Toward a better understanding of HIV risk among young South Africans

South Africa is in the midst of a severe HIV epidemic and prevention efforts to date have had only limited success. The aim of this dissertation is to provide insight into behavioral and attitudinal dynamics that continue to support the spread of the virus, particularly those that may not be adequately addressed in current prevention efforts. All three papers use data from a nationally representative, household HIV survey conducted among 15-24 year olds in South Africa. The first paper explores the HIV risk associated with concurrency or overlapping sexual partnerships. It finds that concurrency is associated with increased risk for HIV infection among women, but not men, after controlling for key demographic characteristics, risk factors, and sexual health characteristics. The findings underscore the need for frank, concerted messages about fidelity and highlight the need to address contextual issues such as poverty, unemployment, and gender power inequities. The second and third papers focus on the perceptions of risk that mediate high risk sexual behavior. Virtually all behavioral theories view perceived risk as a principal motivation for behavior change. The second paper explores which risk behaviors are associated with heightened perceived risk and finds that, among women, older sexual partners, multiple partners, and concurrency were not associated with perceived risk for HIV. These findings suggest gaps in current prevention messages and efforts. The third paper explores whether perceptions of risk are associated with HIV infection. It finds that among young men, but not young women, perceptions of risk are associated with HIV infection after controlling for demographic characteristics, risk behaviors, and sexual health characteristics. The findings suggest that in the context of voluntary counseling and testing, asking young men about their perceived risk of infection could help clinicians and others identify those most in need of testing and counseling. The fact that perceptions of risk and HIV infection are not associated among young women suggests that opt-out HIV testing may be a more appropriate testing model for South Africa.