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We explored transactional sex and relationships (TSR) among South African adolescent girls and young women (AGYW) using (1) survey data from 4,399 AGYW aged 15-24 years, and (2) qualitative data from 237 AGYW and 38 male peers. Ten percent of sexually active AGYW reported having ever had transactional sex; 14% reported having stayed in a relationship for money or material items. Factors associated with higher reporting of TSR included HIV positivity, higher food insecurity, and alcohol use. Those AGYW who were between the ages of 20-24 years (OR: 1.0; 95% CI: 0.81-1.24), had a sexual partner older than her by 5 years or more (OR: 1.89; 95% CI: 1.58-2.26), and had a transactional relationship in the past (OR: 61.1; 95% CI: 47.37-78.76) were more likely to report having transactional sex. AGYW qualitative narratives included both assertions of agency in choosing to engage in TSR, and power inequities resulting in condomless sex. Our findings can inform interventions to addressing transactional sex and relationships, critical to South Africa's HIV response., (© 2021. The Author(s).)

In South Africa, adolescent girls and young women (AGYW) are at risk of poor mental health, HIV infection and early pregnancy. Poor mental health in AGYW is associated with increased sexual risk behaviours, and impeded HIV testing and care. Using in-depth interviews and focus group discussions, we explored subjective experiences of mental health and sexual and reproductive health (SRH) amongst 237 AGYW aged 15-24 years in five South African districts. Respondents shared narratives of stress, emotional isolation, feelings of depression, and suicidal ideation, interconnected with HIV, pregnancy and violence in relationships. Findings show that AGYW in South Africa face a range of mental health stressors and lack sufficient support, which intersect with SRH challenges to heighten their vulnerability. Framed within the syndemic theory, our findings suggest that South African AGYW's vulnerability towards early pregnancy, HIV infection and poor mental health are bidirectional and interconnected. Considering the overlaps and interactions between mental health and SRH amongst AGYW, it is critical that mental health components are integrated into SRH interventions.