by Dr. Molly Rosenberg
The Champions for the AIDS-Free Generation, a union of former presidents and other African leaders determined to help create an HIV/AIDS-free generation, met recently in Johannesburg and redoubled their commitment to ending the AIDS epidemic by 2030. But with over 300,000 new HIV infections occurring each year in South Africa, this goal seems still out of reach.
Young women have been particularly hard-hit by the epidemic – they are more than three times as likely to be HIV-infected compared to young men, and by the time they reach their mid-twenties nearly a third are already infected. Finding new and effective preventive interventions, particularly for young women, is critical to stopping the spread of HIV.
If we are serious about preventing HIV and other Sexually Transmitted Infections (STIs), perhaps we should focus our efforts to reduce access to places that may promote risky sex. I have become convinced that one such place is alcohol outlets – places that sell alcohol like bars, taverns, shebeens and bottle shops.
Our recent research in rural Mpumalanga province has found that young women who visit alcohol outlets have heightened HIV risk behaviors like unprotected sex and multiple sex partners, and are more likely to report transactional sex. Even more compelling, we also find that young women who live in communities with more alcohol outlets are more likely to have a prevalent herpes infection, another STI transmitted in a similar way to HIV. For every additional alcohol outlet, we found that herpes prevalence in young women increased by 10%.
There are quite a few reasons we might expect alcohol outlets to be related to STIs. Most obviously: they sell alcohol, and drinking alcohol can directly lead to risky sexual activity. Alcohol use and abuse lowers inhibitions, makes risky decision-making more likely, and has been linked to HIV risk around the world.
Secondly, young women often meet new sex partners in alcohol outlets, and there is reason to believe that these sex partners are generally riskier than those met in other places. In particular, older men willing to exchange money for sex often patronise alcohol outlets and transactional sex relationships with young women are regularly established within the outlets.
Finally, the alcohol outlets themselves may promote risky sexual activity. Common attributes of alcohol outlets like dim lights, music, unisex toilets, and no access to condoms may inadvertently provide both encouragement and opportunities for risky sex to occur on premises.
So if alcohol outlets are a potential source of HIV/STIs, what can we do? I, like many other parents and concerned community members, care deeply about the health of our next generation. HIV and other STIs have devastating consequences. Teenagers understandably seek independence and freedom as they transition into adulthood. But, while they remain in our care, it is our duty to help guide them into making healthy decisions and remove unnecessary risks to their sexual health.
Although the legal drinking age in South Africa is 18, we find that young women as young as 13 are reporting recent visits to alcohol outlets.
Given our findings in young women, we advocate, at the very least, that underage drinking laws should be better enforced. Although the legal drinking age in South Africa is 18, we find that young women as young as 13 are reporting recent visits to alcohol outlets. For a variety of health and safety reasons, in addition to the risk of sexually transmitted infection, this should not be happening.
National conversations about raising the drinking age to 21 should include this new information suggesting the potential to reduce HIV/STI transmission. At home, parents should be informed about the sexual risks associated with their teens visiting alcohol outlets and make and enforce their own rules accordingly.
To be sure, alcohol outlets can serve important roles in our communities, not only economically, but also for the opportunities that they provide for social connections. And correlation does not necessarily imply causation – we don’t know, for example, whether restricting access to alcohol outlets would definitely reduce sexual risk, or just shift risky activity to different locations.
With that in mind and given our knowledge so far, we are not advocating to prohibit or restrict the sale of alcohol to adults. But it is possible we could reduce HIV transmission with creative solutions that keep underage teens out of alcohol outlets and/or with targeting sexual health interventions to alcohol outlets.
It has become a truism that “it takes a village to raise a child.” That sentiment should not stop once the child reaches adolescence. Let’s work to make our villages safer with respect to the sexual health of our teens. An AIDS-free generation can only happen if we stop new HIV infections, and new infections are likely occurring in alcohol outlets. So let’s keep our teens out of alcohol outlets with purposeful decisions we make as a nation, as communities, and at home.
Dr. Molly Rosenberg is a David E. Bell Fellow at the Harvard Center for Population and Development Studies. She is an epidemiologist whose work has focused on the sexual health outcomes of adolescents in rural South Africa.