Alcohol, sex and violence: a dangerous cocktail that makes young women vulnerable to HIV

South Africa has the largest HIV epidemic in the world, with adolescent girls and young women aged 15-24 at the highest risk of getting HIV. HIV prevalence among girls and women in this age group is roughly double that of their male peers.

Research has identified numerous factors that increase vulnerability among women and girls. These include unequal power dynamics in relationships, challenges in negotiating condom use, as well as exposure to violence. Heavy alcohol consumption or binge drinking can amplify these situations, thus increasing HIV vulnerability.

Binge drinking is defined as consuming five or more drinks in one sitting. This behaviour is widespread and normalised in many South African communities with 54% of male drinkers and 35% of female drinkers reporting that they binge drink.

As socio-behavioural scientists our interests lie in the areas of sexual and reproductive health, and sociocultural norms and structural barriers to HIV prevention.

Our recent research sought to explore the intersection between alcohol use, HIV risk and HIV acquisition among adolescent girls and young women living in high HIV-burdened communities in South Africa. We used data from the HERStory3 study, an impact evaluation of the My Journey programme. My Journey is a combination HIV prevention intervention that aims to reduce HIV, teenage pregnancy and gender based violence, as well as keep girls in school and improve their access to economic opportunities.

We found that hazardous drinking was common and strongly linked to sexual violence and condomless sex. But it was not directly associated with HIV acquisition in this study. That does not make alcohol irrelevant. It suggests the pathway from drinking to HIV is indirect, layered, and shaped by other social conditions.

Our findings suggest that HIV prevention for adolescent girls and young women cannot focus only on condoms or individual behaviour change. It needs to confront the conditions that make risk possible.

How the study was done

Our team conducted the HERStory3 study, which was an external evaluation of the My Journey programme. The programme has been delivering services in schools, colleges, dedicated safe spaces and mobile clinics since 2016.

Services start with an HIV risk and vulnerability assessment. Then depending on their needs, girls are offered HIV testing, prevention and treatment services as well as pregnancy testing and contraceptives.

The programme is being implemented in 12 sub-districts with a high HIV burden across eight provinces in South Africa.

To evaluate the programme, we conducted a post-intervention household survey in 2024 with 5,025 adolescent girls and young women. The survey was conducted in the 12 intervention sub-districts, and 12 matched sub-districts that didn't receive the intervention, for comparison. To complement the survey, our study also included in-depth telephonic interviews with 68 young women from seven provinces.

Those interviews were important because they gave girls the chance to tell us their stories, and help to explain two things. First, whether alcohol was associated with risk. Second, how alcohol fitted into girls' social worlds.

What we found

We tested the relationship between hazardous drinking and specific sexual risk behaviours. Our analysis showed no statistically significant association between alcohol use and HIV status. However, we found it was associated with sexual violence and condomless sex. Hazardous drinking also appeared to be linked to transactional sex. But this relationship was not strong or consistent once the other risk behaviours were considered.

The interviews helped provide a backdrop to why alcohol consumption among women and girls in South Africa is increasing.

In the narratives of the young women we spoke to, alcohol was woven into peer culture, family and community drinking spaces. Girls described engaging in age-disparate and transactional relationships. These commonly end up in situations in which girls obtain alcohol from older men who expect sex in exchange. The interviews showed that alcohol is not just a drink but a social currency that shapes how girls navigate bars and other drinking venues.

In the social context of bars and informal drinking venues, this exchange can blur consent because alcohol may be used to initiate or pressure sexual access. And the power imbalance created by age, money and intoxication makes it harder for girls to insist on condoms or leave safely.

The risk does not end with sexual coercion.

When girls refuse sex after receiving alcohol, they may face anger, intimidation, or physical violence. This shows how alcohol-related exchange can escalate from social interaction into gender-based harm. This pathway helps explain why alcohol use among adolescent girls and young women cannot be separated from transactional sex, coercion and violence in high HIV-burden settings.

The HIV link

The lack of a direct statistical link between hazardous drinking and HIV infection is not surprising once the broader context is considered. HIV acquisition is the result of repeated exposures over time. Our survey measured drinking and HIV acquisition at a single point in time.

If alcohol increases HIV risk gradually through exposure to sexual violence and condomless sex as a result of transactional or age-disparate relationships, that effect may not appear as a simple one-to-one association in cross-sectional data.

The findings from the interviews make that chain of influence more visible. They show how alcohol can weaken bargaining power, place girls and young women in unsafe settings, and make negotiations for condom use harder.

In the interviews, girls described being expected to have sex after men bought them drinks, and that refusal could lead to rape, threats, or physical violence. The interviews also show that alcohol use among adolescent girls and young women is socially embedded rather than purely individual. This is important for interpreting the study findings.

What the findings mean

HIV prevention for this population needs to address the settings in which alcohol is accessed, the gendered power relations that shape sexual decision-making, and the violence that can follow from those relationships.

The findings point to the importance of safer recreational spaces, community-level alcohol harm reduction, and interventions that reduce women's dependence on transactional exchanges with older men.

There is also a message here for programme design. Multi-component HIV prevention interventions are more likely to work when they are tailored to the social realities of young women's lives, not just their knowledge of risk.

Future research should follow participants over longer periods, use stronger causal designs where possible, and test whether reducing hazardous drinking also lowers violence and condomless sex over time.

Zoe Duby is employed by the South African Medical Research Council, and is affiliated with the University of Cape Town. The HERStory studies were funded by the Global Fund to Fund AIDs, Tuberculosis and Malaria.

Kate Bergh works for the South African Medical Research Council. She received funding from the Global Fund to Fund AIDs, Tuberculosis and Malaria for this research. She is also affiliated with the University of Cape Town.

By Zoe Duby, Socio-behavioural public health researcher, South African Medical Research Council And

Kate Bergh, Senior Scientist, South African Medical Research Council