Background: Anal sexual intercourse can significantly increase HIV transmission risk. However, eliciting valid information on anal sex history in surveys can be complicated by heterogeneous understanding of the term “anal sex”, and by the social undesirability of reporting such behaviour. We explored how questions regarding anal sex were interpreted in a high-HIV-prevalence rural KwaZulu-Natal community, including understanding of terms and acceptability of questions.
Methods: 341 adults (53% female) completed a quantitative questionnaire including questions about anal sex. Cognitive interviews were conducted with 13 men and 15 women post-questionnaire. Interviewers used both pre-scripted and spontaneous retrospective verbal probing techniques. Interviews were audio-recorded, transcribed and analysed.
Results: 3% of respondents reported ever having had anal sex; 7% declined to answer the question. Levels did not differ by gender, however those aged under 30 reported having had anal sex significantly more often (7.3%) than those aged over 30 (1.6%). In cognitive interviews, interviewees reported that anal sex is practiced locally. The majority of interviewees perceived anal sex as socially unacceptable; a few perceived it as increasing HIV infection risk. Two-thirds of men understood anal sex as being practiced primarily by men-who-have-sex-with-men, prisoners and ex-convicts. One woman reported anal sex as a way of gaining sexual pleasure; one woman perceived it as a contraceptive method. 65% of the interviewees (59% women; 41% men) found the survey question “Have you ever had anal sex” easy to answer, although only 71% of these interpreted the term “anal sex” as intended in the survey. Other interpretations including non-anal sex (''dog style'', ''thigh sex'') and gendered readings (''inserting his penis into a woman''s anus'', ''into another man''s anus''). The majority of interviewees (62%) stated that the survey question can be included in regular survey questionnaires.
Conclusions: Reporting of anal sex remains socially undesirable to many in this setting, but asking questions about this topic is considered broadly acceptable. Anal sex may be an important risk factor for HIV in rural KwaZulu-Natal, but given widespread misperceptions about the term, careful explanation within survey questionnaires is likely to be a pre-requisite to generating valid prevalence data.

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