Open Access Research article

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

Seth C Kalichman1*, Steven D Pinkerton2, Michael P Carey3, Demetria Cain1, Vuyelwa Mehlomakulu4, Kate B Carey3, Leickness C Simbayi4, Kelvin Mwaba4 and Ofer Harel1

Author Affiliations

1 Department of Psychology, 406 Babbidge Road, University of Connecticut, Storrs, CT 06269, USA

2 Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA

3 Center for Health and Behavior, Syracuse University, Syracuse, New York, USA

4 Human Sciences Research Council, Cape Town, South Africa

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BMC Public Health 2011, 11:807  doi:10.1186/1471-2458-11-807

Published: 14 October 2011



The most efficient sexual behavior for HIV transmission is unprotected receptive anal intercourse. However, it is unclear what role heterosexual unprotected anal sex is playing in the world's worst HIV epidemics of southern Africa. The objective is to examine the prevalence of heterosexual unprotected anal intercourse among men and women who drink at informal alcohol serving establishments (shebeens) in 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.