HIV prevalence in our sample was 21%. Most women (71%) reported inconsistent condom use, and 12.8% reported having had more than one sexual partner in the past 12 months. Almost 27% reported low relationship control, and nearly 4% reported that they had been physically forced to have sex by their most recent partner (just under 10% reported ever having been physically forced to have sex). Approximately 50% of women reported ever having been pregnant, and 19.2% reported having had an unusual vaginal discharge in the past 12 months. Almost 19% of women reported knowing their HIV status. Other information on sociodemographic factors and HIV risk behavior of the sample is presented in Table 1.

Lack of power in sexual relationships has been hypothesized to increase women’s risk of HIV infection (3,4,19,28,29), but little research has shed rigorous light on this question. In this nationally representative survey, women reporting limited sexual power were not more likely to be infected with HIV. Sexual power was, however, associated with inconsistent condom use, which, in turn, was significantly associated with HIV infection.

We hypothesized that limited sexual power would increase a woman’s risk of HIV infection, primarily by compromising her ability to use condoms. Women with low relationship control were significantly more likely to report inconsistent condom use (OR 2.10, 95% CI 1.17–3.78), which is consistent with other studies (25,30). This finding suggests that efforts to promote consistent condom use, a key element of HIV prevention, would benefit from efforts to enhance women’s sexual power. Such efforts should not target women alone; rather, they should target and involve men as partners, essential stakeholders in improving women’s sexual decision-making power.

Women reporting forced sex with their most recent sexual partner were also significantly less likely to report consistent condom use (OR 5.77, 95% CI 1.86–17.91). While only 4% of our sample reported that their most recent partner had physically forced them to have sex, approximately 10% of all women reported having experienced forced sex. Since many women may be reluctant to disclose this information in a household survey, this figure is likely to be an underestimate (31). In the context of masculine norms defined by male control over sexual decision-making and prevalent forced and coercive sex, many women do not have the right of refusal (6,8,10,32). In addition, our measure of physically forced sex captures only a narrow element of coercive or nonconsensual sex, which actually occurs on a continuum ranging from persuasion and trickery to force and rape (6,31).

As hypothesized, inconsistent condom users were significantly more likely to be HIV-positive (OR 1.58, 95% CI 1.10–2.26). Although this finding supports previous research on the effectiveness of consistent condom use to prevent HIV infection (33), our cross-sectional design renders it impossible to assess whether or not HIV was acquired when condom use consistency was assessed. Also possible is that the relationship operates in the opposite direction, i.e., that HIV seropositivity influences condom use consistency among persons aware of their status. Given, however, that consistent condom use is protective against HIV, the fact that fewer than one-third of women reported consistent condom use indicates that most are at risk for future infection.

We did not find a direct association between our measures of sexual power and HIV infection, which suggests that the primary mechanism through which sexual power exerts effects on HIV risk is condom use consistency. Nevertheless, this preliminary analysis considered a limited subset of sexual power measures. As such, we cannot be certain that we captured the scope and dimensions of sexual power that have a bearing on HIV risk in ways other than through consistent condom use. Recent research conducted among antenatal clinic attendees who accepted routine HIV testing in Soweto adapted and validated the SRPS, which included 12 items, for use in that context,. Measured in this way, sexual relationship power was found to be associated with prevalent HIV infection (OR 1.53, 95% CI 1.10–2.04) (34); however, the authors did not control for condom use in their analysis, which may account for their findings. Associations between power and sexual behavior are likely to depend on sample characteristics, the conceptualization and measurement of power and risk behaviors, or a combination of these factors (35). Our nationally representative sample included young women from multiple regions, races, and cultures, among which key elements of sexual power dynamics are likely to differ.

Woman’s sexual negotiating power is likely to be compromised in transactional sexual relationships, in relationships with older partners, and following early coital debut (28), and these factors would be expected to influence both condom use consistency and HIV risk. In this survey, the self-reported prevalence of all three of these behaviors was low: only 1.3% of women reported that they had transactional sex with their most recent partner; 5.5% reported that their most recent partner was >10 years older; and 7.8% reported having had sex at age 14 or younger. Transactional sex and early coital debut are particularly likely to be subject to underreporting due to social desirability bias. Further, young women whose first sexual encounter is nonconsensual, which is fairly common in this context (8), may not define it as “coital debut.” All three of these variables were associated with increased risk of HIV infection, although the associations were not significant. Transactional sex was not associated with condom use consistency in this study. Women who reported older partners and early first sexual experience were more likely to report inconsistent condom use, though this difference was not statistically significant.

The strongest risk factor for not always using condoms with the most recent sexual partner was not having talked to that partner about condom use (OR 12.91, 95% CI 5.85–28.51). Communication between partners about contraceptive use, including condoms, has been shown to be associated with consistent use in other studies (29). In the context of our cross-sectional study, confirming the direction of the relationship is not possible: although couples who discuss condoms may be more likely to use them, those who consistently use condoms may also be more likely to discuss them. Sexual power may have an effect on partner communication and should be explored further in future research.

Figure

Figure. Example of message from loveLife’s HIV prevention program in South Africa.

Given the associations between sexual power and condom use consistency, more research is warranted to assess the determinants of sexual negotiating power and to test the effectiveness of gender-sensitive HIV prevention interventions. A large national HIV prevention campaign for youth in South Africa, loveLife, has incorporated gender power issues into its media campaign by addressing issues of transactional sex, older partners, and women’s lack of decision-making power in relationships (www.lovelife.org.za) (Figure). The Stepping Stones package, which is used by Planned Parenthood South Africa, also aims to challenge gender norms (32) and was recently found to increase women’s sexual power in a pilot evaluation (36).

A small but growing body of research suggests that economic empowerment strategies may improve women’s sexual power, with potential health benefits. In Gabarone, Botswana, economic independence was more strongly related to women’s negotiating power in relationships than any other variable explored (19), and in Zimbabwe, adolescents who had their own income were significantly more likely to be consistent condom users (Megan Dunbar, pers. comm.). In the Limpopo province of South Africa, the Intervention with Micro-finance for AIDS and Gender Equity (IMAGE) program is being evaluated to determine its effect on gender-based violence, sexual behavior, and HIV incidence (37). The intervention combines a micro-finance program with a participatory learning and action curriculum. In collaboration with local partners, the University of California–San Francisco Department of Obstetrics, Gynecology, and Reproductive Sciences is currently engaged in a multisite program of research to further elucidate the linkages among economic power, sexual negotiating power, and sexually transmitted infection (STI) outcomes and to develop and test related interventions.

Debate centers around the relative effectiveness of each of the “ABCs” of HIV prevention: abstinence, being faithful to one partner, and condom use (38). However, all three elements likely play a role. Indeed, a decontextualized focus on these elements is likely to fail. HIV prevention strategies must take full account of the barriers persons, particularly women, face in bringing about behavior changes over which they may have little control. Many of these barriers are rooted fundamentally in gender inequalities.

For a number of years, HIV activists and researchers have highlighted the role gender inequality may play in placing women at increased risk for HIV infection. At the recent International AIDS Conference in Bangkok, United Nations Secretary-General Kofi Annan made the empowerment of women and girls a priority focus area for HIV prevention: “No less pressing, empowering women and girls to protect themselves against the virus.… What is needed is positive change that will give more power and confidence to women and girls. Change that will transform relations between women and men at all levels of society.” While empiric evidence documenting the relationship between women’s sexual power and their HIV risk has been in short supply, a small but growing body of research confirms that women’s lack of power in relationships compromises their sexual health. While this exploratory study did not find an association between sexual power and HIV serostatus, it did confirm an association between two measures of sexual power, relationship control and forced sex, and condom use consistency. Further work is needed to refine and apply measures of sexual power and to assess the complex relationship between sexual power and HIV susceptibility in the South African context. Additional research should also aim to elucidate the underpinnings of sexual power, with a particular focus on identifying avenues for intervention.