Heterosexual anal intercourse and HIV infection risks in the context of alcohol serving venues, Cape Town, South Africa

Cross-sectional surveys were collected from a convenience sample of 5037 patrons of 10 shebeens in a peri-urban township of Cape Town, South Africa. Analyses concentrated on establishing the rates of unprotected anal intercourse practiced by men and women as well as the factors associated with practicing anal intercourse.We found that 15% of men and 11% of women reported anal intercourse in the previous month, with 8% of men and 7% of women practicing any unprotected anal intercourse. Multiple logistic regression showed that younger age, having primary and casual sex partners, and meeting sex partners at shebeens were independently associated with engaging in anal intercourse. Mathematical modeling showed that individual risks are significantly impacted by anal intercourse but probably not to the degree needed to drive a generalized HIV epidemic.Anal intercourse likely plays a significant role in HIV infections among a small minority of South Africans who patronize alcohol serving establishments. Heterosexual anal intercourse, the most risky sexual behavior for HIV transmission, should not be ignored in HIV prevention for South African heterosexuals. However, this relatively infrequent behavior should not become the focus of prevention efforts.The prevalence of anal intercourse among heterosexual adults has not been well-studied in many populations. This knowledge gap is important because, relative to vaginal intercourse, anal intercourse may be as much as 20 times more efficient for transmitting HIV. Given the transmission efficiency of anal intercourse, even a low prevalence of anal sex among heterosexuals could account for a large number of HIV infections [1].Estimates from the U.S. and U.K. suggest an average heterosexual anal intercourse prevalence of 11% (range = 2% to 39%) [1,2]. The highest rates have been found among female sex workers and patients at sexually transmitted infections (STI) clinics [3]. As many as 20% of STI clinic patients in South Africa re