Women's HIV rates twice as high in young couples in South Africa: Is it gender, drugs or community risks?

Background: South Africa's HIV epidemic is driven heterosexually. Although many couples stay together for long periods, competing and overlapping sexual risks and substance use in the community increase vulnerability to HIV transmission, particularly among women. We present drug use and HIV prevalence among couples who live in different communities within a large low socioeconomic township and discuss the implications for couple-based prevention. Methods: Geographical mapping of taverns was conducted and revealed 30 geographic clusters of taverns that were randomized for an NIH HIV prevention study. Between 2010 and 2012, 300 couples ages 18-35 in long-term relationships were recruited and completed alcohol, drug, HIV testing and behavioral assessments. Results: HIV prevalence was 19.5% and it was present in 83% (25/30) of clusters. HIV prevalence within clusters ranged from 0% to 46% and varied by gender from 13% in males to 26% in females. Residents from 67%, 33%, and 10% of clusters used marijuana, methamphetamine, and opiates, respectively. Drug use varied by cluster and gender and was highest males. HIV prevalence was highest in clusters where drug use was high. Conclusions: HIV and poly-substance use were geographically clustered in. Although HIV prevalence is very high in this larger township, African women were the most likely to test HIV positive despite being less likely than their male partners to use drugs. These findings underscore women's disproportionate vulnerability to HIV and highlight the need for Couple-based HIV prevention that combine behavioral and biomedical HIV prevention strategies for long term couples.