Reviewing gender and cultural factors associated with HIV / AIDS among university students in the South African context

Correspondence address Annalene van Staden Department of Psychology o f Educa­ tion, Faculty o f Education, University o f the Free State, Abstract: Curationis 32 (4): 19-28 South Africa is in the midst of a catastrophic AIDS epidemic. HIV prevalence statis­ tics in most countries indicate that up to 60% of all new infections occur among 15 to 24 year olds, whilst this group also boasts the highest incidence o f sexually transmit­ ted infections (STIs). Statistical findings among South African students predict a 10% increase in the HIV infection rate, highlighting the inability o f universities to cope with societies’ demands for academically trained workers which, in the near future, will have a detrimental effect on the economy o f South Africa. From the literature it is evident that HIV/AIDS is more than a health issue, it is an inter-sectoral challenge to any society. This paper explored the interplay o f gender and cultural factors on South African students’ sexual behaviour by inter alia discussing the following factors that might put students at risk for HIV infection: male dominance vs. female submissiveness; age of first sexual encounter; gender-based violence; contraception; circumcision; financial status; myths and ‘othering’; demonstrating the need for effective strategies, policies and programmes to protect young people, especially females from sexual abuse/rape and its consequences, including HIV. The literature review revealed that South African students, despite adequate HIV/AIDS knowledge, demonstrated high rates of sexual practices that place them at risk for HIV infection, i.e. unprotected sex, multiple partners and ‘sugar-daddy practices’. The paper concludes with a discussion on recommendations for future HIV preven­ tion/intervention programmes, highlighting the fact that it acquires an inclusive ap­ proach. Such interventions should move beyond the individual level to be effective and target gender-based inequalities, human rights violations, including sexual vio­ lence and rape, as well as stigma and poverty reduction, both at community and tertiary educational level.


Introduction
The Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) pandemic has re ceived overwhelming attention at all levels of social intervention.Michael Gibbons, Secretary-General of the As sociation of Commonwealth Universi ties, warned that the HIV and AIDS pandemic would lead to the decimation of higher education structures in South Africa (Bridgraj, 2000:9).This means that universities will not be able to cope with society's demand for academically trained workers (Bridgraj, 2000:9).Look ing at the pandemic from this perspec tive helps us to realise the vulnerabil ity of young adults, as well as the fact that HIV infection is spread through modern sexual behaviour (Marcus, 2002:23).
For many students university life is an opportunity to experiment and be ad venturous.Very often experimentation with sex, alcohol and drugs occurs dur ing their university years, lowering stu dents' inhibitions and leading to riskier sexual behaviour and even date rape (Southern African Regional Universi ties Association, 2009:19).Recent data suggest that up to 60% of all new HIV infections occur among young people in the age group 15 to 24 years, whilst this group also boasts the highest in cidence of sexually transmitted infec tions (STIs) o f all age groups (Givaudan, Leenen, van de Vijver, Poortinga & Pick, 2008:98).The exist ence of HIV has certainly changed the situation from times when the possibil ity of an unwanted pregnancy was all a student had to worry about after par ticipating in unprotected sexual activ ity (Thom & Cullinan, 2003:47).

Problem statement and research questions
Several problems currently exist in the battle against HIV and AIDS among students.Abt Associates (in Levine & Ross, 2002:90) estimated that, in the year 2000, the HIV infection rate at univer sity undergraduate level was roughly 22%.Estimates for 2005 rose to about 33%.Tertiary institutions will therefore be confronted with an increasing number of students who will commence their studies as HIV-positive individu als, as well as an increasing number of students who will be infected with HIV by the time they have completed their studies (Crewe, 2000:11).The negative impact of HIV/AIDS will result in stu dents never reaching senior levels in the economic work sector; thus directly affecting efforts directed at addressing structural problems, including high lev els of unemployment, skills shortages and high levels of income inequality (Comelissen, 2005:1).
Previous educational prevention pro grammes to combat HIV among stu dents focused on informing the youth about the modes of transmission of HIV (Strydom & Stiydom, 2002:216).Knowl edge, Attitude, Belief and Practice (KABP) surveys were mainly used to study students' sexual behaviour in relation to HIV.The reason was that researchers believed if the youth could develop the proper skills and had the right information (facts) surrounding HIV and its modes of transition and their beliefs (positive or negative feel ings and opinions) were taken into con sideration, it might help predict and in fluence their health-related behaviour, and would they be in the position to change their high-risk sexual behaviour (Badenhorst, Van Staden & Coetsee, 2008:106-120).
After reviewing recent research find ings, it became clear that, despite hav ing a sufficient knowledge base with regard to HIV and its modes of trans mission to protect themselves, students still put themselves at risk for HIV in fection (Southern African African Re gional U niversities A ssociation, 2009:17-20;Akande, 2001:239).This demonstrates that knowledge alone is not enough to prevent HIV infection and that those factors such as gender and culture should also be researched to help stop the spreading of HIV (Levine & Ross, 2002:90;Eaton & Flisher, 2000: 111;Coughlan, Coughlan & Jameson, 1996:255).
Emanating from the above, the follow ing research questions guided this re search:

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To what degree do gender and culture influence high-risk sexual behaviour among stu dents at South African univer sities?

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To what degree do high-risk sexual practices of students dif fer on the basis of gender, cul ture and their awareness of HIV/ AIDS?

Purpose
The main purpose of the present study is to review the South African litera ture on students' sexual practices and high-risk behaviour in order to identify prevailing themes and trends so that new directions may be identified in the research on students and HIV/AIDS prevention.Hence, in the present study the authors set out to:

Interplay of gender and cultural factors on South African students' sexual behaviour
Studies by the Department of Health (1994:14) and Trussler and Marchand (1997:51)  Studying the culture of individuals in relation to their gender and sexual prac tices will shift the focus from a rational choice based on an individual response to guidelines focusing on cultural dif ferences (Ntlabati, Kelly & Mankayi, 2001:17).Culture and gender influence a lot of aspects surrounding students' high-risk sexual behaviour with regard to HIV infection.These factors play a direct role in an individual's choice to use safe sexual practices to protect himself/herself against HIV.In addition, research findings suggest that gender inequality and gender-based violence are essential determinates of women's HIV risk, worldwide as well as in South Africa (Dunkle, Jewkes, Brown, Gray, Mclntryre & Harlow, 2004:1415).Thus, in the next section the influence of gen der relations and cultural habits on the sexual practices of female and male stu dents will be discussed by investigat ing the interplay of factors such as male dominance vs. submissiveness, age o f first sexual encounter, gender-based violence, contraception, circumcision, financial status, myths, as well as the concept o f 'othering'.

Male dominance vs. female submissiveness
Male and female roles are often shaped by society, culture, the immediate and extended family, communities and indi vidual decisions (Southern African Regional U niversity Association, 2009:19).Research findings over whelmingly demonstrate how gender inequality may impact negatively on the vulnerability of females.The stere otypical behaviour of some men, to gether with unfavourable cultural pre scriptions such as submissiveness, sexual subordinates, obedience, and willingness, makes women in particu lar more vulnerable to become HIV in fected (Van den Berg & Van Rooyen, 2007:208).Not only does male domi nance influence the sexual behaviour of female students and place them at risk, but cultural practices such as male students' view of perceived masculin ity, condom use, myths and expecta tions based on financial status also in crease male students' own risk for HIV infection.
A ccording to Le C lerc-M adlala (2002:29), one of the gender factors that place both African and Western male students at higher risk for HIV infec tion is their striving to be seen as 'mas culine' by their peer groups.Masculin ity can be placed on a continuum be tween what is considered masculine and 'macho', and what is seen as refined and being a 'sissy'.Thus, from an early age, 'to be a real man among boys', is in the majority of South African cul tures associated with "power, virility and domination of women in sexual re lationships" (Chikore, 2000:39).Conse quently, male students who believe that risk-taking is an expression of mascu linity may be more likely to engage in high-risk sexual and drug-using behav iour, because they have to meet certain expectations to attain the status of 'masculine and macho'.The risk lies in these expectations, which may include having several sexual partners, engag ing in casual sex, unprotected sex, dem onstrating negative attitudes toward condom use, having control over women, and owning expensive acces sories (Selikow, Zulu & Cedras, 2002:24).'Macho' male students from an African cultural background regu larly distinguish between their female partners as belonging to one of two groups, i.e. as 'girlfriends' they are seen as long-term sexual partners (with whom condoms are often not used); whilst those in the second group are seen as casual sexual partners (with whom condoms are preferably used).This might add to the fact that research among female students demonstrates that they frequently regard not using condoms during sex as a way of en hancing their social status.They might believe that this choice will make male students see them as permanent girl friends, rather than 'casual partners'.
Focusing on female students, several cultural customs seem to influence a female student's view of protecting herself against HIV infection.As seen in the Western and African cultures in South Africa and discussed above, male dominance in society plays a ma jor role in the behaviour of female stu dents.A female is expected to be sub missive to her male partner, to raise their children and not to speak openly about their sexual concerns and interests (Ferrante, 2003:342).By contrast, a man is expected to be the leader in the com munity and in family life (Taylor, Peplau & Sears, 2000:274).The literature makes it clear that most gender-based power, both in marriage and courtship, is given to males through social conventions.The problem is that male students con trol the most easily accessible barrier against HIV infection, the male condom.Female students are more at risk of HIV infection, as they may feel powerless to insist on condom use (Finchilescu, 2002:109-131).

Age of first sexual encounter
Gender stereotypes, combined with age differences between partners in a sexual relationship, may constitute a risk fac tor for women (UNAIDS, 2005).Many women, especially younger females, cannot refuse unwanted sex or negoti ate protection from pregnancy and STIs, including HIV, because they fear retaliation -resulting in multiple ad verse physical, social and emotional outcomes (Dunkle et al., 2004(Dunkle et al., :1415(Dunkle et al., -1421)).
Age influences the vulnerability of fe male students in two ways.Firstly, fe male students -notwithstanding their cultural background -often prefer to have sexual relationships with older men.These men, in view of their sexual behaviour (the possibility of having had multiple sexual partners), carry a higher risk of infecting their current fe male partner(s) with HIV.Secondly, younger female students' risk of HIV infection is further increased due to their inexperience in negotiating for safer sex.Furthermore, in situations of forced sex or coercion, whether by strangers, acquaintances, family mem bers, boyfriends or 'sugar daddies', negotiating condom use is virtually impossible (UNAIDS, 2005;Marcus, 2002:27).Contributing to the escalation of this risk factor is the unique South African phenomenon that female sub missiveness, barricaded beliefs regard ing male dominance, high levels of sexual crime and the fear of HI V infec tion propel men towards seeking in creasingly younger groups of females for sexual relationships (Le Clerc-Madlala, 2002:23).This has direct im plications for younger females because of their biological, immunological andI or virological susceptibility, which changes in age, making them more vul nerable to infections in their teens and early twenties (Van den Berg & Van Rooyen, 2007:209).Younger females' reproductive tract is not fully devel oped and the skin is more likely to rip or tear during sexual intercourse, which increases the risk of HIV infection (Van den Berg, 2004:83).In addition, re search findings have demonstrated that women who began their sexual activity before the age of 17 are more prone to herpes simplex infections, which cause cellular changes and may result in cer vical cancer.Moreover, research find ings have demonstrated that 33% of girls between the ages of 12 and 17 years have already had sexual inter course; that girls even as young as 8 years are sexually active; and that 4% of girls between the ages of 12 and 17 years have already been pregnant (Henry Kaiser Family Foundation, 2001:23).

Gender-based violence
Researchers postulate that genderbased violence and gender inequality are important determinants that place women at greater risk of contracting the HIV/AIDS virus (UNAIDS, 2005;Garcia-Moreno & Watts, 2000:253-265).Gender-based violence refers to a range of harmful custom behaviours against girls and women, including intimate partner violence, domestic violence and assaults, child sexual abuse and rape (A uerbach, Byram & K andathil, 2005:1).Forced sex is not the only cause of HIV infection; in addition, the atti tudes and mindset that underlie the act of forced sex, the disrespect for the rights of others, including the failure to disclose one's HIV status, all con tribute to spreading the HIV virus (A nderson, H o-Foster, M atthis, M arokoane, M ashiane, M hatre, Mitchell, Mokoena, Monasta, Ngxowa, Salcedo & Sonnekus, 2004:952-954).According to Chinkdanda (as cited in Van den Berg & Van Rooyen, 2007:206), women become victims to men's abu sive behaviour and sexual violence because of women's perceived tradi tional role in society as 'the weaker sex' and in some cases women are even 'rel egated to the same status as children'.Prevalence estimates for gender-based violence vary widely as a result of dif fering definitions of violence, but cur rent estimates indicate that between 8% and 70% of women worldwide have been physically or sexually assaulted by a male partner at least once in their lives (Auerbach et al. 2005).Moreo ver, it is reported that one of the driv ing forces behind the HIV/AIDS epi demic in South Africa, is rape.By esti mate there are more than one and a half million rapes in this country each year (Meel, 2005:207-208).Many times this can be ascribed to stereotypical male behaviour, which associates masculin ity with having easy access to women and in an attempt to emphasise male control women are being forced to have sexual intercourse (Van den Berg & Van Rooyen, 2007:207;UNAIDS, 2005); Evidence also exists that gangs regard girls in their area as their 'property' with a view that they 'must be available for sexual intercourse' -thus increasing the risk for gang rapes and HIV infec tion (Le Roux, 1994:269).Moreover, re sults from other South African studies inter alia demonstrated that 25% of sexually active females admitted that they had been forced to have sexual intercourse; that child sexual assault, forced first intercourse and adult sexual assault by non-partners were signifi cantly correlated with increased sexu ally risky behaviour (Dunkle et al. 2004(Dunkle et al. :1419)).Although those suffering from forced sexual intercourse believe that there is a good possibility that they are HIV positive, they are less willing to go for testing.Despite the fact that there is a visible association between the increase in sexual violence against women and the increased incidence of HIV infection in South Africa, HIV in fection as a result of sexual assault has merited much less attention in this coun try (Meel, 2005:268).Focusing on the development and implementation of future HIV/AIDS prevention pro grammes, the government and NGOs have to take cognisance of how sexual abuse affects the way 'survivors' in terpret HIV risk awareness initiatives, understanding both their impact on in dividual risk reduction and how a his tory of abuse might further affect the spreading of HIV/AIDS (Anderson et al. 2004:952-954).

Contraception
There is a growing body of literature bearing testimony to cultural risk fac tors for HIV infection of female stu dents, including assault, coercion, poor interpersonal communication and high levels of risk-taking.According to the 'International Women's Health Coali tion' (2008:3), the imbalance of power between male and female partners in heterosexual relationships, greatly re duces the ability of young women to either refuse or negotiate the use of condoms.Research among students from a Western cultural background found that both male and female stu dents see contraception as the respon sibility of the female (Marcus, 2002:26).In addition, female students from an African cultural background often be lieve that not using a condom will en hance their social status with their male counterparts (Seloilwe, Jack, Letshabo, Bainame, Veskov, Mokoto, Kobue & Muzila, 2001:204).They may even be expected to demonstrate their fertility by having children before they can get married (Preston-Whyte & Zondi, in LeClerc-Madlala, 2002:28).The choices made by female students regarding whether or not to use contraception, what type of contraception to use and whether it will prevent HIV infection, affect their vulnerability.Factors con tributing to female students not choos ing contraception that also serves as a barrier against HIV infection, include the reality that female students are more concerned about an unplanned pregnancy than HIV, and that condoms are often seen in a negative light (Marcus, 2002:8-9;Skidmore & Heyter, 2000:31;Serlo&Aavarinne, 1999:469).
In both African and Western cultures, gender may influence male students' use of the male condom as a barrier method against HIV and unwanted pregnancy.As mentioned above, a male paradigm is recognised in condom use (Harrison, Xaba, Kunene & Ntuli, 2001:67-69).Research findings reported the following reasons why men do not always use condoms during sexual en counters, i.e. they 'dislike condoms because they are unromantic; condoms are uncomfortable and caused loss of erection/decreased sexual perform ance; or the unavailability of condoms' (Badenhorst et al. 2008:106-123;UNAIDS, 2005).In addition, in some cases male students will use insincere 'expressions of love' in order to have unprotected sex with female students -thus fear of rejection may cause fe male students to engage in unsafe sexual practices.Furthermore, both male and female students indicated feeling uncomfortable in talking with their part ner about issues related to HIV risk (Thom pson-R obinson, Richter, Shegog, Weaver, Trahan, Sellers & Brown, 2005:27).According to Levine and Ross (2002:94), the associations made by students between love, pas sion and trust combine in such a way that asking questions about previous sexual relationships and requesting condom use sex are deemed in appropriate.Despite the fact that stu dents have a sufficient knowledge base with regard to HIV and its modes of transmission to make them more aware and more careful to avoid being in fected with the HIV virus and STIs (Levine & Ross, 2002:89-108;Uys, 2002:295-311;Eaton & Flisher, 2000:97-124;Coughlan et al. 1996:255-261), many of them still do not use any form of contraception.Recent research find ings conducted at South African uni versities confirm this trend among stu dents, for example, 44% of sampled stu dents at the University of the Free State, comprising students from Afri can and Western cultures, indicated having had sex with between two and five sexual partners since their regis tration at this tertiary institution, whilst nearly 20% of UFS students admitted to using not any form of contraception.In practice, this implies that a fifth of these participating students are cur rently at risk of infection or being in fected by their partner (Badenhorst et «/.2008:106-123).

Circumcision
Unprofessionally performed, circumci sion provides a cultural, gender-related risk factor for HIV infection among male students.The circumcision of young males is practised in several cultures, and may be performed for medical, cul tural or religious reasons.In South Af rica, male circumcision is seen as an important part of African cultures' ini tiation process, symbolically leading the young male into adulthood.Tradi tionally, it is believed that the male's masculinity is tested during this pro cedure.However, major problems have emerged as far as traditional male cir cumcision in South Africa is concerned.Several health risks are associated with the procedure.If it is not done by a medically qualified person -this may include among others unhealthy sur roundings, incorrectly performed cir cumcisions -it may lead to infection of circumcision wounds, gangrene of the penis, or even death (Peltzer, Nqeketo, Petros & Kanta, 2008:1024).During group circumcision procedures unsteri lized tools (such as a razor or a piece of glass) are sometimes used (Louw, 1998:480), resulting in participants in fecting one another with HIV.In stark contrast to the negative perceptions associated with unprofessionally per formed circumcision procedures, some health professionals are in favour of medically performed male circumcision procedures and inter alia postulate that male circumcision can be an additional important intervention to reduce the risk of heterosexually acquired HIV (Peltzer et al. 2008(Peltzer et al. :1024(Peltzer et al. -1025)).The theory that male circumcision may pro vide protection against HIV infection originated and developed in North America and is based on the following assumptions, namely keratinisation of the glans when not protected by the foreskin; quick drying after sexual con tact, reducing the life expectancy of HIV on the penis after sexual contact with an HIV positive partner; and the reduc tion of numerous target cells on the foreskin.In addition, it is postulated that male circumcision may also cause a reduction in STIs, which in turn will reduce the acquisition of HIV (Auvert et al. 2005(Auvert et al. :1120)).However, despite nu merous observational studies that were carried out in Africa, insufficient evi dence was found to suggest that male circumcision intervention prevented HIV infection.
Pervasive gender inequalities mean that females in particular face numer ous violations to their sexual and re productive health and rights, includ ing sexual initiation ceremonies and female circumcision procedures that have a detrimental effect on their physi cal and em otional w ell-being (Jejeebhoy, Shah & Thapa, 2005:171-185).Female circumcision is undoubt edly one of the gravest forms of gen der-based human rights' violations committed against women.The most severe form of female circumcision, also known as female genital mutilation, is called 'pharaonic' circumcision and in volves the removal of the 'clitoris, la bia minora and parts of the labia majora'.The two sides of the 'vulva' is stitched together, leaving only a small opening for urination and menstruation (Van den Berg & Van Rooyen, 2007:210).Direct consequences of female circumcision are the contraction of infections and risk of HIV infection due to unsterilized instrum ents and the perform ance thereof by ignorant people and laymen; chronic urinary tract infections; incom plete healing; and excessive scar tis sue that can cause vaginal obstruction.Young females sometimes bleed to death or they become infertile (Van den Berg & Van Rooyen, 2007:210;Brady, 1999:209-211).Thus, it is imperative that health-care providers fulfil an important role in the eradication of this cultural practice, acting as advocates by in creasing professional and public aware ness about such practices, and explain ing the dangers and lifelong disabili ties it imposes (Brady, 1999:714-716).

Financial status
Social and economic realities have a direct impact on HIV/AIDS as well as the quality of life and potential success of university students.Many students are forced to migrate to bigger towns to attend university, which affects their financial security and makes them more vulnerable to HIV.Students who are economically and socially disadvan taged in particular, are at the highest risk for HIV infection because of the impoverished living conditions they are exposed to (Van den Berg & Van Rooyen, 2007:213).In addition, many students' bursaries are not dispersed until well into the academic year, creat ing an unstable economic situation (Southern African Regional Universi ties Association, 2009:19).South Afri can literature of the last five years makes it abundantly clear that finan cial status is a major HIV risk factor, often influenced by gender.A lower economic status adds to the problem of females having unwanted sexual re lationships (Evian, 2003:204).It was found that 'sugar daddy' practices and prostitution occur in South African stu dent communities (Kelly, 2001:30-31).Money often plays a role in young women bargaining with older men for sexual favours.A regular practice in African and Western cultures is that of males presenting female sexual partners with gifts.These partners are seen as 'girlfriends' and not as 'prostitutes' (Delius & Walker, 2002:7).
Female students sometimes regard sexual practices and their gender as a source from which to gain material and financial advantages.Sexual favours may vary on a continuum from rewards for meeting basic needs to sex for ex pensive item s.The tendency of younger women to form relationships with men five to ten years their senior and to accept money or favours in re turn for sex increase the likelihood that they will be exposed to HIV (Chikore, 2000:39).The literature also points to the fact that young women are even becoming greedier in their financial ex pectations when bargaining for sexual favours (Le Clerc-Madlala, 2002:30-31).Female students might also see sex with older men as a means to increase their social status.The financial position gained by these practices compensates for their lack of social and sexual power.Levine and Ross (2002:102-103) warn that fem ales' subm issiveness and sexual liaisons should not only be linked to students from an African cul tural background, but are applicable to Western gender roles as well.
Male students' financial status be comes a risk factor when they do not have the financial resources to buy ex pensive accessories (Selikow et al. 2002:24).South Africa's high unem ployment rate may be seen as a con tributing factor in pressurising male students to prove their masculinity in other ways than their financial means (Barnes, 2000:19).Uncertainty about their financial future as a result of lim ited job opportunities could lead to male students being more aggressive towards their female partners in sexual relationships.This supports the find ings by Strydom and Strydom (2002:262) that HIV prevention among students is hampered by social and economic factors that are beyond their personal control.Since male students see themselves as initiators of sex, based on their gender norms, they can pursue several sexual relationships as an alternative route in order to gain macho status (Le Clerc-M adlala, 2002:30, 33).Moreover, Levine and Ross (2002:101 -102) warn against link ing male licentiousness and female submissiveness only to African cul tures, since they may also be found in other cultural groups.It is highly likely that this phenomenon, in view of intercultural relations on campus and the patriarchal basis of Western cul ture, will also be found among male stu dents from a Western cultural back ground.

Myths
M isconceptions about HIV/AIDS amongst South Africans are often linked to cultural beliefs and convic tions, such as "individuals that have been bewitched because ancestral spir its have been disobeyed and aggra vated; ancestral spirits purportedly punishing individuals to fall ill; that diseases that were initiated by ances tors is seldom fatal and can be over come by offering sacrifices to restore the positive relationship between the individual and the ancestor" (Van den Berg & Van Rooyen, 2007:201).Culture and gender may be linked to myths surrounding HIV that make women more vulnerable to HTV/AIDS infection.These factors are entwined with one another, and must be viewed as uni versal to females, with individual ef fects and influences on their behaviour and how members of the opposite sex and the community see them.Research suggests that widely believed myths still exist amongst many cultures, thus reinforcing negative attitudes about safer sex, one of the most prominent of these myths being the virgin-cleansing myth, i.e. the belief that sex with a virgin will cure HIV infection and AIDS (Jewkens, 2002:13;Levine & Ross, 2002:89).If these myths are believed in specific cultural groups, there is a pos sibility that many female students, in view of their gender, are the 'victims' of gender-based sexual violence and rape by HIV-positive men in their com munities believing them to be virgins.In contrast, female students may take part in these 'sugar daddy' practices and prostitution, not only because of the possible enhancement of financial and social status, but due to the myth that HIV is only found among young people, and that unprotected sex with older men is therefore seen as 'safe' (Levine & Ross, 2002:104).
The myth that HIV does not cause AIDS, and that it is only a method used by Western cultural groups to restrict their population growth, might lead to students (both male and female) from African cultural backgrounds not con sidering the risk of HIV infection being a reality (Le Clerc-Madlala, 2002:39).Myths that condoms have microscopic holes in them, which can let the HIV virus through, might improve the chances of male students not using condoms (which are already viewed in a negative light) (Coetsee, 2007:15).

'Othering'
People's attitudes towards HIV/AIDS may also affect their own sexual behav iours.Several researchers have found a general inclination among students of different cultural groups (who see their peers as part of their 'in-group') to associate the risk of HIV infection with specific groups (identified as peo ple outside their peer group, and seen as the 'out-group').Since students are not part of the identified stereotypical out-groups in which HIV infection is perceivably found, they see them selves as 'safe' during sexual encoun ters with a person belonging to their in-group, resulting in high levels of sexual activity with a lower level of safer sex practices (B adenhorst et al. 2008:119-121.This ' othering' of the dis ease leads to the possibility that female students, in view of their gender, cul tural group and social habits, might not see themselves as at risk of being in fected with HIV.Female students from both African and Western cultures have stigmatised the following groups' cul tural backgrounds as carriers of HIV: poor rural women, gay men, prostitutes and drug addicts (Levine & Ross, 2002:93;Shaw, 2002:92;Uys, 2002:388).
Male students, like females, are also inclined to 'othering'.This issue causes male students to regard HIV as something that only happens to 'other people' belonging to stereotypical out groups.Students perceive their social circle to be closed to people of the out groups, and therefore see their in-group as 'safe'.Their belief that their social networks are not promiscuous is con fused with the notion that "birds of a feather flock together" (M arcus, 2002:32).Myths and stories about out groups ('they') being infected with HIV may quickly reach levels of conviction and influence how they are treated by the rest of the student community.Poor individuals without scholastic or terti ary education, gay men, and hetero sexual students may be included in these stigmatised groups.Cultural stigmatisations also exist among stu dents; and students from a Western cultural background see students from African cultural backgrounds as the carriers of the disease.Students, not w ithstanding their cultural back grounds, stigmatise poor black people with a lack of education as being re sponsible for spreading HIV (Badenhorst et al. 2008:106-123;Levine & Ross, 2002:100).Marcus (2002:27) affirms that back ground, education and culture combine to form a sense of individual or collec tive safety.HIV infection is also seen as an abstract fear by students, and the groups identified as the carriers of HIV (by an in-group) are seen as dis tant from the students themselves, ei ther through age, race, cultural or so cial associations.Even though stu dents may admit that the risk of HIV infection is closer and greater than they want to believe, it does not mean that they will stop looking for ways to reassure themselves.All these factors contribute to students not seeing them selves as being at serious risk of con tracting HIV (Akande, 2001:248;Kelly, 2001:19;Heunis, 1994:149).

Conclusion
Tertiary education represents a time for sexual exploration and freedom for many young people.Many students become sexually more active as they move to urban settings away from their homes and enter a developmental phase during which experimentation and risk-taking with a variety of sexual practices seem appealing.Unfortu nately this sexual exploration and free dom can result in students contracting HIV (Thom pson-Robinson et al. 2005:26).Statistical findings among students predicting a 10% increase in the HIV infection rate of universities' undergraduates in only five years (Levine & Ross, 2002:90), as well as the possible inability of universities to cope with societies' demands for academi cally trained workers due to the effect of HIV and AIDS on students (Bridgraj, 2000:9), draw attention to new high-risk behavioural patterns among students who are normally seldom targeted in HIV/AIDS prevention programmes.
According to Gordon (2008:7) negative outcomes associated with sexual be haviour are the result of both risk (at the personal level) and vulnerability (the socio-economic and cultural fac tors that put people at risk in the first place).In this literature review a myriad of factors that might influence students' HIV risk behaviours were discussed, for example, male dominance vs. female submissiveness; age of the first sexual encounter; gender-based violence; contraception; circumcision; financial status; myths; as well as the concept o f'othering'.
The ever-increasing statistical records of HIV/AIDS prevalence, especially in South Africa and other sub-Saharan countries, further bear testimony of the fact that current HIV/AIDS interven tion programmes have failed to address the underlying concepts of masculin ity and high-risk violent practices of sexuality.What is warranted is a new and inclusive understanding of the HIV/AIDS crisis, recognising that it not just a health issue, but also a develop mental, gender, social and economic issue that should be regarded inclu sively.Moreover, in a country such as South Africa, deeply rooted AIDS-related stigmas and fear of abandonment (especially women), create a barrier to HIV testing and have negative conse quences for AIDS prevention and treat ment (Meiberg, Bos, Onya & Schaalma, 2008:49,53).Thus it is imperative that future HIV/AIDS educational pro grammes, both at school and tertiary educational levels, should also address issues such as poverty reduction, gen der inequality, stigmatisation and dis crimination, which place people at greater risk for HIV, STIs and unwanted pregnancy.In practice this implies the coordination of HIV prevention activi ties with strategies that address the poor economic conditions and unequal gender norms that encourage young people, including students, to engage in risky sexual relationships (Gordon, 2008:10).Any national policy should be inclusive, involving all stakeholders in the process, including students.Fur thermore, greater pressure must be placed on government and tertiary edu cation institutions to implement pro grammes to contend with and educate growing numbers of tertiary education students who may be receiving no or inadequate sexual health education.In conclusion, we would like to make the following recommendations to address the issue of HIV/AIDS infection in gen eral, as well as the high risk sexual be haviour of university students specifi cally:

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The culture o f'silence' that sur rounds human sexuality, which provides fertile ground for the undetected spread of HIV and STIs, needs to be broken (Shisana, 2004:8)

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