Background: Transactional sex (TS), or the exchange of sex for financial or material gain, has been well documented as a contributor to the HIV epidemic in sub-Saharan Africa. Studies conducted among young women in South Africa have found that approximately 20% of participants reported engaging in TS. Previous research has yet to identify psychosocial factors that make young women vulnerable to TS. Self-esteem has been associated with the adoption of risk behaviors among young people. The objective of this analysis was to determine if self-esteem is associated with TS among young women in South Africa.
Methods: HPTN-068 was a 3-year randomized controlled trial to assess the impact of a conditional cash transfer on HIV incidence among young women in rural South Africa that enrolled 2,533 participants from 2011-2012. In 2015-2017, a cross-sectional survey was offered to all participants from the main trial who had not died or been withdrawn. The current analysis utilized this post-intervention visit survey. Self-esteem was derived from the Rosenberg self-esteem scale and dichotomized at the median. TS was derived from 8-yes/no items that inquired if a participant had exchanged sex for food, money, material goods, or social status since their last visit in the main trial. Participants who responded “yes” to one or more items were categorized as having TS. Log-binomial regression was used to compute a prevalence ratio (PR). Additional covariates were specified to minimize confounding bias.
Results: 1,942 young women ages 17-26 years (M=20 years) were included. Approximately half (49%) were categorized as having high self-esteem and 15% reported having engaged in TS since their last visit. The prevalence of TS among those with low self-esteem (23.79%) was 5.05 times the prevalence of TS among those with high self-esteem (4.71%), 95% CI: 3.61-7.08, p< 0.001. The effect remained significant after adjusting for age, education, financial security, intimate partner violence, gender attitudes, and adverse childhood experiences (PR=4.10, 95% CI: 2.91-5.78, p< 0.001).
Conclusions: Findings provide support for the association between low self-esteem and TS in this context. Future research should examine self-esteem and incident TS to establish causality. Psychosocial factors, including self-esteem, should be considered when designing intervention programs.

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