In 2006, Professor Neil Andersson used the term choice disabled to describe people unable to make choices to protect themselves against HIV infection, even when they have the knowledge to do so.

Choice disability is an important driver of the AIDS epidemic in Southern Africa. People who have experienced sexual abuse as children are more likely to engage in risky behaviours as adults, such as having multiple sexual partners and not consistently using condoms. In a large-scale CIET survey among school going youth in South Africa, those who had experienced forced sex were more likely to hold risky attitudes about HIV and more likely to say they would spread the infection deliberately if they found themselves to be infected.

Choice disability factors include poverty, lack of education, educational and income disparity with partners, and experience of gender violence, including childhood sexual abuse, physical intimate partner violence and forced sex. Women are more likely than men to be choice disabled, but men are not immune. In Southern Africa, choice disability affects young women disproportionately, reflecting marked power inequality in sexual relationships, particularly in transactional and inter-generational sex. It helps to explain the shape of the AIDS epidemic in the Southern African countries at its epicentre. Women overall are more affected than men and in women the rates of HIV infection are highest among those aged 15-29 years, while in men the highest rates are among those aged 30-45 years.

What young women said about inter-generational sex, Botswana, Namibia and Swaziland, 2009

Focus groups of young women in Botswana, Namibia and Swaziland made clear they understood the risks of transactional sex with older men, but still found themselves drawn into such relationships because of the perceived benefits that supplied serious financial needs or peer-pressure fuelled “wants”.

2008 survey among young men and women aged 15-29 years in Botswana, Namibia and Swaziland found choice disability factors of poverty, low education, income disparity with partner, and experience of intimate partner violence were associated with the risk of being infected with HIV. The risk was cumulative with increasing number of choice disability factors.

The concept underlying the Choice Disability trial is that dealing with choice disability is pivotal in stopping the AIDS epidemic in Southern Africa.