Intimate partner violence, child sexual assault, forced first intercourse and adult sexual assault by non-partners were generally associated with increased HIV risk behaviors, as were mid or high scores on the Sexual Relationship Power Scale (SRPS) which measured women’s power in her relationship. Overall, of participants reported transactional sex, which we defined as sex with a non-primary male partner in exchange for material goods or money. Women who reported intimate partner violence, problematic substance use, urban residence, ever [having worked], or living in substandard housing were more likely to report transactional sex, while women who delayed first coitus, were married, or had a post-secondary education were less likely to do so. Transactional sex was associated with increased risk of HIV

Harmful traditional practices

A number of practices increasing a woman’s risk of HIV infection are often justified in the name of cultural values and traditions. Some of these are discussed under themes of sexual rights and economic independence. The three practices discussed here are: early marriage, wife inheritance and genital mutilation.



Early marriage

The Convention on the Rights of the Child does not set a fixed minimum legal age of marriage. However, other treaties do specify a minimum legal age for marriage. Although data is incomplete it appears that, in practice around the world, girls marry earlier than boys. Child marriage involves a number of factors which increase a young woman’s risk of HIV infection. The following factors increase potential exposure to the virus: lack of awareness of measures required for self-protection; lack of power within the marital relationship; family pressure to obey a husband; and pressure to start a family which militates against the use of condoms. Some studies have found a higher prevalence of HIV in young married women compared to unmarried women in the same age group, particularly where the husband is significantly older than the wife. Researchers have suggested that the increased risk is linked to older men’s increased sexual experience and exposure to HIV, young wives Inability to make demands on older husbands, and less use of means of protection.
Child marriage impedes a girl’s access to education with all that implies for managing her relationships, gaining employment and negotiating sexual behaviour. In
Ethiopia , for example, some 80% of married young women have had no education and are unable to read.

Wife inheritance

Wife inheritance is the practice of the transfer of the widow of a deceased man to that man’s brother she is "inherited", sometimes into a polygamous family. Subsequent sexual activity is often coerced and unsafe. The possibility that either the wife or the new husband will already be living with HIV increases the risk of transmission and thus facilitates the spread of the virus. In some traditions the woman must consent to the new marriage but if she refuses she will not receive any of the property associated with her previous married life and will lose her home. Either decision is likely to have an unwelcome outcome for the woman.

Female genital mutilation or cutting (FGM or FGC)

Cutting of the female genitalia as a cultural practice is widespread in parts of Africa and the
Middle East . Female genital mutilation can involve excision of the clitoral hood, with or without excision of part or all of the clitoris; excision of the clitoris with partial or total excision of the labia minora; or removal of part or all of the external genitalia and stitching/narrowing of the vaginal opening. The practice places girls and women at increased risk to HIV infection through several routes. Firstly, the use of unspecialized razors or knives to carry out the procedure among a number of girls risks passing the virus from one girl to the next should one of them be HIV-positive. Secondly, FGM renders the genitals more likely to tear during intercourse. In cases of infibulations or sewing up of the vaginal entrance, penetration is bound to lead to bleeding, which in turn makes sexual transmission of the virus from an HIV-positive partner much more likely. Thirdly, difficulties with intercourse may make a woman less likely to welcome the partner’s advances and lead him to a more violent approach to sex; or to engage in sexual practices with his wife (such as unprotected anal intercourse) which might place her at increased risk of HIV infection