Trading in sexual currency: Transactional sex, sexual coercion and sexual behaviours among young people in Uganda

The growing incidence and prevalence of sexually transmitted infections among young people, particularly HIV, is a public health concern in Uganda. There is increasing evidence that Ugandan youth engage in risky sexual behaviors, transactional sex, and experience sexual coercion. Most research on sexual behaviors has been limited to inter- and intra-personal factors that influence sexual behaviors. Prior research on transactional sex has often concentrated only on young girls, their motivations for receiving gifts, money, or favors in exchange for sex along with unsafe sex and sexual coercion due to power differential in such relationships. The general aim of this thesis was to gain a detailed understanding of the range of ecological factors that influence HIV-related sexual risk behaviors among the youth in Uganda, with a special focus on transactional sex. The findings of this thesis can help inform evidence-based interventions that are locally relevant and culturally adaptable in order to prevent the spread of HIV among Ugandan youth. The thesis is based on a mixed-method approach that includes quantitative cross-sectional and qualitative studies. Data was obtained from a questionnaire study conducted in 2010 among university students in Uganda (Studies 1 and 2); qualitative focus group discussions with students at a Ugandan university in 2014 (Study 3); and a nationally representative population-based survey of HIV sero-status carried out in 2011 (Study 4). Logistic regression was used as the main tool for analysis in the cross-sectional studies, while grounded theory was used for analysis of qualitative data. Study 1 revealed that alcohol consumption in relation to sexual activity was associated with such risky sexual behaviors such as multiple sexual relationships and inconsistent condom use with new partners. The findings of Study 2 show that sexual coercion, physical violence, and mental health were associated to a statistically significant degree with transactional sex among university students in Uganda. The qualitative findings showed that macrosystems such as cultural sexual scripts, gendered sexual scripts, poverty, and globalization influence the contexts in which young people engage in sex, not excluding transactional sex among university students. Finally, Study 4 revealed that among young women, receiving something for sex, and among young men, paying something for sex was associated with multiple concurrent relationships. Moreover, HIV positive sero-status was significantly associated with paying for sex among young men. The findings of this thesis suggest that there is need for HIV interventions, which address the multiple factors that influence sexual behaviors and transactional sex. Both sexes are equally vulnerable to sexual coercion and HIV risks associated with transactional sex, and therefore both should be targeted in intervention programs. A nuanced and flexible approach is needed. Young people should be actively engaged in the design and implementation of interventions that incorporate gender transformative approaches by critically challenging the implicit assumptions about traditional gender norms and socio-cultural factors that promote and facilitate sexual risk behaviors and transactional sex