“My childhood affected my ability to be resilient in both good and bad ways”: A mixed methods examination on the links between adverse childhood experiences, resilience, and transactional sex among young South African women

BACKGROUND: South African women are disproportionately impacted by HIV. Among these women, adverse childhood experiences (ACEs) are common and have been linked to HIV risk behaviors, including transactional sex (TS). Resilience-or multi-level processes related to overcoming adversity-provides a strengths-based lens that may buffer effects between ACEs and TS. METHODS: We conducted a convergent mixed methods study among women aged 18-25 years in Mpumalanga, South Africa. We used logistic regression to assess the association between ACEs and TS; and tested moderation effects of five resilience scales across social-ecological levels hypothesized to dampen the effect of ACEs on TS. In parallel, we conducted a photovoice study that utilized participant-generated images and narratives, and thematic and sequence analysis to explore how women exposed to ACEs perceive and use resilience to navigate TS relationships. RESULTS: Our analysis included 1,222 women aged 18-25 years, of whom 714 (58.43%) reported ACE exposure, with 519 (42.47%) reporting 1-2 ACEs and 195 (15.96%) reporting ≥3 ACEs; 340 (27.82%) reported TS. Women reporting ACE exposure had increased odds of TS compared to those without ACE exposure, controlling for confounders (AOR = 1.52, 95% CI: 1.17-1.99, P = 0.002). Among women with histories of ACEs, women with ≥3 ACES had 2.55 times the odds of TS than those reporting 1-2 ACEs (95% CI: 1.79-3.63, P=