How common and frequent is heterosexual anal intercourse among South Africans? A systematic review and meta‐analysis

Abstract

Background: HIV is transmitted more effectively during anal intercourse (AI) than vaginal intercourse (VI). However, patterns of heterosexual AI practice and its contribution to South Africa’s generalized epidemic remain unclear. We aimed to determine how common and frequent heterosexual AI is in South Africa. Methods: We searched for studies reporting the proportion practising heterosexual AI (prevalence) and/or the number of AI and unprotected AI (UAI) acts (frequency) in South Africa from 1990 to 2015. Stratified random-effects meta-analysis by sub-groups was used to produce pooled estimates and assess the influence of participant and study characteristics on AI prevalence. We also estimated the fraction of all sex acts which were AI or UAI and compared condom use during VI and AI. Results: Of 41 included studies, 31 reported on AI prevalence and 14 on frequency, over various recall periods. AI prevalence was high across different recall periods for sexually active general-risk populations (e.g. lifetime = 18.4% [95%CI:9.4–27.5%], three-month = 20.3% [6.1–34.7%]), but tended to be even higher in higher-risk populations such as STI patients and female sex workers (e.g. lifetime = 23.2% [0.0–47.4%], recall period not stated = 40.1% [36.2–44.0%]). Prevalence was higher in studies using more confidential interview methods. Among general and higher-risk populations, 1.2–40.0% and 0.7–21.0% of all unprotected sex acts were UAI, respectively. AI acts were as likely to be condom protected as vaginal acts. Discussion: Reported heterosexual AI is common but variable among South Africans. Nationally and regionally representative sexual behaviour studies that use standardized recall periods and confidential interview methods, to aid comparison across studies and minimize reporting bias, are needed. Such data could be used to estimate the extent to which AI contributes to South Africa’s HIV epidemic.

What Proportion of Female Sex Workers Practise anal Intercourse and How Frequently? A Systematic Review and Meta-analysis

“…Although scarce, the available data on AI frequency suggests that AI is practised frequently, with 2.4-15.9% of all intercourse acts being anal among all FSW study participant samples. Similar to previous review findings regarding heterosexual AI practice among young people and South Africans [37,38], we found a non-statistically significant indication that AI prevalence may have increased over time. In qualitative research Indian and East African FSW have described AI practice during sex work as becoming more common over time due to increased client demand [9,[39][40][41].…”

“…AI is a highly stigmatised behaviour in many societies and thus its reporting is likely subject to social desirability bias and is likely more accurately reported using more confidential interview methods [37,38]. As the majority of studies in this review used FTFI, the least confidential interviewing method, our pooled estimates of AI prevalence and estimates of AI frequency likely underestimate its practice among FSW.…”

“…However, the language restriction is unlikely to have influenced results substantially given the large number of articles included (N = 131). We searched for grey literature in our similar review of heterosexual AI among South Africans [37] and found none eligible.…”

“…It is clear from this review and others [37,38] that data collection on AI practice requires improvement, especially given how effectively HIV is transmitted during AI and how commonly it is practiced. Previous research suggests that survey items must be carefully piloted in order to minimise misunderstanding and that one effective approach may be the use of pictograms to unambiguously clarify what is meant by AI [44].…”

Widespread changes in sexual behaviour in eastern and southern Africa: Challenges to achieving global HIV targets? Longitudinal analyses of nationally representative surveys

“…Trends in prevalence and frequency of heterosexual anal intercourse may affect trends in population‐level sexual risks, which further depends on condom use during anal intercourse. This is may be to be lower than for vaginal intercourse , although a systematic review of South Africa indicated equal or higher condom use during anal intercourse . Some studies suggest that heterosexual anal intercourse has become more common over time but, generally, trends in heterosexual anal intercourse in sub‐Saharan Africa are poorly understood and impacts of different types of sexual intercourse on population‐level sexual risks could not be evaluated in this study.…”