

All data were analysed using SPSS version 29 (IBM Corp., Armonk, New York, United States). Categorical data were calculated using frequencies, percentages, and standard deviation. Data were correlated using Pearson Chi-Square and Fisher Exact tests to determine bivariate associations. Missing data were excluded from the analyses. Participants with incomplete responses were not excluded from the dataset unless all responses for a construct were missing. In line with SPSS defaults, pairwise deletion was applied for descriptive and reliability analyses, while listwise deletion was used for regression models to ensure only participants with complete data on included predictors were analysed. A P-value of < 0.05 was deemed statistically significant.

Ethical considerations

Ethics approval was obtained from the Durban University of Technology Institutional Ethics Review Committee (reference number: IREC 148/20). Permission from the research clinic site, clinic manager, and the Department of Health, South Africa, was obtained prior to commencing the research. All participation was voluntary, and written informed consent was obtained. The questionnaire was answered in the privacy of a clinic room. Verbal cues and body language were taken into consideration, as the study population was predominantly younger, ensuring the participants’ welfare was protected, especially if they did not voice their discomfort. In the current study, none of the participants displayed any signs of discomfort or voiced any questions they might have.

Results

The demographic profile and sexual behavioural characteristics of the participants is reported in Table 1. Most participants were Black African (n = 376; 100%), single (n = 343; 91.5%), and heterosexual (n = 368; 98.1%). The mean age of the participants was 30.2 ± 6.99 years. Sexual debut occurred at 18.4 ± 2.58 years. Only 41.7% disclosed that they were in a serodiscordant relationship (n = 88). A small proportion (n = 76; 20.2%) was previously diagnosed with a sexually transmitted infection. Thirty-one participants (8.3%) reported having been subjected to some form of abuse, with some experiencing more than one type of abuse. Of those, physical abuse (n = 5; 16.1%), emotional abuse (n = 31; 8.2%), mental abuse (n = 1; 3.2%), and sexual abuse (n = 1; 3.2%) were identified among the participants. Those who were single and male reported having five or more lifetime partners. Concurrent sexual partners were more commonly reported among male participants than their female counterparts. Age-disparate relationships and transactional sex were reported by women.

TABLE 1: Participant characteristics at the point of pre-exposure prophylaxis initiation.

Factors associated with sexual behaviour trends are shown in Table 2. Bivariate analysis indicated that younger participants were more likely to have a sexual partner aged 5 years or older than themselves. Specifically, 55.6% (n = 40) of participants aged 18 years to 24 years reported having partners five or more years older. Notably, only 3.4% of participants aged 35 years to 39 years (n = 2), and none of those aged 40 years and older, reported having partners at least 5 years or older (Fisher’s Exact test P < 0.001; Table 2). More participants aged 18 years to 24 years (n = 10; 12.2%) reported engaging in transactional sex compared to those aged 35 years to 39 years (n = 1; 1.7%; Fisher’s Exact test P < 0.034). None of the participants aged 40 years and older reported transactional sex. Participants who reported sexual debut at the age of 19 years or younger were more likely to have five or more lifetime partners (Fisher’s Exact P < 0.001). A linear trend was observed between age of sexual debut and number of lifetime sexual partners (Pearson Chi-Square test P < 0.001). Having five or more lifetime partners was reported for those who reported sexual debut at an age younger than 15 years (n = 18; 9.3%), or those between the ages of 15 years and 19 years (n = 144; 74.2%). However, when sexual debut occurred between the ages of 20 years and 24 years, 42.5% (n = 17) reported having only two lifetime partners. Early sexual debut was also positively correlated with age-disparate relationships (Fisher’s Exact test P < 0.033).

TABLE 2: Factors influencing behavioural trends among the cohort initiating pre-exposure prophylaxis.

Although the relationship between the number of lifetime partners and the likelihood of having a partner aged 5 years or older was not statistically significant (Pearson Chi-Square test P = 0.093), a linear-by-linear association indicated a trend between age disparity and number of lifetime partners (P = 0.009). Of those who had only one lifetime partner,few (n = 8; 21.6%) reported age-disparate relationships, in contrast to 39.3% (n = 72) participants with five or more lifetime partners being in age-disparate relationships (Table 2).

Discussion

The current study explored sexual practices that increased HIV vulnerability amongst primary healthcare clinic clients at the point of PrEP initiation. Early sexual debut, serodiscordant relationships, multiple concurrent sexual partnerships, age-disparate relationships, and transactional sex were identified, particularly amongst younger participants aged 18 years to 24 years. Transactional sex and age-disparate relationships were more common among women and among younger participants. Young people, aged approximately 18 years, are likely to have completed secondary education and are entering a tertiary institution, which may require a move away from home to a new city.28 This is often accompanied by stresses of living expenses or concern about their family households’ expenses, leading to relationships with older partners who are financially secure.29,30 Such transactional relationships not only pay for the basic needs of these young students but also provide funds for luxuries such as hair and nail salon visits and other extravagant items.31,32

Women in transactional relationships are unable to negotiate safe sex, including the use of condoms,33,34 thus increasing their vulnerability to HIV infection. When men are perceived as benefactors of resources, it gives them control over sexual relationships.31 Furthermore, when a man pays for a restaurant bill, which often includes alcohol, women reciprocate by exchanging sexual favours.35 When evaluating immediate benefits, the concept of seroconverting held little significance, as economic gain was prioritised above health considerations.31 In addition, peer pressure and social media influence are also drivers for transactional sex among adolescents, as it improves their social status.10,29,30,36 This is because of the pressure of social trends to access the current fashionable accessories or other material goods, emphasising the importance of material ownership. Additionally, friends were envious of their lifestyles and felt pressured to maintain their social appearances, which resulted in transactional sex where their male partners were able to finance their desired lifestyle.

A Nigerian study30 reported that family pressure for financial support contributed towards engaging in transactional sex. This was supported by a study conducted in Kenya, which reported that these requests for familial support were because of unemployment, with mothers in particular applauding their daughters when they sent money and other items home. As the men were aware of this parental influence, it increased the power imbalance in the relationship.37 Financial constraints are contributing factors towards transactional relationships where sexual favours are exchanged for material support. This highlights the cultural norms within relationships, where men make decisions about sexual health, and women are financially reliant on their partners. However, this sexual exchange is confused with affection, further highlighting male dominance and unequal gender dynamics.

The current study population accessed public healthcare facilities, since private healthcare is expensive in South Africa. Only 16.2% of South Africans access private healthcare through private medical schemes.38 Our participants were thus from low socio-economic communities, with financial constraints and financial demands by family possibly leading to early sexual debut, particularly when adolescents come from single-parent homes.39,40 In this study, sexual debut occurred at a mean age of 18.4 years, with some reporting sexual debut before the age of 15 years. McClinton Appollis et al.41 found that 8.9% of adolescent girls and young women aged 15 years to 24 years in six districts in South Africa had sex before the age of 15 years. This is also common in other countries in Africa.42,43 Early sexual initiation was disproportionately concentrated among the poor in sub-Saharan Africa.44 Surprisingly, being without access to the internet was significantly correlated with early sexual debut in Zambia,43 as well as having the ideology that sex was okay even before 18 years.45 Peer pressure, societal norms, and substance use also play a role in early sexual debut.35,46,47 In contrast, when the family restricts dating, early sexual debut is less likely to occur.40 Early sexual debut not only increases the risk of HIV infection and other sexually transmitted infections, but also of unplanned pregnancy and unsafe abortion.44

Early sexual debut has further consequences. We report a positive correlation between early sexual debut and age-disparate relationships, as well as a higher number of lifetime sexual partners. Young women with older partners are at a higher risk of engaging in unsafe sexual behaviours, such as unprotected sex and being in relationships with partners living with HIV.48 Furthermore, a higher number of sexual partners is another risk factor for HIV acquisition, as it creates many interwoven sexual networks.49 Our findings are supported by McClinton Appollis et al.41 and Kyei-Arthur, Agyekum and Kyei-Gyamfi,50 who also reported the association between early sexual debut and age-disparate relationships. Furthermore, these studies also reported that early sexual debut was associated with a higher number of lifetime partners. Thus, this cycle of transactional sex, age-disparate relationships, and early sexual debut was also identified in the current study as being associated with vulnerability, leading to HIV infection. We recommend that interventions to tackle age-disparate relationships, especially among young females aged 15 years to 24 years, should be tailored towards increasing education about sexual risk behaviours and economic independence.

Recommendations

Early sexual health education should be implemented within schools and communities, in an attempt to delay sexual debut. Parents, guardians, and caregivers should be included in these programmes to facilitate open and honest conversations about sexual health. Mainstream and social media can portray accurate decisions in sexual relationships and their consequences. Economic support, such as scholarships or stipends, would be vital to young girls and women to mitigate early sexual debut and transactional sex.

Limitations

Our sample comprised those enrolling for PrEP, thus the reported sexual behaviours may be biased and not representative of the entire population. Furthermore, the responses were self-reported, which could have the potential of under-reporting certain behaviours, such as transactional sex or abuse, for social desirability. Similarly, the missing data could be a result of social desirability bias. The cross-sectional design limits causal inference. Multivariate analysis was not conducted due to missing data and purposive sampling, which would not be beneficial for regression models. Data on sensitive topics such as sexual behaviours can be underreported and affect the validity of multivariate models. Convenience sampling can cause potential bias.

Conclusion

Sexual practices that increase HIV vulnerability identified in this study allude to participants’ self-awareness of their perceived risk for HIV acquisition. Hence, their exploration of PrEP as an HIV prevention strategy. The study alludes to economic constraints leading to sexual behaviours that may increase vulnerability to HIV. Thus, initiatives that promote financial independence and life skills among adolescent girls and young women can reduce economic dependence on men, decreasing these behaviours that lead to HIV vulnerability. Gender-transformative approaches would be vital in breaking the power disproportionateness, fostering healthier relationship dynamics, and contributing to long-term reductions in HIV incidence through enhanced agency and structural resilience.

Acknowledgements

The authors thank the study participants for their time,Mr Deepak Singh for their time and valuable input, Xoliswa Mtolo for assisting with data collection. This article is based on data from a larger study. A related article focuses on motivators for oral PrEP uptake and has been published in AIDS Care (2023; https://doi.org/10.1080/09540121.2023.2208322). The present article addresses a distinct research question, exploring baseline sexual practices of a cohort commencing PrEP. This article is based on research originally conducted as part of Jyotika Basdav’s doctoral thesis titled ‘The evaluation of adherence and effects of PrEP on a cohort of PrEP users in KwaZulu-Natal’, submitted to the Faculty of Health Sciences, Durban University of Technology in 2025. The thesis is currently unpublished and not publicly available. The thesis was supervised by Poovendhree Reddy and Firoza Haffejee. The manuscript has been revised and adapted for journal publication. The author confirms that the content has not been previously published or disseminated and complies with ethical standards for original publication.

Competing interests

Jyotika Basdav received funding from the Durban University of Technology PhD research funds. The terms of this arrangement have been reviewed and approved by Durban University of Technology in accordance with its policy on objectivity in research.

CRediT authorship contribution

Jyotika Basdav: Conceptualisation, Methodology, Investigation, Writing – Original Draft, Writing – Review & Editing. Poovendhree Reddy: Conceptualisation, Methodology, Supervision, Writing – Review & Editing. Firoza Haffejee: Conceptualisation, Methodology, Supervision, Writing – Review & Editing, Resources. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication, and take responsibility for the integrity of its findings.

Funding information

Jyotika Basdav received funding from the Durban University of Technology PhD research funds.

Data availability

The data that support the findings of this study are available on request from the corresponding author, Jyotika Basdav.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings, and content.

References

  1. Rebe K, editor. Sexually transmitted infections in vulnerable groups. Presentation given at the Southern African HIV Clinicians Society 3rd Biennial Conference; 2016 April 13–16; Johannesburg, South Africa.
  2. National Department of Health. High transmission areas: Key populations. Pretoria: National Department of Health; 2015.
  3. Pettifor A, O’Brien K, MacPhail C, Miller WC, Rees H. Early coital debut and associated HIV risk factors among young women and men in South Africa. Int Perspect Sex Reprod Health. 2009;35(2):82–90. https://doi.org/10.1363/ifpp.35.082.09
  4. Wand H, Ramjee G. The relationship between age of coital debut and HIV seroprevalence among women in Durban, South Africa: A cohort study. BMJ Open. 2012;2(1):e000285. https://doi.org/10.1136/bmjopen-2011-000285
  5. Richter L, Mabaso M, Ramjith J, Norris SA. Early sexual debut: Voluntary or coerced? Evidence from longitudinal data in South Africa – The Birth to Twenty Plus study. S Afr Med J. 2015;105(4):304–307. https://doi.org/10.7196/SAMJ.8925
  6. Zuma K, Shisana O, Rehle TM, et al. New insights into HIV epidemic in South Africa: Key findings from the National HIV prevalence, incidence and behaviour survey, 2012. Afr J AIDS Res. 2016;15(1):67–75. https://doi.org/10.2989/16085906.2016.1153491
  7. Ranganathan M, Heise L, Pettifor A, et al. Transactional sex among young women in rural South Africa: Prevalence, mediators and association with HIV infection. J Int AIDS Soc. 2016;19(1):20749. https://doi.org/10.7448/IAS.19.1.20749
  8. Zuma K, Setswe G, Ketye Y, Mzolo T, Rehle T, Mbelle N. Age at sexual debut: A determinant of multiple partnership among South African youth. Afr J Reprod Health. 2010;14(2):47–54.
  9. Gibbs A, Reddy T, Dunkle K, Jewkes R. HIV-Prevalence in South Africa by settlement type: A repeat population-based cross-sectional analysis of men and women. PLoS One. 2020;15(3):e0230105. https://doi.org/10.1371/journal.pone.0230105
  10. UNAIDS and STRIVE. Transactional sex and HIV risk: From analysis to action. Geneva: Joint United Nations Programme on HIV/AIDS and STRIVE; 2018.
  11. Mampane JN. Exploring the ‘Blesser and Blessee’ phenomenon: Young women, transactional sex, and HIV in rural South Africa. Sage Open. 2018;8(4):1–9. https://doi.org/10.1177/2158244018806343
  12. Kilburn K, Ranganathan M, Stoner MC, et al. Transactional sex and incident HIV infection in a cohort of young women from rural South Africa. AIDS. 2018;32(12):1669–1677. https://doi.org/10.1097/QAD.0000000000001866
  13. Allinder SM, Fleischman J. The world’s largest HIV epidemic in crisis: HIV in South Africa 2019 [homepage on the Internet]. 2020 [cited 2020 Apr 21]. Available from: https://www.csis.org/analysis/worlds-largest-hiv-epidemic-crisis-hiv-south-africa
  14. UNAIDS. UNAIDS data 2019 [homepage on the Internet]. 2019 [cited 2020 Apr 16]. Available from: https://www.unaids.org/sites/default/files/media_asset/2019-UNAIDS-data_en.pdf
  15. Leung SC, Pant PN, Bartlett SJ, Esmail A, Dheda K, Bhatnagar S. Socioeconomic factors impact the risk of HIV acquisition in the township population of South Africa: A Bayesian analysis. PLoS Glob Public Health. 2023;3(1):e0001502. https://doi.org/10.1371/journal.pgph.0001502
  16. Malone S, editor. Breaking the cycle of transmission: Increasing adoption of and adherence to HIV prevention among adolescent girls and young women (AVAC) and increasing uptake of HIV testing, prevention and treatment among young men (PSI). Presentation given at the International AIDS Conference; 2018 July 23–27; Amsterdam.
  17. Govender K, Beckett S, Mukuku O, et al. Psychosocial and behavioral factors associated with HIV among adolescent girls and young women in DREAMS districts in South Africa: Cross-sectional survey. Front Public Health. 2025:13:1620084. https://doi.org/10.3389/fpubh.2025.1620084
  18. Madiba S, Ngwenya N. Cultural practices, gender inequality and inconsistent condom use increase vulnerability to HIV infection: Narratives from married and cohabiting women in rural communities in Mpumalanga province, South Africa. Glob Health Action. 2017;10(suppl 2):1341597. https://doi.org/10.1080/16549716.2017.1341597
  19. WHO Africa. HIV/AIDS 2024 [homepage on the Internet]. 2024 [cited 2025 Jun 11].Available from: http://www.afro.who.int/health-topics/hivaids
  20. Bekker LG, Rebe K, Venter F, et al. Southern African guidelines on the safe use of pre-exposure prophylaxis in persons at risk of acquiring HIV-1 infection. South Afr J HIV Med. 2016;17(1):455. https://doi.org/10.4102/sajhivmed.v17i1.455
  21. Gombe MM, Cakouros BE, Ncube G, et al. Key barriers and enablers associated with uptake and continuation of oral pre-exposure prophylaxis (PrEP) in the public sector in Zimbabwe: Qualitative perspectives of general population clients at high risk for HIV. PLoS One. 2020;15(1):e0227632. https://doi.org/10.1371/journal.pone.0227632
  22. Irungu EM, Ngure K, Mugwanya KK, et al. ‘Now that PrEP is reducing the risk of transmission of HIV, why then do you still insist that we use condoms?’ The condom quandary among PrEP users and health care providers in Kenya. AIDS Care. 2021;33(1):92–100. https://doi.org/10.1080/09540121.2020.1744507
  23. Chebet JJ, McMahon SA, Tarumbiswa T, et al. Motivations for pre-exposure prophylaxis uptake and decline in an HIV-hyperendemic setting: Findings from a qualitative implementation study in Lesotho. AIDS Res Ther. 2023;20(1):43. https://doi.org/10.1186/s12981-023-00535-x
  24. Kawuma S, Katwesigye R, Walusaga H, et al. Determinants of continuation on HIV pre-exposure prophylaxis among female sex workers at a referral hospital in Uganda: A mixed methods study using COM-B model. BMC Public Health. 2025;25:143. https://doi.org/10.1186/s12889-024-20975-y
  25. Haffejee F, Fasanmi-Kana O, Ally F, Thandar Y, Basdav J. Four years later: Do South Africans know what pre-exposure prophylaxis for HIV is? AIDS Care. 2023;35(4):466–473. https://doi.org/10.1080/09540121.2022.2032573
  26. McCombes S. Understanding different sampling methods 2019 [homepage on the Internet]. 2020 [cited 2020 Apr 16]. Available from: https://www.scribbr.com/methodology/sampling-methods/
  27. Health Knowledge. Methods of sampling from a population 2020 [homepage on the Internet]. 2020 [cited 2020 Apr 16]. Available from: https://www.healthknowledge.org.uk/public-health-textbook/research-methods/1a-epidemiology/methods-of-sampling-population
  28. Selepe K, Ngwenya BN, Albers AL, Jankey OM. Transactional sex relations among tertiary education students in the urban-village of Maun, Botswana. Botsw Not Rec. 2017;49:168–183.
  29. Gabster A, Mayaud P, Jhangimal M, Pascale J, Francis S, Cislaghi B. Social norms that sustain transactional sex and associations with sexual health outcomes: A mixed-methods study in the Comarca Ngäbe-Buglé, a rural-Indigenous region of Panama. PLoS One. 2024;19(5):e0304805. https://doi.org/10.1371/journal.pone.0304805
  30. Oyeoku EK, Ibezim NE, Agwu PC, Okoye UO. Transactional sex in Nigerian universities among female students: Drivers and safety concerns. J Int Women’s Stud. 2022;24(5):a11.
  31. Zembe YZ, Townsend L, Thorson A, Ekström AM. ‘Money talks, bullshit walks’ interogating notions of consumption and survival sex among young women engaging in transactional sex in post-apartheid South Africa: A qualitative study. Glob Health. 2013;9:28. https://doi.org/10.1186/1744-8603-9-28
  32. Gichane MW, Joyce W, Kaitlyn A, et al. The influence of cash transfers on engagement in transactional sex and partner choice among adolescent girls and young women in Northwest Tanzania. Cult Health Sex. 2020:1–15. https://doi.org/10.1080/13691058.2020.1811890
  33. Haffejee F, Koorbanally D, Corona R. Condom use among South African university students in the province of KwaZulu-Natal. Sex Cult. 2018;22(4):1279–1289. https://doi.org/10.1007/s12119-018-9523-5
  34. Haffejee F, Ducray J, Basdav J, Kell C. Factors influencing the adoption of HIV prevention measures in low socio economic communities of inner-city Durban, South Africa. SAHARA J. 2023;20(1):2185806. https://doi.org/10.1080/17290376.2023.2185806
  35. Khumalo S, Taylor M, Makusha T, Mabaso M. Intersectionality of cultural norms and sexual behaviours: A qualitative study of young Black male students at a university in KwaZulu-Natal, South Africa. Reprod Health. 2020;17(1):188. https://doi.org/10.1186/s12978-020-01041-3
  36. Dunkle KL, Jewkes RK, Brown HC, Gray GE, McIntryre JA, Harlow SD. Transactional sex among women in Soweto, South Africa: Prevalence, risk factors and association with HIV infection. Soc Sci Med. 2004;59(8):1581–1592. https://doi.org/10.1016/j.socscimed.2004.02.003
  37. Munala L, Mohamed A, Okunna N, Yewhalawork B, Kibati P, Kihuha J. ‘Instead of asking for fare, you ask her to pay with sex’: Male perspectives on the factors influencing schoolgirls’ participation in age-disparate transactional sex relationships. Adolescents. 2024;4:1–13. https://doi.org/10.3390/adolescents4010001
  38. National Department of Health. White Paper on National Health Insurance, towards Universal Health Coverage, South Africa. Pretoria: National Department of Health; 2015.
  39. Alhassan AR, Abdulai K, Alhassan MA. Early sexual debut among Ghanaian women: Correlates and psychological effect. BioMed Res Int. 2021;2021:5838510. https://doi.org/10.1155/2021/5838510
  40. Cribb Fabersunne C, Milliren C, Schuster MA, et al. Sexual debut in early adolescence and individual, school, and neighborhood social capital. J Adolesc Health. 2024;75(2):333–343. https://doi.org/10.1016/j.jadohealth.2024.04.007
  41. McClinton Appollis T, Kim J, Roxanne B, et al. Early sexual debut and the effects on well-being among South African adolescent girls and young women aged 15 to 24 years. Int J Sex Health. 2021;34(2):242–253. https://doi.org/10.1080/19317611.2021.1979162
  42. Omona K, Ssuka JK. Early sexual debut and associated factors among adolescents in Kasawo sub-county, Mukono district, Uganda. Cogent Public Health. 2023;10(1):2183561. https://doi.org/10.1080/27707571.2023.2183561
  43. Sserwanja Q, Mwamba D, Poon P, Kim JH. Prevalence and factors associated with risky sexual behaviors among sexually active female adolescents in Zambia. Arch Sex Behav. 2023;52(1):205–215. https://doi.org/10.1007/s10508-022-02385-6
  44. Fentie EA, Kidie AA, Fetene SM, Shewarega ES. Socioeconomic inequality in early sexual initiation among female youths in sub-Saharan African countries: A decomposition analysis. BMC Public Health. 2023;23(1): 1283. https://doi.org/10.1186/s12889-023-16124-6
  45. Millanzi WC, Osaki KM, Kibusi SM. Attitude and prevalence of early sexual debut and assoicated risk sexual behvaiour among adolescents in Tanzania; Evidence from baseline data in a Randomized Controlled Trial. BMC Public Health. 2023;23(1): 1758. https://doi.org/10.1186/s12889-023-16623-6
  46. Durowade KA, Babatunde OA, Omokanye LO, et al. Early sexual debut: Prevalence and risk factors among secondary school students in Ido-ekiti, Ekiti state, South-West Nigeria. Afr Health Sci. 2017;17(3):614–622. https://doi.org/10.4314/ahs.v17i3.3
  47. Muhammad T, Srivastava S, Kumar P, Patel SK. What predicts the early sexual debut among unmarried adolescents (10–19 years)? Evidence from UDAYA survey, 2015–16. PLoS One. 2021;16(6):e0252940. https://doi.org/10.1371/journal.pone.0252940
  48. Reed DM, Radin E, Kim E, et al. Age-disparate and intergenerational sex partnerships and HIV: The role of gender norms among adolescent girls and young women in Malawi. BMC Public Health. 2024;24(1):575. https://doi.org/10.1186/s12889-024-17868-5
  49. Kenyon CR, Tsoumanis A, Schwartz IS, Maughan-Brown B. Partner concurrency and HIV infection risk in South Africa. Int J Infect Dis. 2016;45:81–87. https://doi.org/10.1016/j.ijid.2016.03.001
  50. Kyei-Arthur F, Agyekum MW, Kyei-Gyamfi S. ‘You cannot stay with one person once you begin having sex at a young age’: The prevalence, correlates and effects of early sexual debut among children in Ghana. Reprod Health. 2024;21(1):38. https://doi.org/10.1186/s12978-024-01775-4


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