Abstract
Understanding how sexual behaviors cluster in distinct population subgroups along the life course is critical for effective targeting and tailoring of HIV prevention messaging and intervention activities. We examined interrelatedness of sexual behaviors and variation between men and women across a wide age range in a rural South African setting with a high HIV burden. Data come from the Ha Nakekela population-based survey of people aged 15–85-plus drawn from the Agincourt Health and Socio-Demographic Surveillance System. We used latent class analysis of six sexual behavior indicators to identify distinct subgroup sexual behavior clusters. We then examined associations between class membership and sociodemographic and other behavioral risk factors and assessed the accuracy of a reduced set of sexual behavior indicators to classify individuals into latent classes. We identified three sexual behavior classes: (1) single with consistent protective behaviors; (2) risky behaviors; and (3) in union with lack of protective behaviors. Patterns of sexual behaviors varied by gender. Class membership was also associated with age, HIV status, nationality, and alcohol use. With only two sexual behavior indicators (union status and multiple sexual partners), individuals were accurately assigned to their most likely predicted class. There were distinct multidimensional sexual behavior clusters in population subgroups that varied by sex, age, and HIV status. In this population, only two brief questions were needed to classify individuals into risk classes. Replication in other situations is needed to confirm these findings.
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Akers, A. Y., Cohen, E. D., Marshal, M. P., Roebuck, G., Yu, L., & Hipwell, A. E. (2016). Objective and perceived weight: Associations with risky adolescent sexual behavior. Perspectives on Sexual and Reproductive Health,48(3), 129–137. https://doi.org/10.1363/48e11416.
Akobeng, A. K. (2006). Understanding diagnostic tests 1: Sensitivity, specificity and predictive values. Acta Paediatrica,96, 338–341.
Angotti, N., Houle, B., Schatz, E., & Mojola, S. A. (2018). Classifying and contextualizing sexual behavior practices across the life course: Implications in later life. Paper presented at the Population Association of America, Denver, CO.
Bajos, N., & Marquet, J. (2000). Research on HIV sexual risk: Social relations-based approach in a cross-cultural perspective. Social Science and Medicine,50(11), 1533–1546.
Berhan, A., & Berhan, Y. (2012). Is the sexual behaviour of HIV patients on antiretroviral therapy safe or risky in Sub-Saharan Africa? Meta-analysis and meta-regression. AIDS Research and Therapy,9(1), 14. https://doi.org/10.1186/1742-6405-9-14.
Carrasco, M., Esser, M., Sparks, A., & Kaufman, M. (2016). HIV-alcohol risk reduction interventions in Sub-Saharan Africa: A systematic review of the literature and recommendations for a way forward. AIDS and Behavior,20(3), 484–503. https://doi.org/10.1007/s10461-015-1233-5.
Carrasco, M. A., Nguyen, T. Q., & Kaufman, M. R. (2018). Low uptake of voluntary medical male circumcision among high risk men in Malawi. AIDS and Behavior,22(2), 447–453. https://doi.org/10.1007/s10461-016-1633-1.
Cederbaum, J. A., Gilreath, T. D., & Barman-Adhikari, A. (2014). Perceived risk and condom use among adolescents in Sub-Saharan Africa: A latent class analysis. African Journal of Reproductive Health,18(4), 26–33.
Clark, S. J., Collinson, M. A., Kahn, K., Drullinger, K., & Tollman, S. M. (2007). Returning home to die: Circular labour migration and mortality in South Africa. Scandinavian Journal of Public Health,69, 35–44. https://doi.org/10.1080/14034950701355619.
Cochran, S. D., de Leeuw, J., & Mays, V. M. (1995). Optimal scaling of HIV-related sexual risk behaviors in ethnically diverse homosexually active men. Journal of Consulting and Clinical Psychology,63(2), 270–279.
Cockerham, W. C. (2005). Health lifestyle theory and the convergence of agency and structure. Journal of Health and Social Behavior,46(1), 51–67.
Danielson, C. K., Walsh, K., McCauley, J., Ruggiero, K. J., Brown, J. L., Sales, J. M., & Diclemente, R. J. (2014). HIV-related sexual risk behavior among African American adolescent girls. Journal of Womens Health,23(5), 413–419. https://doi.org/10.1089/jwh.2013.4599.
Dariotis, J. K., Sonenstein, F. L., Gates, G. J., Capps, R., Astone, N. M., Pleck, J. H., & Zeger, S. (2008). Changes in sexual risk behavior as young men transition to adulthood. Perspectives on Sexual and Reproductive Health,40(4), 218–225. https://doi.org/10.1363/4021808.
Davies, S. L., Cheong, J., Lewis, T. H., Simpson, C. A., Chandler, S. D., & Tucker, J. A. (2014). Sexual risk typologies and their relationship with early parenthood and STI outcomes among urban African-American emerging adults: A cross-sectional latent profile analysis. Sexually Transmitted Infections,90(6), 475–477. https://doi.org/10.1136/sextrans-2013-051334.
Doyle, J. S., Degenhardt, L., Pedrana, A. E., McBryde, E. S., Guy, R. J., Stoové, M. A., … Hellard, M. E. (2014). Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behavior: A systematic review and meta-analysis. Clinical Infectious Diseases,59(10), 1483–1494. https://doi.org/10.1093/cid/ciu602.
Dworkin, S., Treves-Kagan, S., & Lippman, S. (2013). Gender-transformative interventions to reduce HIV risks and violence with heterosexually-active men: A review of the global evidence. AIDS and Behavior,17(9), 2845–2863. https://doi.org/10.1007/s10461-013-0565-2.
Elwy, A. R., Hart, G. J., Hawkes, S., & Petticrew, M. (2002). Effectiveness of interventions to prevent sexually transmitted infections and human immunodeficiency virus in heterosexual men: A systematic review. Archives of Internal Medicine,162(16), 1818–1830.
George, L. K. (1993). Sociological perspectives on life transitions. Annual Review of Sociology,19(1), 353–373.
Gilbert, L., & Walker, L. (2002). Treading the path of least resistance: HIV/AIDS and social inequalities—A South African case study. Social Science and Medicine,54(7), 1093–1110.
Gómez-Olivé, F. X., Angotti, N., Houle, B., Klipstein-Grobusch, K., Kabudula, C., Menken, J., & Clark, S. J. (2013). Prevalence of HIV among those 15 and older in rural South Africa. AIDS Care,25(9), 1122–1128.
Gorbach, P. M., Drumright, L. N., & Holmes, K. K. (2005). Discord, discordance, and concurrency: comparing individual and partnership-level analyses of new partnerships of young adults at risk of sexually transmitted infections. Sexually Transmitted Diseases,32(1), 7–12. https://doi.org/10.1097/01.olq.0000148302.81575.fc.
Hallfors, D. D., Iritani, B. J., Miller, W. C., & Bauer, D. J. (2007). Sexual and drug behavior patterns and HIV and STD racial disparities: The need for new directions. American Journal of Public Health,97(1), 125–132. https://doi.org/10.2105/ajph.2005.075747.
Halpern, C. T., Hallfors, D., Bauer, D. J., Iritani, B., Waller, M. W., & Cho, H. (2004). Implications of racial and gender differences in patterns of adolescent risk behavior for HIV and other sexually transmitted diseases. Perspectives on Sexual and Reproductive Health,36(6), 239–247. https://doi.org/10.1363/psrh.36.239.04.
Haydon, A. A., Herring, A. H., & Halpern, C. T. (2012). Associations between patterns of emerging sexual behavior and young adult reproductive health. Perspectives on Sexual and Reproductive Health,44(4), 218–227. https://doi.org/10.1363/4421812.
Houle, B., Angotti, N., Clark, S. J., Williams, J., Gómez-Olivé, F. X., Menken, J., … Tollman, S. M. (2016). Let’s talk about sex, maybe: Interviewers, respondents, and sexual behavior reporting in rural South Africa. Field Methods,28(2), 112–132.
Houle, B., Clark, S. J., Gómez-Olivé, F. X., Kahn, K., & Tollman, S. M. (2014). The unfolding counter-transition in rural South Africa: Mortality and cause of death, 1994–2009. PLoS ONE,9(6), e100420. https://doi.org/10.1371/journal.pone.0112563.
Houle, B., Mojola, S. A., Angotti, N., Schatz, E., Gomez-Olive, F. X., Clark, S. J., … Menken, J. (2018). Sexual behavior and HIV risk across the life course in rural South Africa: Trends and comparisons. AIDS Care,30, 1435–1443. https://doi.org/10.1080/09540121.2018.1468008.
Hunter, M. (2007). The changing political economy of sex in South Africa: The significance of unemployment and inequalities to the scale of the AIDS pandemic. Social Science and Medicine,64(3), 689–700. https://doi.org/10.1016/j.socscimed.2006.09.015.
Joint United Nations Programme on HIV/AIDS (UNAIDS). (2014). The Gap Report. Retrieved December 21, 2019, from http://files.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2014/UNAIDS_Gap_report_en.pdf.
Kabudula, C., Houle, B., Collinson, M., Kahn, K., Gómez-Olivé, F., Clark, S., & Tollman, S. (2017a). Progression of the epidemiological transition in a rural South African setting: Findings from population surveillance in Agincourt, 1993–2013. BMC Public Health,17, 424. https://doi.org/10.1186/s12889-017-4312-x.
Kabudula, C., Houle, B., Collinson, M. A., Kahn, K., Tollman, S., & Clark, S. (2017b). Assessing changes in household socioeconomic status in rural South Africa, 2001–2013: A distributional analysis using household asset indicators. Social Indicators Research, 133, 1047–1073. https://doi.org/10.1007/s11205-016-1397-z.
Kahn, K., Collinson, M. A., Gómez-Olivé, F. X., Mokoena, O., Twine, R., Mee, P., … Khosa, A. (2012). Profile: Agincourt health and socio-demographic surveillance system. International Journal of Epidemiology,41(4), 988–1001.
Kordoutis, P., Loumakou, M., & Sarafidou, J. (2000). Heterosexual relationship characteristics, condom use and safe sex practices. AIDS Care,12(6), 767–782. https://doi.org/10.1080/09540120020014318a.
Logan, T., Cole, J., & Leukefeld, C. (2002). Women, sex, and HIV: Social and contextual factors, meta-analysis of published interventions, and implications for practice and research. Psychological Bulletin,128(6), 851–885. https://doi.org/10.1037//0033-2909.128.6.851.
Lurie, M. N., Williams, B. G., Zuma, K., Mkaya-Mwamburi, D., Garnett, G. P., Sweat, M. D., & Karim, S. S. (2003). Who infects whom? HIV-1 concordance and discordance among migrant and non-migrant couples in South Africa. AIDS,17(15), 2245–2252.
Mackesy-Amiti, M. E., Ouellet, L. J., Finnegan, L., Hagan, H., Golub, E., Latka, M., … Garfein, R. S. (2014). Transitions in latent classes of sexual risk behavior among young injection drug users following HIV prevention intervention. AIDS and Behavior,18(3), 464–472. https://doi.org/10.1007/s10461-013-0601-2.
Masters, N. T., Beadnell, B., Morrison, D. M., Hoppe, M. J., & Wells, E. A. (2013). Multidimensional characterization of sexual minority adolescents’ sexual safety strategies. Journal of Adolescence,36(5), 953–961. https://doi.org/10.1016/j.adolescence.2013.07.008.
Masters, N. T., Casey, E., Beadnell, B., Morrison, D. M., Hoppe, M. J., & Wells, E. A. (2015). Condoms and contexts: Profiles of sexual risk and safety among young heterosexually active men. Journal of Sex Research,52(7), 781–794. https://doi.org/10.1080/00224499.2014.953023.
McGrath, N., Eaton, J. W., Bärnighausen, T. W., Tanser, F., & Newell, M.-L. (2013). Sexual behaviour in a rural high HIV prevalence South African community. AIDS,27(15), 2461–2470. https://doi.org/10.1097/01.aids.0000432473.69250.19.
McMahon, R. C., Stanforth, E. T., Devieux, J. G., & Jean-Gilles, M. (2016). HIV risk behavior and internalizing/externalizing psychopathology among adolescents in court-ordered treatment. The American Journal of Drug and Alcohol Abuse,42(2), 187–195. https://doi.org/10.3109/00952990.2015.1132719.
Mee, P., Collinson, M. A., Madhavan, S., Root, E. D., Tollman, S. M., Byass, P., & Kahn, K. (2014). Evidence for localised HIV related micro-epidemics associated with the decentralised provision of antiretroviral treatment in rural South Africa: A spatio-temporal analysis of changing mortality patterns (2007–2010). Journal of Global Health,4(1). https://doi.org/10.7189/jogh.04.010403.
Mojola, S. A., Williams, J., Angotti, N., & Gómez-Olivé, F. X. (2015). HIV after 40 in rural South Africa: A life course approach to HIV vulnerability among middle aged and older adults. Social Science and Medicine,143, 204–212.
Mustanski, B., Byck, G. R., Dymnicki, A., Sterrett, E., Henry, D., & Bolland, J. (2013). Trajectories of multiple adolescent health risk behaviors in a low-income African American population. Development and Psychopathology,25(4 Pt 1), 1155–1169. https://doi.org/10.1017/s0954579413000436.
National Department of Health, Statistics South Africa, South African Medical Research Council, and ICF. (2019). South Africa demographic and health survey 2016. Pretoria, South Africa and Rockville, Maryland: NDoH, Stats SA, SAMRC, and ICF.
Nnko, S., Boerma, J., Urassa, M., Mwaluko, G., & Zaba, B. (2004). Secretive females or swaggering males? An assessment of the quality of sexual partnership reporting in rural Tanzania. Social Science and Medicine,59(2), 299–310. https://doi.org/10.1016/j.socscimed.2003.10.031.
Noor, S. W., Ross, M. W., Lai, D., & Risser, J. M. (2014). Use of latent class analysis approach to describe drug and sexual HIV risk patterns among injection drug users in Houston, Texas. AIDS and Behavior,18(Suppl. 3), 276–283. https://doi.org/10.1007/s10461-014-0713-3.
Nylund, K. L., Asparouhov, T., & Muthén, B. O. (2007). Deciding on the number of classes in latent class analysis and growth mixture modeling: A Monte Carlo simulation study. Structural Equation Modeling: A Multidisciplinary Journal,14(4), 535–569. https://doi.org/10.1080/10705510701575396.
Pettifor, A., The, H. p. t., MacPhail, C., Selin, A., Gómez-Olivé, F. X., Rosenberg, M., … Kahn, K. (2016). HPTN 068: A randomized control trial of a conditional cash transfer to reduce HIV infection in young women in South Africa—Study design and baseline results. AIDS and Behavior, 20(9), 1863–1882. https://doi.org/10.1007/s10461-015-1270-0.
Pflieger, J. C., Cook, E. C., Niccolai, L. M., & Connell, C. M. (2013). Racial/ethnic differences in patterns of sexual risk behavior and rates of sexually transmitted infections among female young adults. American Journal of Public Health,103(5), 903–909. https://doi.org/10.2105/ajph.2012.301005.
Rosenberg, M. S., Gómez-Olivé, F. X., Rohr, J. K., Houle, B. C., Kabudula, C. W., Wagner, R. G., … Tollman, S. M. (2017). Sexual behaviors and HIV status: A population-based study among older adults in rural south Africa. Journal of Acquired Immune Deficiency Syndromes,74(1), e9–e17.
Satorra, A., & Bentler, P. M. (2010). Ensuring positiveness of the scaled difference Chi square test statistic. Psychometrika,75(2), 243–248. https://doi.org/10.1007/s11336-009-9135-y.
Tibbits, M. K., Caldwell, L. L., Smith, E. A., Vergnani, T., & Wegner, L. (2016). Longitudinal patterns of active leisure among South African youth: Gender differences and associations with health risk behaviours. World Leisure Journal,58(1), 60–68. https://doi.org/10.1080/16078055.2015.1089317.
UNAIDS. (2016). Country overview: South Africa. Retrieved December 21, 2019, from http://www.unaids.org/en/regionscountries/countries/southafrica.
Varga, C. A. (2003). How gender roles influence sexual and reproductive health among South African adolescents. Studies in Family Planning,34(3), 160–172. https://doi.org/10.1111/j.1728-4465.2003.00160.x.
Vasilenko, S. A., Kugler, K. C., Butera, N. M., & Lanza, S. T. (2015). Patterns of adolescent sexual behavior predicting young adult sexually transmitted infections: A latent class analysis approach. Archives of Sexual Behavior,44(3), 705–715. https://doi.org/10.1007/s10508-014-0258-6.
Venkatesh, K., Flanigan, T., & Mayer, K. (2011). Is expanded HIV treatment preventing new infections? Impact of antiretroviral therapy on sexual risk behaviors in the developing world. AIDS,25(16), 1939–1949. https://doi.org/10.1097/QAD.0b013e32834b4ced.
Vollmer, S., Harttgen, K., Alfven, T., Padayachy, J., Ghys, P., & Bärnighausen, T. (2017). The HIV epidemic in sub-Saharan Africa is aging: Evidence from the demographic and health surveys in sub-Saharan Africa. AIDS and Behavior, 21(Suppl. 1), 101–113. https://doi.org/10.1007/s10461-016-1591-7.
Waller, M. W., Hallfors, D. D., Halpern, C. T., Iritani, B. J., Ford, C. A., & Guo, G. (2006). Gender differences in associations between depressive symptoms and patterns of substance use and risky sexual behavior among a nationally representative sample of U.S. adolescents. Archives of Women’s Mental Health,9(3), 139–150. https://doi.org/10.1007/s00737-006-0121-4.
Wechsberg, W. M., Myers, B., Kline, T. L., Carney, T., Browne, F. A., & Novak, S. P. (2012). The relationship of alcohol and other drug use typologies to sex risk behaviors among vulnerable women in Cape Town, South Africa. Journal of AIDS and Clinical Research. https://doi.org/10.4172/2155-6113.s1-015.
Wechsberg, W. M., Peasant, C., Kline, T., Zule, W. A., Ndirangu, J., Browne, F. A., … van der Horst, C. (2017). HIV prevention among women who use substances and report sex work: Risk groups identified among South African women. AIDS and Behavior,21(Suppl. 2), 155–166. https://doi.org/10.1007/s10461-017-1889-0.
Wellings, K., Collumbien, M., Slaymaker, E., Singh, S., Hodges, Z., Patel, D., & Bajos, N. (2006). Sexual behaviour in context: A global perspective. Lancet,368, 1706–1728.
Wu, J., Witkiewitz, K., McMahon, R. J., & Dodge, K. A. (2010). A parallel process growth mixture model of conduct problems and substance use with risky sexual behavior. Drug and Alcohol Dependence,111(3), 207–214. https://doi.org/10.1016/j.drugalcdep.2010.04.013.
Acknowledgements
We thank all the respondents who participated in this study and the Ha Nakekela field team. We are also grateful to members of the HIV survey investigative team for their numerous contributions to the project. We also thank the people of the Agincourt sub-district for their long involvement with the MRC/Wits Rural Public Health and Health Transitions Research Unit.
Funding
We are grateful for funding support from: the US National Institute on Aging—R01 AG049634 HIV after 40 in rural South Africa: Aging in the Context of an HIV Epidemic (PI Sanyu Mojola); the National Institutes of Health—R24 AG032112-05 Partnership for Social Science AIDS Research in South Africa’s Era of ART Rollout (PI Jane Menken); the University of Colorado, Innovative Seed Grant HIV after 40 in rural South Africa (PI Sanyu Mojola); the Eunice Kennedy Shriver National Institute of Child Health and Human Development—K01 HD057246 (PI Samuel Clark); and the William and Flora Hewlett Foundation 2009-4060 African Population Research and Training Program (PI Jane Menken). The MRC/Wits Rural Public Health and Health Transitions Research Unit and Agincourt Health and Socio-Demographic Surveillance System, a node of the South African Population Research Infrastructure Network (SAPRIN), is supported by the Department of Science and Innovation, the University of the Witwatersrand, and the Medical Research Council, South Africa, and previously the Wellcome Trust, UK (Grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z). This work has also benefited from research, administrative, and computing support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development–funded University of Colorado Population Center (R24HD066613, P2C HD066613).
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Houle, B., Yu, ST., Angotti, N. et al. Clusters of HIV Risk and Protective Sexual Behaviors in Agincourt, Rural South Africa: Findings from the Ha Nakekela Population-Based Study of Ages 15 and Older. Arch Sex Behav 49, 2057–2068 (2020). https://doi.org/10.1007/s10508-020-01663-5
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DOI: https://doi.org/10.1007/s10508-020-01663-5