Transactional and Age Disparate Sex in Hyperendemic Countries

Introduction

  1. Definition of the Prevention Area

    Transactional sex is defined as an exchange of money, favors, or gifts in exchange for sexual relations. The term is used to distinguish the informal or less formal exchanges for sex that happen within relationships from the formal, immediate sex for money, which is referred to as “sex work” or “prostitution."

    Transactional sex is widely practiced in sub-Saharan Africa. It is closely linked to sociocultural expectations of gender whereby men are expected to act as a provider to their partners, and women expect compensation for having sex. Young women may engage in transactional sex with older men to support their basic needs (e.g., food, clothing, school fees, and desire for love), or to obtain desirable consumer goods (e.g., cell phones, fashionable clothing, jewelry, and meals at expensive restaurants) and the status that goes with them. Gifts for sex may be seen as symbolizing the love and respect a man feels for his partner and the importance he places on the relationship. In contrast, “giving away” sex for free can stigmatize young women in society as “loose” and lacking self-respect.

    An age-disparate relationship is defined as one where there is an age difference of five or more years between partners, with the man being older than the woman in the relationship. Often, transactional sex occurs in age-disparate relationships between young women and older men because older men are more likely than boys to have the means to offer gifts for sex. An “intergenerational/cross-generational” relationship is a specific type of age-disparate relationship, in which the man is 10 or more years older than the woman. While these relationships take different forms, this document largely focuses on age-disparate transactional sexual relationships.

  2. Epidemiological Justification for the Prevention Area

    Young women and girls are especially vulnerable to HIV due to biological and social factors. For example, unequal access to economic opportunity often compels them to trade their sexuality. The epidemiological record shows that young women in sub-Saharan Africa are two- to four-and-a-half times more likely to be living with HIV than their male counterparts. There is compelling evidence that these gender disparities stem in part from the frequency of age-disparate and transactional sexual networking.

    Transactional sex often coexists with other risky sexual behaviors such as early sexual debut, and inconsistent condom use. As a result, there is considerable evidence linking transactional sex to undesirable sexual and reproductive health outcomes including sexually transmitted infections, unintended pregnancies, unsafe abortions, and gender-based violence.

  3. Core Programmatic Components

    Interventions addressing age-disparate transactional sexual relationships explicitly or as a secondary outcome have focused on the economic and social drivers of young people’s risk. Thus, focus areas have included changing gender norms, improving school attendance, improving young women's economic situation through microfinance and microcredit, creating safe spaces, engaging in healthy sexual behavior, and strengthening the parenting of young people. Increasing men's involvement in prevention programs that challenge gender and other social norms is another important programmatic component.

    These components have often been combined—for example, joining an educational intervention with microcredit and community mobilization, or gender empowerment training with life skills and financial literacy. Some interventions have addressed gender inequality and livelihood insecurity by supporting educational attendance for girls.

  4. Current Status of Implementation Experience

    Some interventions to reduce young people's vulnerability to HIV have demonstrated a positive effect on outcomes such as condom use, number of partners, gender-based violence, transactional sex, and ultimately, HIV incidence. However, few interventions have explicitly tried to address age-disparate transactional sex and few have been rigorously evaluated.

    One intervention, Stepping Stones, documented a 35 percent reduction in the incidence of HSV-2 (but not HIV) among participants; a reduction in the proportion of men reporting that they committed intimate partner violence; and the proportion of men reporting transactional sex. The Girls’ Power Initiative reported that its behavior change and communication model reduced the likelihood that young women would engage in transactional sex.

    Moving forward, programmers must identify and account for possible variations in the populations engaged in transactional sexual relationships where age disparities are not involved, and how different forms of sexual partnering affect HIV vulnerability in different settings. Successful programs will also be based on an understanding of specific social norms that influence transactional and age-disparate sexual relationships. It will then be critical to integrate such knowledge into combination prevention programs addressing the biomedical, cultural, behavioral, and structural factors that contribute to sex-related HIV risk and vulnerability. All programs need to implement a rigorous evaluation strategy to assess whether and how they work to reduce young women’s vulnerability to HIV.

Updated July 2015

What We Know

Do Age-Disparate Relationships Drive HIV Incidence in Young Women? Evidence from a Population Cohort in Rural KwaZulu-Natal, South Africa

Harling, G., Newell, M.L., Tanser, F., et al. Journal of Acquired Immune Deficiency Syndromes (August 2014), 66(4), pp. 443–51, doi:10.1097/QAI.0000000000000198.. 

Between January 2003 and June 2012 the authors studied 2,444 seronegative 15- to 29-year-old women in rural KwaZulu-Natal to determine whether the age disparity of women’s most recent sexual partner was associated with subsequent HIV acquisition. Each of the women was tested for HIV between two and eight times. During the study period, more than one-third of the young women had a partner five or more years older. The authors found no evidence that having an older male partner increased the risk of HIV infection in the young women. This finding was not influenced by the partner’s specific age or his age group, or the women's age, marital status, education, or household wealth. The authors hypothesized that this result may be due to young women in age-disparate relationships choosing less-risky partners than do young women in relationships with men of a similar age; and with older HIV-infected men being less infectious than younger men. The authors concluded that campaigns warning women about the risks of sexual partnerships with older men may reduce unwanted pregnancies or school dropout rates. However, they added that in the high-prevalence context of rural South Africa, these campaigns may not be a cost-effective way of using HIV-prevention resources.

Giving or Receiving Something for Sex: A Cross-Sectional Study of Transactional Sex among Ugandan University Students

Choudhry, V., Östergren, P.O., Ambresin, A.E., et al. PLOS ONE (November 2014), doi:10.1371/journal.pone.0112431. 

The authors of this study used a self-administered questionnaire to determine the prevalence of transactional sex among 1,954 undergraduate students at a Ugandan university, and to assess the relationship between transactional sex and sexual coercion, physical violence, mental health, and alcohol use. More than one-fourth of the survey respondents reported that they had taken part in transactional sex. Accepting money, gifts, or some other form of compensation in exchange for sex was more common among women, while paying, giving a gift, or compensating in exchange for sex was higher among men. Being a victim of physical violence in the past 12 months, having experienced sexual coercion, and poor mental health status were significantly associated with having transactional sex for both men and women. In addition, heavy episodic drinking was significantly associated with having transactional sex among men. Given these findings, the authors urged consideration of the roles of sexual coercion, physical violence, alcohol use, mental health, and social environmental factors in shaping young people's sexual behaviors. 

Community Environments Shaping Transactional Sex among Sexually Active Men in Malawi, Nigeria, and Tanzania

Stephenson, R., Winter, A., and Elfstrom, M. AIDS Care (2013), 25(6), pp. 784–92, doi:10.1080/09540121.2012.748161.

In this study, the authors examined responses by sexually active men on their participation in risky transactional sex aggregated from the respective Demographic and Health Surveys of Malawi, Tanzania, and Nigeria. The authors then examined the association of these responses and community characteristics including economic, gender norms, HIV behavior and knowledge, and demographic factors. Men residing in communities characterized by high rates of women’s education and employment and later age at first birth were less likely to report risky transactional sex. In communities where men reported higher numbers of sexual partners, they were also more likely to report risky transactional sex. Based on the findings, the authors concluded that interventions to reduce HIV should take into account the social, cultural, and behavioral contexts that create unequal opportunities and risks for men and women. Such interventions could include initiating microcredit programs to shift gender power dynamics and reduce women's financial dependence on men, or conducting community-level dialogues on the roles of men and women to change behaviors and beliefs.

“Money Talks, Bullshit Walks” Interrogating Notions of Consumption and Survival Sex among Young Women Engaging in Transactional Sex in Post-Apartheid South Africa: A Qualitative Enquiry

Yanga, Z., Townsend, L., Thorson, A., and Ekström, A.M. Globalization and Health (2013), doi:10.1186/1744-8603-9-28.

The authors examined factors driving transactional sex among young women ages 16–24 in a peri-urban community in the Western Cape of South Africa. Focus groups and interviews with young women, men, and community members of various ages showed transactional sex enabled young women to meet their basic subsistence and consumption needs for items such as food and electricity. In this poor community, the practice also enabled them to attain highly desired symbols of modernity like fashionable clothing and alcohol; and acceptance by their peers. Transactional sex was associated with the domination of young women by their often older and wealthier sexual partners. However, these women could also use proceeds from transactional sex to take on provider roles in sexual relationships with younger men, suggesting new gender dynamics in the community. Many transactional sexual relationships were unprotected, which increased women's vulnerability to HIV. Respondent attitudes toward HIV were casual. The authors called for innovative strategies that offer young women safer ways to access the image and items they desire, help them avoid social exclusion from their peer groups, and foster a sense of urgency about protecting themselves from HIV.

Consuming Sex: The Association between Modern Goods, Lifestyles and Sexual Behaviour among Youth in Madagascar

Stoebenau, K., Nair, R.C., N., Rambeloson, V., et al. Globalization and Health (2013), 9(13), doi:10.1186/1744-8603-9-13.

The authors conducted focus groups and administered a survey to 2,255 youth ages 15–24 in four areas of Madagascar to investigate the association between young people's interests in the consumption of modern goods and their sexual behavior. Overall, 7.3 percent of women and 30.7 percent of men reported having had multiple partners in the last year, while 5.9 percent of women had ever engaged in transactional sex. Perceived importance of fashion and a modern lifestyle were the key drivers for having multiple partners among both men and women. A desire for fashion, going to nightclubs, and meeting foreigners was most strongly associated with having transactional sex. Men with the highest reported personal expenditures and women who came from non-poor households were more likely to report having had multiple partners. Given this finding, the authors suggested that women who report multiple partners may not be engaging in sexual activity out of economic need, but out of choice. The authors recommend examining sociocultural belief systems (including attitudes toward modern goods and lifestyles) when designing interventions to prevent HIV transmission. 

Is Younger Really Safer? A Qualitative Study of Perceived Risks and Benefits of Age-Disparate Relationships among Women in Cape Town, South Africa

Beauclair, R., and Delva, W. PLOS ONE (2013), 8(11), doi:10.1371/journal.pone.0081748.

The authors conducted in-depth interviews with 23 women in urban communities in Cape Town to explore perceived risks of age-disparate and similar-age relationships; the benefits of relationships with older men; and drivers of decisions about starting or ending a relationship. The majority of respondents indicated that women were motivated to participate in age-disparate relationships for financial or material gains, and a plurality did not view age-disparate relationships as posing risks. Psychosocial benefits like affection, kind treatment, and prestige were associated with having a relationship with an older man. Many respondents were less inclined to date same-age or younger men, viewing them as disrespectful and perpetrators of intimate partner violence (IPV). The authors recommended more research to determine whether younger or same-age male partners do, in fact, perpetrate more IPV. They also argued that initiatives should raise awareness about the risks of age-disparate relationships; employ holistic approaches to relationship health; address gender equity; and make relationships with same-age peers seem more attractive.

Porn Video Shows, Local Brew, and Transactional Sex: HIV Risk among Youth in Kisumu, Kenya

Njue, C., Voeten, H., and Remes, P. BMC Public Health (2011), 11(635), doi:10.1186/1471-2458-11-635.

The authors interviewed 150 adolescents ages 15–20, held four focus groups, and directly observed areas where youth congregate to explore factors that contribute to the high HIV-prevalence among youth in Kisumu, Kenya. A third of participants interviewed reported that porn videos shown at video halls influence youth sexuality. Many of the sexually active girls reported some degree of force or persuasion during their first sexual experience, and most reported a large age difference with first and current partners. Few adolescents reported condom use at first sex. Over half of sexually active adolescents reported having multiple sexual partners. Heavy alcohol intake and drugs reinforced and often accompanied these risky encounters. Some girls had transactional sex to obtain material benefits, not only for themselves but also for parents or guardians. Based on their findings, the authors concluded that the government should regulate and monitor local brew dens and porn video halls; and that prevention activities should target young men to change attitudes about power and control in relationships. Additionally, the authors recommended empowering girls to negotiate safe sex, and reducing poverty among girls through income-generating activities or programs to keep them in school longer.

Transactional Sex amongst Young People in Rural Northern Tanzania: An Ethnography of Young Women’s Motivations and Negotiation

Wamoyi, J., Wight, D., Plummer, M., et al. Reproductive Health (2010), 7(1), p. 2, doi: 10.1186/1742-4755-7-2. 

Conducted among youth ages 14–25 in nine rural villages in Tanzania, this ethnographic study examined young women’s motivations to exchange sex for gifts or money. Study participants generally were unmarried with only primary schooling. Transactional sex was common and not considered immoral; participants saw the exchange as both parties gaining what they wanted. Furthermore, participants alluded to family member complicity in certain transactional sex situations. Most relationships were formed on the basis of financial gain: romantic love or finding a marriage partner were rarely factors. Macro-level factors such as the distribution of economic power and the lower status of women overwhelmingly favored men in transactional sexual relationships. At a micro-level, however, there were different dimensions of power, some of which generally benefited men (e.g., physical strength), while others tended to benefit women (e.g., sexual attractiveness or their prestige as sexual partners). Individual economic circumstances affected both sexual partners' bargaining positions. The authors noted that because transactional sex is so strongly embedded in the culture, any attempts at harm reduction among this population must be carefully designed and piloted. At a minimum, they recommended that educational programs develop communication skills that include scripts relating to expectations and intentions of gift-giving.

“Women’s Bodies are Shops:” Beliefs about Transactional Sex and Implications for Understanding Gender Power and HIV Prevention in Tanzania

Wamoyi, J., Fenwick, A., Urassa, M., et al. Archives of Sexual Behavior (2010), 40(1), pp. 5-15, doi: 10.1007/s10508-010-9646-8. 

This ethnographic research study examined transactional sex in rural Tanzania within the context of family relationships. The authors observed and interviewed young people ages 14– 24 and their parents, and conducted follow-up interviews to explore the principal themes emerging from the first set of interviews. Generally, all informants—parents and youth alike—were in favor of transactional sex. They saw a woman’s body as a commodity. Participants explained that only women who did not value their self-worth would have sex without any exchange. Such women were looked down on by others, seen as stupid or easily cheated, worth nothing, and thus equated with prostitutes, the informants said. They added that the exchange of goods or money was symbolic, signifying seriousness or love. Women often felt that they were exploiting men, and thus transactional sex was a way for women to exert power. Though they knew about the risks to sexual and reproductive health, women generally did not use contraception. Because transactional sex appears to be a social norm, the authors suggested that risk-reduction programs focus on encouraging women to include safer sex in their negotiation for gifts and money.  

Beyond Sugar Daddies: Intergenerational Sex and AIDS in Urban Zimbabwe

Wyrod, R., Fritz, K., Woelk, G., et al. AIDS and Behavior (2010), 15(6), pp. 1275–1282, doi: 10.1007/s10461-010-9800-2.

This study examined the relationships and sexual behavior of 1,313 men in beer halls in Zimbabwe at the peak of the HIV epidemic (2002–2003). Nearly half of the interviewees reported having more than one sexual partner in the six months prior to the interview. Furthermore, nearly two-thirds reported at least one partner who was five or more years younger, many of whom were their wives. Only 2.5 percent of the relationships met the "sugar daddy" criteria. Unexpectedly, the study found that the younger the female partner was, the greater the likelihood of condom use. There was no association between a man’s positive HIV status and his engaging in intergenerational sex. The men reported the lowest levels of condom use with their wives and steady partners. Though participants in this study may not be representative of the broader population, these findings suggest that while age-disparate relationships are a concern for a sustained HIV epidemic, conventional intergenerational relationships—married and long-term couples—pose a greater risk of HIV infection than sugar daddy relationships. The authors concluded that publicizing the dangers of age-disparate relationships may be one way to address this issue, as would changes in social norms that would enable women, regardless of their age, to negotiate safer sex. 

Cultural Scripts for Multiple and Concurrent Partnerships in Southern Africa: Why HIV Prevention Needs Anthropology

Leclerc-Madlala, S. Sexual Health (2009), 6(2), pp. 103–110, doi:10.1071/SH08032.

This qualitative study explored the underlying cultural contexts in which individuals' in southern Africa sexuality is formed. The author held focus groups with 228 members of nongovernmental organizations on contextual factors in HIV transmission, especially the role of culture as related to concurrent sexual partnerships. Patterns in cultural scripts for the performance of sexuality were discernable. One such cultural script suggested that giving gifts commensurate with their wealth is one way men in the region demonstrate love, commitment, or affection to their sexual partners. Men were compelled to share their wealth with sexual partners as a way of showing respect, and expressed the belief that only morally “loose” women would ever give sex for free. The author concluded that protecting individuals and communities from HIV over the long term will require promoting cultural changes to discourage concurrent sexual partners. 

Transactional Sex with Casual and Main Partners among Young South African Men in the Rural Eastern Cape: Prevalence, Predictors, and Associations with Gender-Based Violence

Dunkle, K. L., Jewkes, R., Nduna, M., et al. Social Science & Medicine (2007), 65(6), pp. 1235–1248, doi:10.1016/j.socscimed.2007.04.029.

Secondary analysis of data collected for an HIV behavioral prevention study informed this research on men’s views of transactional sex from 70 villages in the rural Eastern Cape Province of South Africa. Researchers assessed transactional sex practices with primary girlfriends and casual partners, including whether men received resources from female partners. Nearly 20 percent of the men interviewed gave material resources to casual partners, but only 7 percent received them from casual partners. Among main girlfriends, giving and getting resources were nearly equal (15 percent versus 14 percent, respectively). Interestingly, men who gave and received resources were equally likely to report controlling and violent behaviors, including perpetrating interpersonal violence. Furthermore, transactional sex was correlated to sexually assaulting women. The authors concluded that transactional sex should be seen as a part of a cluster of sexually violent and controlling practices. Their findings suggested that rather than seeking to reduce individual risk-taking, interventions must focus on changing the idea that masculinity means sexual success with and control over women. 

Skinning the Goat and Pulling the Load: Transactional Sex among Youth in Dar es Salaam, Tanzania

Maganja, R. K., Maman, S., Groves, A., et al. AIDS Care (2007), 19(8), pp. 974–981, doi:10.1080/09540120701294286.

The authors of this study conducted in-depth interviews and focus group discussions among men and women ages 16–24 years in Dar es Salaam to identify their HIV risk factors. The researchers found transactional sex emerging as a major theme in every discussion. Interviewees identified two types of partners: 1) regular, “true love” partners; and 2) casual partners. The connection between sex and money was explicit in casual relationships. While such an exchange was also expected in the committed relationships, it was not the primary motivation. Men generally engaged in partnerships for sex, while women entered them for social status, the eventuality of marriage, and money. Some women reported engaging in transactional sex as a survival strategy. Men also reported forcing women to have sex after paying for drinks or entrance to a disco, and feeling justified in doing so. Women in committed partnerships, however, could express their sexual desires, refuse sex, and negotiate condom use with their partners. The authors concluded that information about transactional sex has implications for HIV-prevention programming and should be a part of comprehensive HIV prevention for young people. 

Sex, Money, and Premarital Partnerships in Southern Malawi

Poulin, M.J. Social Science & Medicine (2007), 65(11), pp. 2383–2393, doi:10.1016/j.socscimed.2007.05.030.

The author used direct observation and in-depth interviews with 54 young women and men ages 15–24 years in the Balaka district of Malawi to explore sex, money, and premarital relationships. The findings showed that the exchange of money and gifts for sex was a part of traditional courting traditions. In these rural areas, premarital partnerships were the norm, as was providing the female partner with money and/or gifts to show love and affection. Often, these relationships led to marriage. For men, it was a point of masculinity to be able to provide a partner with money for luxury items. Among couples who were together without claiming “true love,” there were elements of transactional sex in the relationship. Contrary to prevailing beliefs about women being disempowered, the interviews found that the woman decided whether to enter into these relationships and when to end them. Yong women often informally asked about potential partners’ sexual behavior as a strategy to minimize HIV risk, but condom use was generally not very high within these partnerships.   

Ties of Dependence: AIDS and Transactional Sex in Rural Malawi

Swidler, A., and Watkins, S.C. Studies in Family Planning (2007), 38(3), pp. 147–162.

The authors reviewed unstructured conversations about HIV, AIDS, and sexual behavior held between journalists and young people ages 20–30 from rural Malawi. The study concluded that patron-client ties and a perceived moral obligation to support the needy, which are fundamental to African social life, were central elements of transactional sex. The authors found that men’s relative wealth compelled them to take sexual partners, and that for women, transactional sex was a pathway to social mobility and economic independence. The authors argued that the exchange of sex for money is better understood as one of the many ties of unequal exchange between patron and client that are a normal part of many African societies. 

Putting it Into Practice

A Review of Interventions Addressing Structural Drivers of Adolescents’ Sexual and Reproductive Health Vulnerability in Sub-Saharan Africa: Implications for Sexual Health Programming

Wamoyi, J., Mshana, G., Mongi, A., et al. Reproductive Health (2014), 11(88), doi:10.1186/1742-4755-11-88.

The authors reviewed 15 interventions addressing structural drivers of sexual and reproductive health risks among adolescents in sub-Saharan Africa. Most of the interventions had more than one focus, such as changing gender norms, improving school attendance, improving economic situation of participants, creating safe spaces, changing sexual behavior, and improving parenting. Few interventions had HIV reduction as the main outcome; instead they were designed to have positive effects on condom use, number of sexual partners, gender violence, and transactional sex. The outcomes of the projects varied widely, with most showing improvements in the targeted areas, though one microcredit project actually increased young women’s risk for HIV because as the women struggled to repay their loans, they adopted riskier sexual behaviors. Few of the interventions were rigorously evaluated, raising questions as to whether any were actually effective in reducing adolescent sexual risk. The authors recommended that future interventions have a clear focus, indicate the pathways of risk they are trying to address, and implement a rigorous evaluation strategy.

The SHAZ! Project: Results from a Pilot Randomized Trial of a Structural Intervention to Prevent HIV among Adolescent Women in Zimbabwe

Dunbar, M.S., Kang Dufour, M.S., Lambdin, B., et al. PLOS ONE (2014), 21(9), doi:10.1371/journal.pone.0113621.

Shaping the Health of Adolescents in Zimbabwe (SHAZ!) was a randomized controlled trial held from 2006 to 2008 that compared the effects of a combined intervention package (life-skills and health education, vocational training, micro-grants, and social support) to life-skills and health education alone. SHAZ! randomly assigned 158 participants to the intervention and 157 to the control group. The intervention group showed statistically significant improvements compared to the control group, including reduced food insecurity, having income, a lower risk of transactional sex, and a greater likelihood of condoms with their current partner over time. There was some evidence that unintended pregnancies were less frequent in the intervention group. However, HIV incidence was the same in both groups, and herpes-2 incidence was slightly higher in the intervention group. Coordination with vocational training programs, the political and economic instability of the area at the time of the study, and the difficulty in creating a true standard of care control arm were major challenges to the trial. The authors recommended that in the future, the model incorporate a wider range of local-language livelihoods options and include flexible hours to better meet the varying needs of young women. They also recommended testing the model in a more economically and politically stable country. 

'Something for Something’: The Importance of Talking about Transactional Sex with Youth in South Africa Using a Resilience-Based Approach

Van der Heijden, I., and Swartz, S. African Journal of AIDS Research (2014), 13(1), pp. 53-63, doi:10.2989/16085906.2014.886602.

This paper presented findings of an evaluation of one session of a peer education program aimed at 14–16-year-olds in two South African provinces. The session, entitled "Something for Something," discouraged transactional sex. While participants responded strongly to the session and understood the risks associated with transactional sex, their responses were similar to those of control participants who had not taken part in the session. Examination of the session's content showed that it focused on the negative aspects of transactional sex, describing it as exploitative and coercive, socially immoral, and a response to the local need for economic survival. This narrow focus failed to recognize the varying drivers and the perceived benefits of transactional sex among youth. This concentration on negative outcomes, the authors said, limited the session's potential to teach youth to respond and protect themselves in risky circumstances. They recommended curricula that present both alternatives to engaging in transactional sex and strategies for staying safe while engaging in transactional sex.

Effects of the Fataki Campaign: Addressing Cross-Generational Sex in Tanzania by Mobilizing Communities to Intervene

Kaufman, M.R, Mooney, A., Kamala, B., et al. AIDS and Behavior (2013), 17(6), pp. 2053–62, doi:10.1007/s10461-013-0428-x.

The authors conducted a cross-sectional household survey to evaluate the national multimedia Fataki campaign. This campaign, aired in Tanzania from 2008 to 2011, was designed to mobilize communities to prevent cross-generational sexual (CGS) relationships. The campaign introduced the label Fataki, Swahili for “explosive,” for older men who engage in sexual relationships with much younger women, often offering money or gifts in exchange. The campaign encouraged communities to take responsibility for keeping CGS from occurring. The authors found that communities that were exposed to the campaign were more likely to engage in interpersonal communication about CGS and intervene in CGS relationships. Women who had high exposure to the campaign were less likely to engage in a CGS relationship. However, no association was found between campaign exposure and current CGS involvement among men. 

Adapting a Multi-Faceted U.S. HIV Prevention Education Program for Girls in Ghana

Fiscian, V. S., Obeng, E. K., Goldstein, K., et al. AIDS Education & Prevention (2009), 21(1), pp. 67–79, doi:10.1521/aeap.2009.21.1.67.

This paper reported on a short-term evaluation of an HIV educational program designed to address sociocultural risk factors among adolescent girls ages 10–17 years in sub-Saharan Africa. The program, adapted from a US-based program called “Making Proud Choices,” combined skills training to encourage participants to consider alternatives to transactional sex for financial support, and an interactive computer-based program about the risks of age-disparate sexual relationships. The post-intervention test showed significant improvements in HIV-related knowledge and self-efficacy for addressing HIV and sex in relationships with boys and men. Nevertheless, many still reported that a sugar daddy could give a girl what she needed. The authors noted, “It is not surprising that this attitude persisted because the financial and social drivers of these relationships have not been changed.” 

Impact of Stepping Stones on Incidence of HIV and HSV-2 and Sexual Behaviour in Rural South Africa: Cluster Randomized Controlled Trial

Jewkes, R., Nduna, M., Levin, J., et al. BMJ (2008), 337, doi: 10.1136/bmj.a506.

Stepping Stones is a 50-hour program that uses participatory learning to improve sexual health, and seeks to stimulate critical reflection through improvements in knowledge, risk awareness, and communication skills. To assess the impact of Stepping Stones on sexual behavior and the incidence of HIV and herpes simplex type 2 (HSV-2), the authors conducted a cluster randomized controlled trial among 1,360 men and 1,416 women ages 15–26 years, most of whom attended schools in 70 villages in South African's Eastern Cape province. Participants were randomized to receive either the curriculum or a three-hour intervention on HIV and safer sex. Participants answered questionnaires and accepted blood tests for HIV and HSV-2 at baseline and 12 and 24 months. The authors found no evidence that Stepping Stones reduced HIV. However, they found a 33 percent reduction in HSV-2 among Stepping Stones participants, along with significant improvements in men's reported risk behaviors, including intimate partner violence (IPV), transactional sex, and problem drinking. In women, desired behavior changes were not reported and those in the Stepping Stones program reported more transactional sex at 12 months than in the control. The authors concluded that Stepping Stones did not reduce HIV incidence, but had positive impacts on related risks factors, including incidence of HSV-2 and IPV.

Researching and Designing Interventions in a Slum: Using Female Out-of-School Youth as Researchers in Nigeria

Ocholi, J., Ankomah, A., Akinyemi, Z., et al. AIDS 2008—XVII International AIDS Conference, Abstract No. MoPE08_3.

Out-of-school young women are a difficult-to-reach target population in HIV prevention interventions. This program engaged 36 out-of-school female youth as researchers. Their research resulted in the design and implementation of an HIV project that included community-wide events, such as theater performances and house visits, for parents. The findings showed that young women shared more information with the peer researchers than they would with outsiders. Some young women reported that their parents encouraged them to engage in intergenerational sex. The study also found that female-focused activities would have more impact on this group than joint male/female youth programs. 

HIV Prevention for Young People through the Education Sector in Zambia

Woods, J., Silwimba, J., Mumba, E., et al. AIDS 2008—XVII International AIDS Conference, Abstract No. WEPE0_1.

HIV incidence among youth in Zambia does not seem to be decreasing, and young women are more likely to be infected than boys. Higher-risk behaviors such as intergenerational sex, transactional sex, and concurrent sexual partnerships are normalized. The Zambian Ministry of Education attempted to address these behaviors through an in-school intervention called CHANGES2 (2005–2009), a program supported by the U.S. Agency for International Development that targeted primary school students and addressed barriers to safer sexual behaviors at both the individual and community levels. School-community partnerships were formed to identify and analyze local risk factors. This approach pinpointed specific risk factors, including student-teacher sexual relationships, gender roles that support men in having multiple partners, and lack of economic opportunities for girls. The data showed that including these partnerships within the program had a significant positive effect on attitudes favoring greater equality in gender relations, along with a decreased tolerance for gender-based violence. 

Engaging Men and Boys in Changing Gender-Based Inequity in Health: Evidence from Programme Interventions

Barker, G., Ricardo, C., and Nascimento, M. World Health Organization (2007). 

Research with men and boys shows how inequitable gender norms influence how men interact with their partners, families, and children on a wide range of issues, including preventing HIV and sexually transmitted infections, contraceptive use, and physical violence against women and between men. This review assessed the effectiveness of programs engaging men and boys in achieving gender equality and equity in health, and highlighted the characteristics of successful programs. The authors found that well-designed programs did lead to changes in attitudes and behavior. Programs considered “gender-transformative” (as compared to gender-neutral or gender-sensitive tended to result in a higher rate of change. Furthermore, integrated programs were more effective in producing behavior change. Behavior change occurred in all program areas and in all types of programs, but relatively few programs involving men took place over the long term.

Addressing Cross-Generational Sex: A Desk Review of Research and Programs

Hope, R. Population Reference Bureau (2007).  

This review employed the “continuum of volition” framework used by Save the Children to explore the causes of intergenerational and transactional sex. The framework assumes that not all young people are vulnerable and/or passive in entering cross-generational sexual relationships. Some empowered youth choose to engage in relationships for “security gains” (emotional or economic). Further along the continuum, “economically rational sex” ranges from sex for “desired material benefits” to sex for survival. At the other end of the continuum are coerced sex and sexual violence, in which young women and boys are forced to participate. This end represents power asymmetries and lack of regard for women’s and girls’ health and wellbeing. The review looked at programmatic approaches to reduce intergenerational and transactional sex such as: 1) creating youth livelihood opportunities; 2) mobilizing and empowering youth to adopt healthy lifestyles; 3) social advocacy; 4) social marketing and “edutainment”; 5) health education and youth rights; 6) addressing power asymmetries, inequity, and poverty; and 7) addressing social and gender norms, including working with men. Despite a gap in concrete evidence on how to reduce intergenerational and transactional sexual relationships, the review includes 10 recommendations that programs can incorporate into their activities and strategies to reduce intergenerational and transactional sex. 

Cross-Generational Relationships: Using a “Continuum of Volition” in HIV Prevention Work among Young People

Weissman, A., Cocker, J., Sherburne, L., et al. Gender & Development (2006), 14(1), pp. 81–94, doi:10.1080/13552070500518293.

The authors of this review considered the causes of intergenerational and transactional sexual relationships, which occur along a “continuum of volition.” This continuum suggests that not all young people who are involved in sexual relationships with older or more powerful individuals are vulnerable or passive. Rather, there are empowered youth who choose to engage in sexual relationships with older people for emotional reasons; young people who engage in “economically rational sex” for things such as clothes or passing grades; and youth involuntarily coerced into sex. This paper reviewed the use of a program planning tool to locate individual adolescent girls along the continuum and develop appropriate strategies to resist unwelcome propositions from men in Malawi. The authors advocated for more reflection on why intergenerational sex and transactional sex are defined as problematic and what aspects are of concern, given that intergenerational sexual relationships occur all over the world. When defining intergenerational and transactional sexual relationships as problematic, they cautioned, it is important to understand young women's choices, or lack thereof, and address concerns about inequality within the socioeconomic context in which they occur.

Tools and Curricula

SHAZ! (Shaping the Health of Adolescents in Zimbabwe)

Panagea (n.d.).

This webpage offers the curriculum for SHAZ! (Shaping the Health of Adolescents in Zimbabwe), an HIV-prevention intervention that empowers HIV-positive adolescent girls ages 16–19 through a combination of HIV treatment, social support, and life-skills and vocational training. The SHAZ! approach is presently being scaled up.

The site provides two versions of a "Facilitator's Guide for Discussion Groups”; one each for HIV-negative and -positive participants. The tools provide facilitators with strategies to guide discussions focused on helping women and girls to take action on behalf of their own health and wellbeing.

The Young Empowered and Healthy (YEAH) Initiative

Communication for Development Foundation Uganda and Health Communication Partnership (2014).

This website contains all the communication materials used for the YEAH (Young Empowered and Healthy) Initiative, a program developed to prevent HIV and unplanned pregnancies while keeping young people in school in Uganda. Materials include audio episodes from a radio serial drama; videos on life choices; pamphlets; posters; and games. 

Men as Partners®

EngenderHealth (2005–2015).

This webpage provides an entry into the work of the Men as Partners project, established in 1996. The program has worked in more than 15 countries worldwide to give men roles that promote gender equity and health. Activities include workshops, improving male health care service delivery, public education, and advocacy networks. Links to video and slideshows, technical resources, and country project websites can be accessed from this main page. 

Identifying Appropriate Livelihood Options for Adolescent Girls: A Program Design Tool

Futures Group (November 2009).

There are limited data on the effectiveness of economic strengthening interventions among adolescent girls and the impact—if any—on HIV prevention. The Futures Group developed a series of tools, including this livelihoods tool, to close this gap. The tool is designed to help program managers conduct more in-depth design, monitoring, and evaluation of activities to reduce adolescent girls’ economic vulnerability. The user is guided through a series of diagnostic steps to identify how such girls are at risk of HIV resulting from their lack of control over their immediate environment. Once the program manager identifies constraints and opportunities for these youth, s/he learns about livelihood interventions that are most appropriate in those situations. 

Livelihood Options for Girls: A Guide for Program Managers

Futures Group (November 2009).

This tool, the second in a series, encapsulates essential information on identifying appropriate livelihood programs for adolescent girls who are at increased risk of HIV. The tool is designed for program managers. Briefs present information on gender-based constraints, opportunities, livelihood options, and program information for different demographic groups. The economic support needs of a married, out-of-school, working rural girl, for example, are different from those of an unmarried, urban schoolgirl. Programming matrices in the appendix elaborate on each livelihood approach and include elements of success, cautions, participant profiles, program description, and evaluation results of existing programs. 

Stepping Stones: Training Packages on Gender Communication and HIV

The Stepping Stones Community of Practice (2011–2015).

Stepping Stones is an HIV-prevention training program designed to improve sexual health through building stronger, more gender-equitable relationships and better communication between partners. Begun in Uganda, the program has been implemented in more than 100 countries. It uses participatory learning techniques to develop communication skills between partners, self-awareness and knowledge about sexual health, and the consequences of risk-taking. This page offers testimonials and Stepping Stones resources, including a manual that can be used to train and educate men and women for up to 18 weeks. During the training period, participants critically assess the societal norms and values influencing their attitudes and behaviors and identify changes they should make to protect themselves and others from HIV. This training helps bring about more general life changes and improvements, such as improved communication with partners and children, more understanding and caring for others, and increased self-respect. 

Additional Resources

Protecting and Empowering Adolescent Girls: Evidence for the Global Health Initiative

Interagency Youth Working Group (2010). 

This webpage includes the proceedings, presentations, and background reading for a meeting held by the Interagency Youth Working Group on June 3, 2010 on the protection of adolescent girls from HIV and reproductive health risks. The page features a list of key resources, including curricula, multimedia products, and advocacy materials, case studies, and reports. 

Technical Meeting on Young Women in HIV Hyper-Endemic Countries of Southern Africa: Intergenerational/Age-Disparate Sex: Policy and Programme Action Brief

Leclerc-Madlala, S. Joint United Nations Programme on HIV/AIDS (2008). 

This action brief summarizes the issue of age-disparate sexual relationships in the high-HIV-prevalence countries of Southern Africa and the effect such relationships have on hastening HIV transmission. A group of technical experts reviewed the information on this phenomenon and developed seven action and policy recommendations to reduce the risk of HIV transmission among this high-risk group. Recommendations include rapidly increasing the number of programs that work directly with men to challenge the norms that sanction age-disparate sex; involving faith-based and traditional leaders and media more fully; and ensuring that laws against underage sexual exploitation are in place and enforced. 

Addressing the Vulnerability of Young Women and Girls to Stop the HIV Epidemic in Southern Africa

United Nations Joint Programme on HIV/AIDS (2008).  

The brief situation analysis in this report identifies multiple reasons for the lack of success in reducing high levels of HIV infection in southern Africa. Participants at an expert meeting in 2008 attempted to understand the challenges to preventing HIV in this context as well as identify ways to respond to them. Meeting attendees represented high-level policy experts as well as researchers and programming experts on women, girls, and HIV from all southern African countries. The report contains four key actions for responding to the high levels of HIV infection among young women and girls in the area. Issues briefs in the report include information on priority interventions to reduce women’s biomedical vulnerability to HIV and gender-based violence. 

Cross-Generational Sex: Risks and Opportunities

Feldman-Jacobs, C., and Worley, H. U.S. Agency for International Development, Interagency Gender Working Group, Interagency Youth Working Group, and PRB (2008). 

This brief summarizes the key information from a desk review on cross-generational sex, including prevalence of the phenomenon according to survey data, the consequences to sexual and reproductive health, and conceptual frameworks for understanding the issue. It describes existing programs and approaches, promising practices, and lessons for the future; and identifies key research gaps, particularly in evaluating the effect of programs on sexual behavior.