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.

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”.

A 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.

Most HIV prevention programmes assume that people can protect themselves once they know what to do, such as be faithful to one sexual partner and insist on using a condom. But in real life not everyone has this choice. Victims of sexual violence, young girls having sex with older men and women who are afraid of their partners are not able to insist on condom use. Although the mechanism of prevention through condom use is straightforward, for these people – mostly young women – something else has to change before they can opt for condom use. INSTRUCT tries to make some of those changes: an enabling environment in their communities, services that understand people who cannot easily act on their prevention choices, and a structurally different economic position.