Lyn's Comment: An number of studies have shown that the practice of men and women having multiple or concurrent sexual partners is a key driver in the HIV epidemic and plays a particular role in the high burden of infection in Southern Africa. Some researchers question the sterngth of this link.
MCP or multiple concurrent partners can be described as when an individual has more than one sexual partner in the same time period.
MCP featured in many presentations at the 4th SA AIDS Conference.
The role of culture in encouraging more than one sexual partner at a time is also often mentioned. We highlight a number of article and tools dealing with MCP:
The idea that concurrency is more prevalent in Africa than elsewhere
Johannesburg - An academic dispute about whether concurrent sexual partnerships are really a major factor behind high rates of HIV in sub-Saharan Africa could affect the future of prevention programmes.
The relatively common practice in many African countries of having ongoing relationships with two or three partners at the same time, has led researchers to explore concurrency as a possible explanation for why parts of the continent have been so hard hit by HIV.
While most Africans report similar numbers of partners over a lifetime as their Western counterparts, having long-term simultaneous relationships is thought to put them at much higher risk from HIV by placing them in overlapping sexual networks that serve as “a superhighway for the rapid spread of HIV”, as scientist and author Helen Epstein, puts it in her book, The Invisible Cure.
As studies from around Africa have provided more evidence to support the theory, it has gradually gained currency with epidemiologists and public health experts. In recent years multiple concurrent partnerships (MCPs) have become widely accepted as one of the main drivers of HIV epidemics in southern and eastern Africa and prevention programmes have been designed accordingly.
But not everyone in the scientific community accepts the theory. Its main proponents – Daniel Halperin, Helen Epstein, Martina Morris and Timothy Mah – have come under fire from several critics in the past year who argue that there is insufficient evidence to support the focus on MCPs.
The latest installment in the debate arrived in September in the form of an article in the Journal of the International AIDS Society by Larry Sawers and Eileen Stillwaggon, both United States-based economists, that minutely reviews the evidence to support the concurrency hypothesis and finds it either lacking or contradictory.
The authors refute the idea that concurrency is more prevalent in Africa than elsewhere, arguing that the mathematical model used to validate the hypothesis was seriously flawed by over-estimates of the frequency of sexual contact and the risk of contracting HIV per sexual encounter among other things.
They insist there must be other explanations for Africa’s extraordinary HIV epidemics, such as high levels of bacterial, viral and parasitic infections in the region that make people more vulnerable to HIV and more likely to transmit it. They also suggest that the role of blood exposures from unsterilized syringes, circumcision and dental procedures deserves more attention.
Finally, and most controversially, Sawers and Stillwaggon call for an end to sexual behaviour research in Africa and “the continued use of financial and human resources to prove Western preconceptions about African sexuality”.
The Response
Speaking to IRIN/PlusNews over the phone from Boston where he is a lecturer on International Health at the Harvard School of Public Health, Halperin described the article as “very damaging potentially” and compared Sawers and Stillwaggon’s approach as similar to that used by AIDS and climate change denialists.
Halperin pointed out that the types of parasitic diseases mentioned by Sawers and Stillwaggon as possible alternative reasons for African HIV epidemics, such as schistosomiasis and malaria are not common in many of the countries that have the highest HIV prevalence rates.
“It seems pretty compelling for someone who’s not up on all the literature," he said. "But it’s actually preposterous what they’re suggesting – that non-sexual transmission is the main reason for high HIV in Africa.
"If you go out to shebeens [informal taverns in South Africa] and talk to people about sexual behaviour, I’m sure you’ll find out what’s going on. Everyone will tell you that strict mutual monogamy is the exception not the rule."
In response to criticisms of the model that was originally used to validate the concurrency hypothesis, Epstein said it was not designed to be realistic but to answer a simple question about the role of over-lapping versus serial relationships in the spread of HIV. In the 13 years since the model was developed, she added, other researchers have looked at data from real populations and found that concurrency did explain a major part of epidemics, but that Sawers and Stillwaggon had not included those studies in their review.
"This isn't a balanced approach," she told IRIN/PlusNews. "I think there definitely needs to be debate about anything that has strong implications for programming because we really don’t have a good handle on prevention in Africa, but I think we really need better scholarship."
Epstein added that the role of concurrent partnerships as a driver of HIV had only become a focus of HIV/AIDS efforts in Africa in the past couple of years. "We’ve really just arrived at this new understanding of what’s going on and we need to give it a chance to work."
Like Halperin, she worried that the debate could influence the types of programmes that donors choose to fund at a time when competition for funding is particularly fierce. "Donors already are backing away from behavioural approaches to HIV and towards taking a totally biomedical approach...and I think that would be a tragedy," she said.
"Red herring"?
Programme implementers on the ground are mostly oblivious to or perplexed by the academic debate. "The merits of programmes need to be looked at for their merits and not dictated by ideological points of view," said Richard Delate, programme director for Johns Hopkins Health and Education in South Africa (JHHESA) which has been involved in a number of campaigns with a MCP focus all of which Delate insisted were evidence-based.
Dr Sue Goldstein, a researcher with the South Africa-based Soul City Institute for Health and Development Communication described the debate as "a red herring".
"We all tend to agree with the UNAIDS call for combination prevention which really looks at biomedical, social and behaviour change together to try and address a massive epidemic," she told IRIN/PlusNews.
She nevertheless endorsed the MCP focus of her organization's OneLove campaign, which has rolled out in nine southern African countries since 2008. "Previously, we’d really pushed condoms and we kind of felt it wasn’t working so we did want to push MCPs, but we looked at underlying issues – cultural and social, which in the end are what are going to change people’s behaviour," she explained. "Our OneLove campaign has been exceptionally well received and people are really keen to start these discussions."
According to Sawers, however, his criticism of the concurrency theory has already gone beyond the level of academic debate. Responding to IRIN/PlusNews by email from Washington DC, where he teaches economic development at American University, he said that he and his co-author had just returned from Nigeria where they met with the National Agency for the Control of AIDS and the local office of the U.S. Centers for Disease Control and Prevention (CDC).
"We found an openness and excitement about our ideas, and an eagerness to implement concrete actions based on our ideas," he wrote. "What we heard from many people...in Nigeria is that a well-reasoned and carefully argued proposal to donors is likely to be funded."
He added that without "effectively dismissing" the concurrency argument first, he had no doubt their reception would have been less enthusiastic.
The theory that multiple, overlapping sexual partnerships are a key driver of generalised HIV epidemics in Africa has been attacked as being based on insubstantial evidence. The critics, writing in the journals AIDS and Behavior and The Lancet, argue that researchers lack a precise definition of concurrency or a standard way to measure it, and that the data do not show a significant association between concurrency and either HIV incidence or prevalence.
However this critique has stimulated a fierce debate in the United States. Proponents of the concurrency thesis argue that the critics’ analysis of the data is selective, that evidence from a wide range of sources supports the thesis, and that it would be irresponsible for prevention programmes in Africa to ignore this issue.
Concurrency
Concurrent sexual partnerships describe situations in which an individual has overlapping sexual relationships with more than one person. They can be contrasted with serial monogamy, when an individual has a sexual relationship with only one partner, with no overlap in time with subsequent partners.
A number of researchers, including Daniel Halperin, Timothy Mah and Martina Morris have suggested that concurrent relationships can increase the size of an HIV epidemic, the speed at which it infects a population and its persistence within a population.
The explanation for this is that in situations where a significant proportion of both men and women have concurrent relationships, even if they only have two partners each, as soon as one person in the network of concurrent relationship contracts HIV, then other people in the network are at risk (unless condoms are used). More people are more often exposed to the virus, including during the acute infection period when people are extremely infectious.
In contrast, in situations of serial monogamy, even if men and women have a relatively high number of sexual partners during their lifetime, one relationship is over before another is started. This means that if HIV is passed on within a relationship, it cannot be further transmitted as long as that relationship lasts. (For more background, click here.)
Critique
Mark Lurie and Samantha Rosenthal however argue that even if this theory is persuasive, empirical evidence for it is lacking. They call for better designed studies to clarify the contribution concurrency may make to generalised epidemics in Southern and Eastern Africa. Moreover, they believe that delivering prevention interventions around concurrency could be counter-productive and may divert resources away from other prevention methods that have proven efficacy.
Lurie and Rosenthal argue that concurrency is often vaguely and inconsistently defined. Some studies in fact collect data on total numbers of partners, and not concurrent relationships. Moreover, some include very brief or one-off liaisons (e.g. with a sex worker), but most do not.
Mah and Halperin, proponents of the concurrency thesis, accept that the lack of a consensus definition of concurrency or of a universally accepted method of measurement hampers comparison between studies.
They report a proposed standard definition from a UNAIDS working group: overlapping sexual partnerships where sexual intercourse with one partner occurs between two acts of intercourse with another partner.
The debate between Lurie and the other researchers focuses on the different type of research studies that may or may not demonstrate the contribution that concurrency makes.
The prevalence of concurrency in a population
A number of studies have taken a representative sample of a population to quantify the proportion of people who are participating in concurrent sexual relationships. These surveys show wide variation between different countries, with populations in sub-Saharan Africa tending to report much more concurrency than populations in other parts of the world.
Lurie and Rosenthal’s main criticism is that these studies simply cannot tell us anything about a link between concurrency and HIV.
In addition, they question the validity of comparisons between countries, given the variety of definitions used by researchers. They believe that there is no substantial evidence that levels of concurrency are significantly higher in Africa than elsewhere.
Lurie and the other authors tussle over the same studies. Referring to a review of sexual behaviour in 59 countries, Lurie insists that it found that concurrency rates could not be compared and that African adults are less sexually active than adults in other regions. In contrast, Mah and Halperin provide the following quote from the same study: ‘‘Evidence is available that, although lifetime numbers of partners might be lower, concurrent relationships in men in some African countries might have been more common and of longer duration than in other regions’’.
Qualitative data
Whereas Mah and Halperin believe that qualitative research can demonstrate that concurrency is a highly normalised behaviour in many parts of southern and eastern Africa and can help us understand its socio-cultural underpinnings, Lurie and Rosenthal dismiss qualitative research as inherently unrepresentative and prone to bias.
Individual studies
Only a few studies have compared individuals’ participation in concurrent relationships and their HIV status, and Lurie and Rosenthal note that a consistent relationship has not been found.
However Martina Morris, a leading researcher of concurrency, argues that such studies are “theoretically misguided and empirically irrelevant”. She says that concurrency is not a risk for the person who has more than one partner, but a risk for that person's partners. A monogamous partner may be exposed to HIV, not by his or her own behaviour, but by the partner’s concurrency. Because of this, future studies will need to enrol partners.
Mah and Halperin also believe that concurrency increases an individual’s risk of transmitting HIV, not their risk of acquiring it. They point to studies from Uganda and Zimbabwe where HIV infection was associated with the belief that one’s partner was having concurrent relationships.
Population studies
In 2001, Lagarde and colleagues reported a study that used a standardised questionnaire to assess concurrency rates and HIV prevalence in five sub-Saharan cities. The study did not find that the two factors were correlated - for example, some lower prevalence cities had high rates of concurrency.
Lurie and Rosenthal cite this as a key study, but Martina Morris rejects the study design entirely. This is because HIV prevalence represents infections that have accumulated over many years, whereas the survey measured concurrency only in the previous year.
Mathematical modelling
Lurie and the proponents of concurrency all agree that the most powerful demonstrations of the influence of concurrency have come from simulation models. For example, Martina Morris and Mirjam Kretzschmar worked on Ugandan data and concluded that increasing the level of concurrency would have a more significant impact on epidemic spread than increasing the number of partnerships.
Lurie and Rosenthal say that even if these models show that concurrency can drive an epidemic, such theoretical work cannot demonstrate whether concurrency is actually doing so in Africa.
They also comment that other modelling studies, which found that the total number of partners or mixing between different social groups were more important than concurrency, tend not to be cited by the other authors.
In addition, in the articles published by Lurie and Helen Epstein, there is much claim and counter-claim as to the definitions used and the validity of the assumptions that were fed into the various modelling studies.
Conclusions
Mark Lurie and Samantha Rosenthal believe that the evidence base for the role of concurrency is weak and contradictory, and that better research with more refined definitions needs to take place before interventions to reduce concurrency can be delivered.
Morris counters that the studies Lurie and Rosenthal have looked at cannot prove or disprove the hypothesis. More sophisticated studies are being worked on and will give a more precise picture of concurrency’s role, “but no one argues that concurrency is irrelevant to transmission,” she says.
As such, she says it would be a “real tragedy” if methodological limitations were used to justify a do-nothing policy.
Mah and Halperin also argue that if HIV prevention interventions were never implemented until the most reliable evidence had been gathered, the only ones in use today would be male circumcision and interventions to prevent mother-to-child transmission. They believe that prevention messages which encourage people to have only one partner at a time are needed as one component of a prevention response.
References
Mah TL & Halperin DT. Concurrent sexual partnerships and the HIV epidemics in Africa: evidence to move forward. AIDS Behav published online ahead of print, 2008.
Lurie MN & Rosenthal S. Concurrent partnerships as a driver of the HIV epidemic in sub-Saharan Africa? The evidence is limited. AIDS Behav published online ahead of print, 2009.
Mah TL & Halperin DT. The evidence for the role of concurrent partnerships in Africa’s HIV epidemics: a response to Lurie and Rosenthal. AIDS Behav published online ahead of print, 2009.
Epstein H. The mathematics of concurrent partnerships and HIV: a commentary on Lurie and Rosenthal, 2009. AIDS Behav published online ahead of print, 2009.
Morris M.Barking up the wrong evidence tree. AIDS Behav published online ahead of print, 2009.
Lurie MN & Rosenthal S. The concurrency hypothesis in sub-Saharan Africa: convincing empirical evidence Is still lacking. Response to Mah and Halperin, Epstein, and Morris. AIDS Behav published online ahead of print, 2009.
Lurie MN et al. Concurrency driving the African HIV epidemics: where is the evidence? Lancet 374: 1420, 2009.
Shelton JD. Author’s reply. Lancet 374: 1420, 2009.
A person’s risk of HIV is driven more by how many sexual partners they have in their lifetime than whether they have more than one lover at a time.
A person’s risk of HIV is driven more by how many sexual partners they have in their lifetime than whether they have more than one lover at a time.
This is according to extensive research conducted over five years by scientists from the Africa Centre in Umkhanyakude district in rural KwaZulu-Natal. The results were published today (Friday 15 July) in the prestigious Lancet journal.
Debate has raged for years about the role that concurrent sexual partnerships play in HIV transmission, with a number of experts arguing that multiple concurrent partnerships is a key driver of the epidemic in Africa.
But according to Dr Frank Tanser, the study’s principal investigator: “Our results clearly demonstrate the impact of multiple partnering on the transmission of HIV but we find no evidence to suggest that sexual partnerships that overlap (concurrent) are playing a disproportionately large role in driving the high rate of new infections.”
Tanser and his team followed 7000 women who were all HIV negative to begin with over five years. Almost 10 percent (693 women) became infected with HIV during the study.
The researchers used questionnaires on sexual behaviour from almost 3000 men to inform their study. Close to three in 10 of these men reported having concurrent sexual relationships.
Using innovative geographical mapping, the researchers plotted communities where men reported a high level of concurrent partners as well as these where men reported higher numbers of lifetime sexual partners.
“The high rates of HIV infection were no different between communities with the highest levels of male concurrency and communities with low levels of concurrent partnerships,” said Tanser.
In contrast, women living in areas where local men reported an increase in the average number of reported life-time partners had a significantly higher risk of becoming infected with HIV infection.
However, the scientists noted that concurrent partners may have played an important role in the rapid spread of HIV during the early phase of the HIV epidemic.
According to the Africa Centre, which is part of the University of KwaZulu-Natal, the results show that HIV prevention messages need to be clear and directed at reducing the number of sexual partners “irrespective of whether these partnerships overlap”.
A new report suggests networks of male friendships could be used to help combat the HIV and AIDS epidemic in Sub-Saharan Africa.
Lilongwe — A new report suggests networks of male friendships could be used to help combat the HIV and AIDS epidemic in Sub-Saharan Africa.
The study titled: Extra-Marital Sexual Partnerships and Male Friendships in Rural Malawi, was published last month by the Max Planck Democratic Research Institute in Germany.
The report found that a man who thinks his best friend has extra-marital sexual partners, is far more likely to report having extra-marital sexual partners himself.
The World Health Organization (WHO) has identified concurrent sexual partnerships and Extra Marital Sexual Partnerships (EMSPs) as being one of the major routes for HIV and AIDS transmission in the region.
Understanding the role that male friendships and networks play in the prevalence of EMSPs are therefore important considerations in the HIV and AIDS dialogue, the report suggests.
"Male friendships are strongly associated with whether men have extra-marital sexual partners," says the report's author, Professor Shelly Clark, an associate professor of sociology at McGill University, Canada.
"Much of the work on HIV and AIDS in sub-Saharan Africa tends to place the burden of HIV prevention on women. Although there is growing recognition that finding ways for men to reduce their risks is essential, research on innovative roles for men remains limited," Clarks says.
The data was taken from the first two waves of the Malawi Diffusion and Ideational Change (MDIC) survey in 1998 and 2001, in which researchers took a random sample of married couples from three rural sites: Rumphi - a northern district, Mchinji - central district and Balaka - a southern district.
This long term study interviewed 1,037 men in 1998 and 935 in 2001, asking them questions about their home life (such as number of wives and children), education, friends' extra-marital sexual behaviour and EMSPs. The interviews were taken from two different years to check for changes in behaviour over time.
Eighty per cent of the respondents told researchers they believed their best friend behaved the same as them. Men, whose closest friends had concurrent sexual relationships, were the most likely to report also having more than one partner, the research found.
Critically, the research found that male friends were often proven right when they suspected a friend of having an affair.
'Forty five per cent of men who reported extra marital sexual partners in the last year were suspected of infidelity by a social network member,' the report states.
"In sub-Saharan Africa, men's social networks could be effective in delivering messages about reducing the total number of concurrent partners and other safe sex practices," recommends Professor Clark.
He also adds, "men often rely on their male friends to define what is acceptable and desirable sexual behaviour, interventions which emphasize the more positive aspects of masculinity, such as being strong and protecting oneself and one's family, within these circles may prove far more effective than relying on messages from outsiders."
"In short, the research, frames men as a possible part of the solution rather than as intractable problems," Professor Clark concludes.
The study suggests that policy makers could use the power of these social networks for HIV and AIDS prevention
The breakthrough was getting that [2006] study done, and then the support just snowballed from there. People in Togo were transformed by that research into advocates
Johannesburg - In southern Africa, prevention campaigns highlighting the HIV risks of having more than one partner at the same time have largely targeted heterosexuals and ignored the fact that men who have sex with men also have multiple partners.
"Men who have sex with men" (MSM) describes men who have reported ever having had sex with another man, but who may not necessarily identify themselves as homosexual, or "gay".
In one of the first studies to investigate multiple concurrent partnerships (MCPs) among African MSM, just over half of the 537 men surveyed in Malawi, Namibia and Botswana reported that they had had sex with both men and women in the last six months, and about a third of these men reported that the relationships had been concurrent. MCPs have been identified as a main driver of the HIV epidemic in southern Africa.
Presented at the annual meeting of the African Network for Strategic Communication in Health and Development (AfriComNet) in Johannesburg, the study also found that about a third of the men surveyed had a wife or long-term girlfriend.
The men in relationships with both men and women were more likely to pay for sex and to use condoms than those who reported only having sex with men, but the study found no difference in HIV prevalence between the two groups, according to researcher Gift Trapence with the Malawi-based Centre for the Development of People (CEDEP).
About 17 percent of all the men surveyed were HIV-positive, and their HIV prevalence rates were almost twice the national average in their respective countries. Trapence said that the findings point to an urgent need to target programming and more research at MSM having multiple concurrent partnerships.
"These issues have never been involved in our HIV prevention work," he told IRIN/PlusNews. "When we try to design these programmes, we need to look at all the sexual behaviours [of men]."
Trapence said a larger, population-based study was planned to explore the findings and provide evidence crucial to prevention efforts targeting MSM, and to decriminalizing homosexuality in African countries.
CEDEP supported the two Malawian men who were recently prosecuted under laws criminalizing sexual acts between people of the same sex. Activists argue that such laws discourage MSM, who are often at increased risk of HIV, from using HIV testing and treatment services, and have a detrimental effect on prevention efforts in general.
At the meeting, representatives of Togo's national AIDS commission, and Manya Andrews, former country head of Population Services International Togo, said research into HIV risk behaviours among MSM by Togo's national university in 2006 had helped influence recent moves in the small West African country towards decriminalising same-sex relationships.
"The breakthrough was getting that [2006] study done, and then the support just snowballed from there," Andrews told IRIN/PlusNews. "People in Togo were transformed by that research into advocates [for MSM HIV prevention programmes and rights].
No complete answer as to why HIV infection is worst in Africa.
Have you ever wondered why HIV spreads so fast in Africa? Have you ever thought that people considered high risk takers, like sex workers and truck drivers, are at more risk of HIV infection than yourself? Molecular biologist and author, Helen Epstein, turns conventional wisdom around in her renowned book, "The Invisible Cure: Africa, the West and the Fight against AIDS".
Published in 2007, the book examines the complex nature of humanity's sexual relations in Africa and how that is an efficient transport system that carries HIV infection from one to many. Helen Epstein, a molecular biologist was working on an AIDS vaccine project in Uganda, east Africa, in the 1990s when she started asking questions about why AIDS was spreading faster in Africa than anywhere in the world.
"I began to notice, along with many others, that the prevailing explanation for the spread of HIV in this region was that there was a theory that HIV was spreading largely because of the behaviour and activities of so-called high-risk groups - prostitutes, truck drivers, mine workers, and so on - people who were assumed to have very high numbers of sexual partnerships. It was thought they were driving the epidemic in the region", Epstein says.
But studies and observations over years proved the argument to be without merit.
"It became clear that people in this part of the world aren't more likely to visit prostitutes than people in other parts of the world, nor do people in this part of the world have more sexual partners over a life-time than people elsewhere do. So, that explanation didn't seem to make sense", she says.
There is no complete answer as to why HIV infection is worst in Africa. But, in her book, Epstein discusses a phenomenon which many experts now think facilitates the spread of HIV in the region, and that is having multiple and concurrent sexual partners. Contrary to conventional wisdom, it has been found that it's easier to transmit HIV infection in sexual relationships that have been maintained over a period of time, than through casual once-off sexual liaisons.
"One possible hypothesis began to intrigue me, which was that it had to do with the fact that there is a greater tendency for men and for women in this region to have over-lapping long-term relationships where people sleep regularly with more than one person", Epstein says.
"And if enough people are doing that it can give rise to a kind of a network of sexual relationships that accesses a sort of super highway for the spread of the HI-virus, even if most people are only having one or two, or at most, three sexual partners. The more I looked into that and the more I talked to Africans themselves about whether this hypothesis made any sense, read studies by anthropologists and others, the more I began to realise that this could be, at least, part of the explanation for what's going on here", she continues.
In these particular networks, where people have more than one regular sexual partner at a time, the use of condoms is likely to fall by the wayside.
"Yes, if they were ever there to begin with. The tragedy of this epidemic in this part of the world in particular is that people are becoming infected in many, many cases by the people they are closest to - their long-term partners, their spouses, the people they trust the most and respect the most", says Epstein.
A abstain, B be faithful and C condomise.
For years South Africans battled to learn their sexual alphabet- A abstain, B be faithful and C condomise. Sexual behaviour has proved stubbornly resistant to change. The majority of people still do not understand that regular unprotected sex with more than one partner increases the risk of infection dramatically.
Surveys show that people from a country like Brazil have more sexual partners in one year than South Africans, but they are largely one night stands.
Here it is common for people to have on-going sexual relationships with more than one person. What’s known as multiple and concurrent partnerships. And this says the experts, is what is driving the spread of HIV.
For years South Africans battled to learn their sexual alphabet- A abstain, B be faithful and C condomise. Sexual behaviour has proved stubbornly resistant to change.
The majority of people still do not understand that regular unprotected sex with more than one partner increases the risk of infection dramatically.
In April, South Africa launched the biggest HIV testing and treatment programme in the world. To kick off the campaign President Jacob Zuma himself took a public HIV test
The aim is test 15-million people by 2011 to treat those who need it with anti-retrovirals.
But terrifyingly for every 2 people put on ARVs another 5 become HIV+. Many of them get infected because they’re having regular sex with a number of different partners.
IRIN/PlusNews takes a look at the evolution of the theory behind MCPs.
Johannesburg - As the debate heats up about whether or not multiple concurrent partnerships (MCPs) are major drivers of Africa’s HIV epidemics, IRIN/PlusNews takes a look at the evolution of the theory behind MCPs.
1982 - Uganda diagnoses its first case of HIV along the shores of Lake Victoria.
1986 - Uganda's civil war ends and the country establishes its first national HIV prevention programme which incorporates the message of “zero grazing” aimed at encouraging faithfulness and partner reduction - effectively the world’s first MCP campaign.
1992 - British epidemiologists Robert May and Charlotte Watts propose that long-term simultaneous partnerships might increase the spread of HIV.
Also around this time, Christopher Hudson becomes interested in concurrency while treating sexually transmitted infections in London. He hypothesizes that MCPs may explain the high prevalence of briefly infectious STIs such as gonorrhea among some groups of his clients. He hypothesizes that if clients had stayed in long-term, monogamous relationships, short-lived infections would have died out within these London communities.
The lingering presence of the disease in some sexual networks could be explained by people infected with gonorrhea having multiple partners during their brief periods of infectivity.1993 - Researcher Martina Morris, drawing on the hypothesis that Africa’s high HIV rates were fuelled by “high risk” populations, such sex workers and truck drivers, develops a mathematical model to predict the spread of HIV in a population and travels to Uganda to test it out. Upon arrival in the country, she meets local doctors who quickly convince her that the model would be irrelevant unless it could take into account the effect of MCPs. Morris collects the sexual histories of more than 1,000 Ugandans, charting not only the number of sexual partners but also concurrency. Around 35 percent of respondents said that at least two of their most recent relationships had overlapped by several months or years. She later conducts similar research in Thailand and the USA.
She later teams up with the mathematician Mirjam Kretzschmar to develop a new model that could compare the spread of HIV through two hypothetical populations: one in which concurrent partnerships were common and another in which serial monogamy was the norm. They found that HIV spread 10 times faster in the first population.
2003 - US President George W. Bush launches the President's Emergency Plan for AIDS Relief (PEPFAR) which places a strong emphasis on abstinence based on the assumption that HIV is spreading mainly through casual sex among youth rather than through longer-term relationships among older people. Uganda expands HIV prevention in schools with US funding. Known as the Presidential Initiative on AIDS Strategy for Communication to Youth (PIASCY), the campaign advocates abstinence-until-marriage.
2004 - Anthrpologist Daniel T. Halperin, and author and scientist Helen Epstein publish their first paper on MCPs in The Lancet Medical journal.
2006 - At a 2006 Southern African Development Community (SADC) meeting in Maseru, Lesotho, MCPs are identified as a key driver of the region's HIV epidemic, along with low levels of male circumcision and inconsistent condom use.
2008 - HIV prevalence in Uganda begins to rise, according to UNAIDS, which in its yearly report notes that new HIV infections are highest among people in long-term relationships where one or both partners have other sexual relationships at the same time.
Meanwhile, MCPs become a key focus of HIV programmes in eastern and southern Africa aimed at achieving a reduction in infections through widespread behaviour change. Campaigns include OneLove, a regional effort rolled out in nine southern African countries.
2009 - A heated debate begins between proponents of the MCP theory, such as Halperin and Epstein, and detractors like US-based social epidemiologist Mark Lurie and public health researcher Samantha Rosenthal, and continues to rage in academic journals.
JOHANNESBURG, 23 September (PLUSNEWS) - Multiple partnerships may not be as common in South Africa as previously thought, according to a study presented at the recent AIDS Research Symposium at the University the Witwatersrand, in Johannesburg.
Saul Johnson, managing director of Health & Development Africa (HDA), a health consultancy which conducted the research, said findings from four sites across the country showed about 26 percent of men and 5 percent of women reported having had more than one partner in the past year.
"The perception out there is that [having multiple partners] is more common than it really is," he told IRIN/PlusNews.
The reason may be that men tend to inflate their partner counts. Johnson and his team found that when men were asked to write down a figure for the number of partners they had had in the last 12 months they exaggerated, but when asked to plot their sexual encounters in more detail, using a sexual partner calendar, they often revised the number down slightly. Women's responses were more likely to be consistent.
Further probing revealed that most respondents - male and female - did not think having multiple partners was acceptable, but assumed that other people did. Johnson speculated that mixed messages in the media might be responsible for this widely held misconception.
"I think there's this weird dichotomy where, on the one hand, mainstream media say how terrible it is, and yet the entertainment media send a very conflicting message through soapies [soap operas] and celebrities that makes having multiple partners seem glamorous."
The survey also revealed a gap between reality and perception in the reasons for having more than one partner. The top reasons both men and women gave were related to sexual satisfaction, but almost half the respondents believed that women were mainly motivated by gifts and money.
"The media create this perception that men are having multiple relationships because they can't control their urges, and women do it because they're desperate," said Johnson. "It's just as common for women to say they're not sexually satisfied, and that's why they're having multiple partners."
Younger men, heavy drinkers, and those who perceived themselves as unable to control their sexual urges were more likely to engage in multiple partnerships.
The study, funded by the US President's Emergency Plan for AIDS Relief (PEPFAR) through Johns Hopkins Health and Education in South Africa (JHHESA), highlighted the need for more interventions targeting men. A number of community-based organizations working with JHHESA will use the findings to guide their future HIV/AIDS programming.
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Bali, 11 August 2009 – An estimated 50 million women in Asia are at risk of becoming infected with HIV from their intimate partners. Evidence from many Asian countries indicates that these women are either married or in long-term relationships with men who engage in high-risk sexual behaviours. These findings are published in a new report by UNAIDS, its Cosponsors and civil society partners entitled HIV Transmission in Intimate Partner Relationships in Asia, being released today at the 9th International Congress on AIDS in Asia and the Pacific in Bali.
The HIV epidemics in Asia vary between countries in the region, but are fuelled by unprotected paid sex, the sharing of contaminated injecting equipment by injecting drug users, and unprotected sex among men who have sex with men. Men who buy sex constitute the largest infected population group – and most of them are either married or will get married. This puts a significant number of women, often perceived as ‘low-risk’ because they only have sex with their husbands or long-term partners, at risk of HIV infection.
It is estimated that more than 90% of the 1.7 million women living with HIV in Asia became infected from their husbands or partners while in long-term relationships. By 2008, women constituted 35% of all adult HIV infections in Asia, up from 17% in 1990.
“HIV prevention programmes focused on the female partners of men with high-risk behaviours still have not found a place in national HIV plans and priorities in Asian countries” said Dr Prasada Rao, Director, UNAIDS Regional Support Team Asia and the Pacific, speaking at the launch of the report. “Integration of reproductive health programmes with AIDS programmes and the delivery of joint services to rural and semi-urban women are the key to reducing HIV transmission among intimate partners.”
In Cambodia, India and Thailand, the largest number of new HIV infections occur among married women. In Indonesia, where HIV was initially concentrated among drug users, the virus is now spreading quickly into sex work networks, including long-term partners and sex workers. Research from several Asian countries indicates that between 15% and 65% of women experience physical and/or sexual violence in intimate partner relationships, placing them at increased risk of HIV infection. According to studies in Bangladesh, India and Nepal, women exposed to intimate partner violence from husbands infected with HIV through unprotected sex with multiple partners were seven times more likely to acquire HIV compared to women not exposed to violence and whose husband did not have sex with multiple partners.
The strong patriarchal culture in Asian countries severely limits a woman’s ability to negotiate sex in intimate partner relationships, according to the report. While there is a societal toleration of extramarital sex and multiple partners for men, women are generally expected to refrain sex until marriage and remain monogamous thereafter.
“Discrimination and violence against women and girls, endemic to our social fabric, are both the cause and consequence of AIDS,” said Dr Jean D’Cunha, Regional Director, UNIFEM South Asia. “Striking at the root of gender inequalities and striving to transform male behaviours are key to effectively addressing the pandemic.”
The report also indicates that the female partners of migrant workers have been shown to be at increased risk of HIV infection when the latter return from working in countries with high HIV prevalence. A study in Viet Nam showed that married migrant workers reported having commercial sex partners and low condom use.
To prevent HIV transmission among intimate partner relationships, the report outlines four key recommendations:
HIV prevention interventions must be scaled-up for men who have sex with men, injecting drug users, and clients of female sex workers and should emphasize the importance of protecting their regular female partners.
Structural interventions should be initiated to address the needs of vulnerable women and their male sexual partners. This includes expanding reproductive health programmes to include services for male sexual health.
HIV prevention interventions among mobile populations and migrants must be scaled-up and include components to protect intimate partners.
Operational research must be conducted to obtain a better understanding of the dynamics of HIV transmission among intimate partners.
“The work that has been started around prevention of HIV transmission in intimate partner relationships is incredibly important because it means a new way of doing our work,” said Vince Crisostomo, Regional Coordinator, Seven Sisters (Coalition of Asia Pacific Regional Networks on HIV/AIDS). “The ultimate goal is the empowerment of women and it shows that the responsibility is on both sides.”
UNAIDS, its Cosponsors, including UNDP and UNFPA, and partners are organizing a symposium today at the conference to address HIV and intimate partner transmission. The aim is to take stock of evidence showing the increasing vulnerability of women to HIV transmission from their intimate partners and address critical policy and programme challenges.
Living with AIDS # 395
Ten years ago, I remember these discussions around condoms and people said: ‘You know what? People are never going to use condoms. It’s like eating sweets with a wrapper on. Don’t tell us. South Africans will never use them’. And if you look at the stats in the HSRC study, they’re absolutely fabulous. People are really using them”, added Goldstein.
Better prevention of HIV could be achieved with education campaigns that promote ideas of gender equality to men
Beliefs about gender equality are strongly predictive of multiple concurrent partnerships and HIV risk behaviours in South Africa, suggesting that better prevention of HIV could be achieved with education campaigns that promote ideas of gender equality to men, and more frequent condom use to women, according to findings presented at the Fourth South African AIDS conference in Durban.
Multiple partnering, often described as concurrency, is a strong risk factor for HIV and is believed by some scientists to be the key factor in explaining why HIV prevalence in southern Africa is so high compared to other regions of the continent. However, despite some evidence of the dangers of the practice, little is known about it, particularly with regards to its interplay with condom use.
In order to better understand the role of concurrent partners and HIV risk, scientists at the Aurum Institute For Health Research examined the 2001 census and randomly sampled 16 of 154 areas in Rustenburg, South Africa. Fieldworkers then superimposed the population distribution onto a satellite map and performed interviews with people from 512 randomly chosen houses.
Residents in each dwelling were numbered and one of them randomly subjected to an interview geared towards obtaining demographic information, beliefs about HIV vulnerability, condom use and perceptions of gender equality. The survey captured sexual acts that occurred three months previous to the interview. Multivariate logistic models were then used to statistically analyse the data.
Of the 351 people sampled, 59.8% were female and 84.9% black. Seventy three percent were sexually active and, of these, 9.7% admitted to having more than one sexual partner. Furthermore, only 56.1% of those surveyed reported using condoms (the definition of condom use included all those who had used a condom once or more during the three months).
Men believing in greater gender equality were more likely [OR 95%, CI: 0.30 (0.13 to 0.68)] to be monogamous while, paradoxically, women of the same belief were more likely to have multiple concurrent partners. [OR 95%, CI: 0.30 (0.13 to 0.68)].
The results suggest that beliefs about gender relations play a strong role in determining multiple concurrent partnering and HIV risk. Men are protected by believing in equality but women are at heightened risk.
The researchers call for more resources to be directed at gender equality campaigns and for women to be more actively encouraged to use condoms.
Reference
Latka M et al. Factors associated with concurrent sexual partnering & condom use are not the same: Results from a Representative Household Survey in Rustenburg, South Africa. (abstract 477). Fourth South African AIDS Conference, Durban, South Africa, abstract 477, 2009.
1. Why the Onelove Campaign?
In May 2006, a Southern African Development Community (SADC) Think Tank meeting took place in Maseru to deliberate on what could be done to curb the problem of HIV in Southern Africa. As is now well-known, this region is the epicenter of HIV and AIDS in the world. Approximately 40% of people living with HIV are in Southern Africa. The SADC Think Tank identified, amongst other things, the practice of multiple concurrent partnering (MCP) as a key driver of the AIDS epidemic in the region and called on member states to tackle the issue of MCP together. The Onelove campaign is a regional response to this call.
2. What are Multiple Concurrent Partnerships (MCP)?
Briefly defined, multiple concurrent partnering refers to 'a situation where partnerships overlap over time, either where two or more partnerships continue over the same period, or where one partnership begins before the other terminates' (Parker et al 2007).
3. Why a regional campaign?
Countries in the southern African region have always had strong connections. They share common cultures and history and there is ever-increasing trade and travel within the region. Studies have also shown that there are higher rates of HIV prevalence among migrants and communities affected by mobility, such as border communities and communities along major transport routes.
4. Research on MCP in the Region
The Onelove campaign is based on extensive target audience research that was conducted in all countries in the region. The primary aim of the research was to gain insight into the audience’s understanding, attitudes, and practices around sexual relationships in the context of HIV prevention. Overall research findings revealed common reasons for MCP among people in the 10 countries of this study. Most of these reasons are driven by gender inequality and cultural and social norms that create a context for MCP. Transactional sex and alcohol also play an important role.
To find out more, see: One Love: Multiple and Concurrent Sexual Partnerships in Southern Africa - A Ten Country Research Report
Onelove Regional Campaign - Overview
The Onelove country campaigns began launching in 2008 and will continue to launch throughout 2009. Onelove is a 5-year programme and different communication activities will be rolled out in each country over the 5-year period. Each country campaign is led and implemented by a range of organisations, and activities differ from country to country, often complementing existing campaigns and media activities. While OneLove is the name adopted by the majority of the partner countries for their national campaigns, different taglines (for example: Talk-Respect-Protect in South Africa) were found to work best in each country. These taglines aim to give local resonance, language, and idiom to the heart of the message: the need to talk about who and how we love and to protect and respect ourselves and the people we care about.
For an overview of the Regional Campaign, see:
OneLove Regional Campaign - Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia, Zimbabwe
Onelove Campaign Website
For up-to-date information on each country campaign and related activities and products, go to the Onelove Campaign website The website also offers quizzes, interviews, articles, blogs, and photos related to Onelove and Multiple Concurrent Partnerships.
Onelove National Campaigns
5. Onelove – Tanzania.
The Onelove campaign in Tanzania was the first to launch in October 2008. This campaign focuses on the need for communication between couples and involves special focus segments integrated into the Fema TV Talk Show and in magazines, as well as billboards, roadshows, and radio spots. Click here for more information. Or contact Femina HIP diana@feminahip.or.tz OR info@feminahip.or.tz
For target audience research around MCP in Tanzania, go to:
Onelove: Multiple and Concurrent Sexual Partnerships Among Youth in Tanzania
6. Onelove South Africa
The South African Onelove campaign was launched in January 2009. The campaign aims to shift social norms away from multiple sexual partnerships and encourage fulfilling monogamous relationships that will prevent the need for other relationships. Specifically, Onelove in South Africa challenges gender stereotypes and cultural norms that reinforce MCP and seeks to create debates around what needs to be done. As part of their communication strategy the campaign is using mass media, which includes the Soul City television drama series, a radio drama, and print materials; and social mobilisation; and advocacy. Click here for more information. Or contact Soul City Institute for Health and Development Communication soulcity@soulcity.org.za
Some of the materials produced by the South African campaign:
Onelove: Preventing HIV in South Africa
This booklet explains why having many partners puts people at risk and talks about other risky behaviours. It also includes information for people who want to take action in their communities to contribute to social change, especially as part of the Onelove campaign.
Multiple and Concurrent Sexual Partners: What's Culture Got to do With It? A Handbook for Journalists The OneLove Campaign also includes a media advocacy strategy which largely focuses on raising public debate on the key factors that drive MCP, such as culture. This handbook is designed for journalists as a tool to promote informed discussion around HIV and MCP.
For target audience research around MCP in South Africa, go to:
Multiple and Concurrent Sexual Partnerships in South Africa: A Target Audience Research Report
7. Onelove - Lesotho
The Onelove campaign in Lesotho was launched in January 2009. The Lesotho campaign activities include a radio magazine show, public service announcements (PSAs), a television drama, and booklets and billboards. Click here for more information. Or contact Phela Health and Development Communications hope@phela.org.ls
Material produced by the Lesotho campaign:
OneLove Booklet (Lesotho)
This booklet looks at why having more than one sexual partner is risky and discusses how HIV can be passed on through sexual networks. It includes an illustrated explanation about the vulnerability of partners in a sexual network.
For target audience research around MCP in Lesotho, see:
Multiple and Concurrent Sexual Partnerships in Lesotho: A Target Audience Research Report
8. Onelove - Swaziland
The Onelove Campaign in Swaziland launched in March 2009. In order to discourage MCP, the campaign aims to highlight the dangers of MCP, promote positive dating patterns and good relationships, encourage single partner relationships, build self efficacy by showing life examples of good relationships and positive dating patterns, and counter the negative relationship role modeling prevalent in Swaziland. The campaign activities include television and radio talkshows, PSAs, outdoor media, public discussions on buses, and a media competition. Click here for more information. Or contact Lusweti Institute of Health and Development fortunate@lusweti.org.sz
For target audience research around MCP in Swaziland, see:
Multiple and Concurrent Sexual Partnerships in Swaziland: A Target Audience Research Report
9. Onelove Mozambique
The Onelove campaign in Mozambique is planning to launch in August 2009. They have already started developing some of their multimedia materials which will include a 30-episode radio drama series called "Masked Lives", a 26-minute short film developed for television, a 30-page booklet on MCP, and a Onelove MCP flyer. For more information, contact N'weti d.namburete@nweti.org.mz
For target audience research around MCP in Mozambique, see:
Nweti Audience Report – Multiple Concurrent Partnerships
10. Onelove - Malawi
The Onelove campaign in Malawi plans to launch its campaign in May/June 2009. The campaign will launch with a 52-episode radio drama and a print booklet on relationships. A theme song for the campaign is also in the process of production. For more information, contact Pakachere Institute of Health and Development Communication ssikwese@pakachere.org
For target audience research around MCP in Malawi, see:
Multiple and Concurrent Sexual Partnerships in Malawi - A Target Audience Research Report
11. Onelove - Namibia
The Onelove campaign in Namibia is planning to launch around the middle of 2009. Their campaign activities will include a radio drama, which will start broadcasting in August 2009, as well as a Onelove booklet and a short film, which will form part of a Onelove regional television series. For more information, contact Desert Soul Health and Development Communication finelda@deserthdc.com
For target audience research around MCP in Namibia, see:
Multiple and Concurrent Sexual Partnerships in Namibia - A Target Audience Research Report
12. Onelove - Zambia
The Onelove Campaign in Zambia is planning to launch in May 2009. Campaign activities will include PSAs on television and radio, a radio talk show, billboards, and print materials. For more information, contact Zambia Centre for Communication Programmes gracesinyangwe@yahoo.com
For target audience research around MCP in Zambia, see:
Multiple and Concurrent Sexual Partnerships in Zambia - A Target Audience Research Report
13. Onelove - Zimbabwe
The national Onelove Campaign in Zimbabwe will launch in April 2009 in Gweru in the Midlands Province. The campaign activities will include a radio drama series, a television drama series, and a Onelove print publication. For more information, contact Action Magazine caroline@action.co.zw
For target audience research around MCP in Zimbabwe, see:
Multiple and Concurrent Sexual Partnerships in Zimbabwe: A Target Audience Research Report
Health minister, Barbara Hogan, is optimistic that the rate of new HIV and Aids infections can be halved within the next two years through the One Love campaign, which was launched in Orlando, Soweto on Saturday.
The campaign seeks to educate people about having no more than one sexual partner.
Hogan said that poverty was driving many women to prostitution and that poverty was the main cause of this.
"We must find out what is motivating people to act this way, we need to speak to communities and get to the root of what causes this," she said. – Sapa
Kaiser Daily HIV/AIDS Report
An increasing number of studies have shown that the practice of men and women having multiple or concurrent sexual partners is the "most powerful force propelling" the spread of HIV in Southern Africa, the Washington Post reports. This new understanding of the effects of multiple sexual partners might help explain why HIV/AIDS has "devastated Southern Africa while sparing other places," the Post reports. In addition, it "suggests how the region's AIDS programs, which have struggled to prevent new infections even as treatment for the disease has become more widely available, might save far more lives" by "discouraging sexual networks," according to the Post. The "most potentially dangerous relationships" for spreading HIV are simultaneous, regular partners for months or years because people in long term relationships often stop using condoms at some point, according to studies. Another crucial factor fueling the spread of HIV in Southern Africa is low rates of male circumcision (Timberg, Washington Post, 3/2). According to final data from two NIH-funded studies conducted in Uganda and Kenya published in the Feb. 23 issue of the journal Lancet, routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65% (Kaiser Daily HIV/AIDS Report, 2/28). The findings help explain why in countries in predominantly Muslim North Africa, where circumcision is the norm, HIV prevalence is low. Also in these countries, societies discourage sex outside of marriage. The dual factors of high rates of multiple sex partners and low rates of male circumcision in Southern, as well as Eastern, Africa have led to a "lethal cocktail" that is fueling the epidemic in those regions, Daniel Halperin, a former AIDS prevention adviser in Africa for the U.S. government, said. He added, "There's no place in the world where you have very high HIV and you don't have those two factors" (Washington Post, 3/2)
1. Expert Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern Africa Report
Paris - HIV infections among heterosexual Africans could be slashed by more than a third if safe-sex counselling was directed at married or cohabiting couples, a new study says.
The investigation, published in Saturday's issue of the British medical weekly The Lancet, probed the rate of new HIV infections among 2 279 Zambians and 1 782 Rwandans living in towns.
Between 55.1 percent and 92.7 percent of new infections occurred among "serodiscordant" marital or cohabiting couples, it found.
"Serodiscordant" means that, at the start of the study, one partner in a couple had the human immunodeficiency virus (HIV) but the other partner did not.
The finding provides statistical ammunition for those who argue that, in Africa, established relationships are a huge vector for spreading the Aids virus.
By targeting these couples with voluntary advice about safe sex and encouragement to get an HIV test, health watchdogs could avert between 36 and 60 percent of heterosexually-transmitted HIV infections that would otherwise occur, the paper says.
Lead author is Kristin Dunkle of the Rollins School of Public Health at Emory University in Atlanta, Georgia.
Around 33 million people around the world are infected with the human immunodeficiency virus (HIV) that causes Aids, according to the agency UNAIDS. Two-thirds of them are living in sub-Saharan Africa.
Previous research in this field suggests that, for African women, the greatest risk of contracting HIV lies within marriage, but few attempts have been made to determine a man's risk within a marital relationship.
Ignorance about one's HIV status and infections from casual sex outside the couple are the major drivers.
Published on the web by HIV-Aids on June 27, 2008.
© HIV-Aids 2008. All rights reserved.
Cape Town - "Multiple, concurrent partnerships" has become the latest catchphrase in the HIV and Aids lexicon. It refers to the practice of having more than one sexual partner at the same time, which experts say is a key driver of Southern Africa's devastating HIV and Aids epidemic.
In a South African population-based survey in 2005, 40 percent of men and 25 percent of women aged between 15 and 24 reported having concurrent partners. To try and understand why, the Soul City Institute for Health and Development Communication, a multimedia health promotion project, conducted research to find out how South Africans actually view these relationships.
Prof Sue Goldstein, a researcher at Soul City, presented the findings from focus groups of men and women across the country to delegates at the 4th Public Health Association of South Africa conference in Cape Town this week.
"Multiple, concurrent partnerships appear to be the accepted norm in many South African communities," she said. The attitudes and beliefs that perpetuated this norm were "astonishingly similar" across rural and urban divides, and even to those found in similar studies in other countries of the region.
Both men and women talked of a primary, long-term relationship based on love, and of secondary relationships that fulfilled other needs. In the case of women the need was often financial, but sometimes it was sexual.
"You know if someone is boring in the bedroom, and you know when you have met someone who hits the spot," said one woman who participated in a focus group in rural KwaZulu-Natal Province. "You carry on with the other one if he gives you other things, but you know that he just doesn't do it for you sexually."
The men blamed their wandering eyes on regular partners letting their looks go, and being attracted to younger, "fresher" women who were less likely to challenge their authority. They tended to trust that their primary partners were faithful and didn't use condoms with them, even if they sometimes had unprotected sex with other women.
The women often viewed a partner's infidelity as a "natural" and unavoidable cause of men's uncontrollable sexual desires, and cultural expectations that they should have more than one partner. Some ignored infidelity because they did not want to break up their families; others took lovers of their own.
"I do my own thing and 'phone my makhwapheni [local term for someone who is hidden - a boyfriend] and laugh; then I won't worry about [her husband's] late-coming," said a woman in the Free State.
Many of the men spoke of their sexual desires being fuelled by alcohol, which also made them less likely to practice safe sex. Peer pressure was another major reason men gave for having multiple partners: "If I don't have sex then my friends will laugh at me. In that way, I will try to prove a point and get involved with more than one," said a man in the rural northern Limpopo Province.
Both genders described sex as a vital component of their relationships and their lives generally, with some even viewing it as essential for good health. Despite this, men as well as women had great difficulty communicating with their partners about sex.
Most of the focus group participants had a good knowledge and understanding of HIV and Aids, but this did not prevent them from having a fatalistic attitude to the likelihood of becoming infected. "They say even if you do not ever get Aids, the fact is, you are still going to die; we are all going to die one day," said a teenage girl in the Free State.
Goldstein concluded that risky sexual practices were not related to levels of knowledge, but to the level of control individuals have over their sexuality.
As one woman put it: "Even if you are faithful to your husband, you cannot guarantee that you will not be infected because you don't know what your husband does, and he could be infected during his outings. All you could do is to pray, and trust that God will protect you because he is the doctor of all diseases."
Soul City aims to incorporate the findings into a new five-year HIV prevention campaign.
Published on the web by HIV-Aids on June 6, 2008.
© HIV-Aids 2008. All rights reserved.
In a South African population-based survey in 2005, 40 percent of men and 25 percent of women aged between 15 and 24 reported having concurrent partners. To try and understand why, the Soul City Institute for Health and Development Communication, a multimedia health promotion project, conducted research to find out how South Africans actually view these relationships.
Prof Sue Goldstein, a researcher at SoulCity, presented the findings from focus groups of men and women across the country to delegates at the 4th Public Health Association of South Africa conference in Cape Town this week.
"Multiple, concurrent partnerships appear to be the accepted norm in many South African communities," she said. The attitudes and beliefs that perpetuated this norm were "astonishingly similar" across rural and urban divides, and even to those found in similar studies in other countries of the region.
A significant other
"You know if someone is boring in the bedroom, and you know when you have met someone who hits the spot," said one woman who participated in a focus group in rural KwaZulu-NatalProvince. "You carry on with the other one if he gives you other things, but you know that he just doesn't do it for you sexually."
The men blamed their wandering eyes on regular partners letting their looks go, and being attracted to younger, "fresher" women who were less likely to challenge their authority. They tended to trust that their primary partners were faithful and didn't use condoms with them, even if they sometimes had unprotected sex with other women.
The women often viewed a partner's infidelity as a "natural" and unavoidable cause of men's uncontrollable sexual desires, and cultural expectations that they should have more than one partner. Some ignored infidelity because they did not want to break up their families; others took lovers of their own.
"I do my own thing and 'phone my "makhwapheni" [local term for someone who is hidden - a boyfriend] and laugh; then I won't worry about [her husband's]late-coming," said a woman in the Free State.
Many of the men spoke of their sexual desires being fuelled by alcohol, which also made them less likely to practice safe sex. Peer pressure was another major reason men gave for having multiple partners: "If I don't have sex then my friends will laugh at me. In that way, I will try to prove a point and get involved with more than one," said a man in the rural northern LimpopoProvince.
The urge
Most of the focus group participants had a good knowledge and understanding of HIV and AIDS, but this did not prevent them from having a fatalistic attitude to the likelihood of becoming infected. "They say even if you do not ever get AIDS, the fact is, you are still going to die; we are all going to die one day," said a teenage girl in the Free State.
Goldstein concluded that related to levels of knowledge, but to the level of control individuals have over their sexuality.
As one woman put it: "Even if you are faithful to your husband, you cannot guarantee that you will not be infected because you don't know what your husband does, and he could be infected during his outings. All you could do is to pray, and trust that God will protect you because he is the doctor of all diseases."
SoulCity aims to incorporate the findings into a new five-year HIV prevention campaign.
© IRIN. All rights reserved. More humanitarian news and analysis: http://www.irinnews.org
CHITUNGWIZA, Zimbabwe -- It's not only the prices of bread and eggs that are out of control in Zimbabwe, land of 4,000 percent inflation. For the man inclined to cheat on his wife, these are trying times. Keeping a mistress, visiting a prostitute or even taking a girlfriend out for beers is simply becoming too expensive, men say. But their strain is Zimbabwe's gain in its fight against AIDS. Alone among southern African countries, Zimbabwe has shown a significant drop in its HIV rate in recent years. A major reason, researchers say, is the changing sexual habits of men forced to abandon costly multiple relationships. "Those extramarital relationships, they're getting tough to sustain," said Thomas Muza, 37, who is struggling to support his wife and a mistress on the shrinking value of a math teacher's paycheck. Worth $50 a month at the beginning of June, it's now worth $17 and falling almost every day. AIDS activists and some researchers long blamed the continent's high poverty rates for its unusually widespread HIV epidemics, arguing that poor medical care and hunger made Africans especially vulnerable to the virus, while financial need accelerated its spread by pushing women into prostitution. Yet Zimbabwe's experience shows that the connection between AIDS and economics is not nearly so straightforward. The country has made strides against HIV during eight years of steep recession. Wealthier neighbors such as South Africa and Botswana, meanwhile, have struggled to curb new infections despite much higher levels of development and massive spending on the disease. Many researchers now suspect that economic vitality -- expressed in rising truck traffic, burgeoning bar scenes and widening income disparity -- encourage the behaviors that fuel a sexually transmitted epidemic. But as men get poorer, they pare back their relationships, making them less likely to contract or spread HIV. AIDS remains severe here, with an estimated one in five Zimbabwean adults infected with the virus that causes the disease, but surveys show that the number of new infections has fallen. Men report fewer girlfriends, fewer visits to prostitutes and less casual sex -- all indicators that in other countries have accompanied a retreating epidemic. Nightclubs, cinemas and brothels have closed in Harare, the capital, and in some cases evangelical churches have taken over the buildings. Less visibly, men say they are abandoning what Zimbabweans call "small houses," a legacy of the polygamous marriages once common here. In these relationships, married men pay rent and other living expenses for a second or even third regular sex partner. As in marriages, condoms rarely are used, creating webs of unprotected sex easily infiltrated by HIV if the man or any of the women become infected. "Having a lot of girlfriends or having 'small houses,' you've got to have a degree of disposable income," said Godfrey Woelk, an epidemiologist at the University of Zimbabwe. "Being poor and being in love does not really work, no matter what the romantics say." Muza, who has a long face and a thin beard, was not poor when he started teaching. He was part of Zimbabwe's broad middle class that also included the bureaucrats, engineers and factory managers whom the country's schools, once the best in Africa, turned out by the tens of thousands. Now these same men find their paychecks tripling or quadrupling some months. But prices are rising so much faster that many are slipping below the poverty line. Some joke bitterly that with a roll of toilet paper costing about 30,000 Zimbabwean dollars, it would be cheaper to stack 100-dollar bills in their bathrooms. Muza earns 2.5 million Zimbabwean dollars a month teaching, and about half goes to the rent, groceries and other expenses of his "small house." "It's very difficult," Muza said softly, his voice trailing off. With rich reddish soil, steady sunshine and seemingly enlightened governance, Zimbabwe for two decades was regarded as the economic miracle of southern Africa. President Robert Mugabe, who took over in 1980 from a white-supremacist government, invested heavily in education. Plentiful commercial farms made Zimbabwe an exporter of food. A steady flow of foreign tourists visited the country's unspoiled game parks and Victoria Falls, a mile-wide torrent of water considered one of the world's natural wonders. But faced with rising political opposition, Mugabe in 2000 endorsed invasions of white-owned commercial farms by landless black peasants. The move won him some support but led to economic ruin and growing political repression. Zimbabwe became one of the world's biggest recipients of international food aid. Its currency tumbled so fast that the money used to buy a new car in 2000 would be worth less than a U.S. penny now. Many AIDS experts feared this turmoil would worsen an epidemic that already was among the most severe in the world. Yet in 2005, the U.N. AIDS agency reported that the country had experienced southern Africa's first major decline in HIV. The drop was clearest among pregnant women who attended prenatal clinics, but studies of other groups showed similar trends. The most recent nationwide survey, conducted in 2005 and 2006, put Zimbabwe's HIV rate for adults at 18.1 percent, still higher than in all but five other countries in the world. Researchers believe it peaked a few years earlier at about 25 percent. This shift came despite Zimbabwe's pariah status at a time when growing international funding has allowed other African countries to dramatically expand their efforts to combat the epidemic. When President Bush created his $15 billion anti-AIDS program, all of Zimbabwe's neighbors -- South Africa, Botswana, Mozambique and Zambia -- were cited as "focus countries" worthy of extra support. Zimbabwe, which Secretary of State Condoleezza Rice labeled an "outpost of tyranny," was not, making it one of Africa's least popular recipients of foreign aid. Botswana and Uganda have received 10 times more annual financial support for each person living with HIV than has Zimbabwe, a U.N. analysis showed. Among the initial skeptics about the falling HIV rate was Zimbabwean AIDS researcher Exnevia Gomo. He recalled the early speculation: Perhaps it was caused by a surge of death in the absence of effective treatment. Or maybe the exodus of young, well-educated people to other countries explained the trend. But several studies show that shifts in sexual behavior drove the HIV decline in Zimbabwe. This finding echoes the changes experienced in Uganda during the early 1990s, when its rate of new infections fell sharply. "That behavior is changing significantly is clear," Gomo said from Blantyre, Malawi, where he recently joined the medical school faculty at the University of Malawi. "The question is: What has caused that change?"
With unemployment estimated at 80 percent, trading sex for money remains an appealing choice for some women, said Tsitsi, a sassy 23-year-old wearing designer jeans and a red, scooped-neck top. She spoke about personal matters on the condition that her last name not be used. A 40-year-old businessman pays Tsitsi about $75 a month to be his girlfriend. She said the man also takes her out to dinner and buys groceries for her parents. Tsitsi said that, though she is not in love, she regards the relationship as better than many marriages. The man agrees to use condoms, and there is no possibility of betrayal if she does not expect sexual fidelity, she said. "He's like an ATM," Tsitsi said. "You just go and punch money and it comes out." Several of her friends have similar relationships, she said, but they are becoming harder to find and maintain. When a man gets low on cash, Tsitsi said, "he'll just take care of his wife." Pastor Elliot Mandaza of NewLifeCovenantChurch in Harare has noticed a similar trend. As the capital's night spots have closed -- the church uses a former cinema for Bible classes -- pews have filled with financially troubled newcomers seeking divine solace. Few of these men can afford several sex partners. "That's by and large now the preserve of the wealthy. You have a 'small house' if you have the money," Mandaza said. "It's hard enough to look after number one." Business is down as well in bars and liquor stores in the dense bedroom community of Chitungwiza, 15 miles south of Harare. Weeknights are especially slow as customers hoard money for the weekend. Every time prices jump, the crowds dwindle again. A brewery truck that once arrived twice a week has stopped coming; bottles now arrive by wheelbarrow because bar owners keep stocks low to hedge against inflation. The changes are not only economic. Most Zimbabweans have watched a family member or a close friend wither away before their eyes. And unlike Zimbabwe's neighbors, which have used international funding to create increasingly extensive treatment programs, AIDS means almost certain death here. Brighton Ndlovu, 35, a trader in computer hardware who wore a dapper black suit on a recent visit to a popular Chitungwiza pub, has lost three brothers to AIDS. Each one got thin, lost his hair and sweated his way through terrible fevers, he recalled. Ndlovu said he uses condoms faithfully, and he made several changes likely to reduce his risk of infection: He avoids prostitutes, cut back on girlfriends and broke up with a "small house" woman whose living expenses he paid. Driving those decisions was a combination of financial stress and fear of AIDS. "I know the consequences," he said. This potent combination has changed business calculations as well. Frank Muhamba, 64, who owns the building that houses Ghetto Blues nightclub in Chitungwiza, said the club no longer employs a night shift of cleaning women who double as prostitutes. Muhamba said that contributing to the death of customers was wrong, and bad for the bottom line, too. "Before, we could go to a bar," he recalled, "and we'd find 10 women wanting us." Now, Muhamba said, "We will go home without talking to any of those girls. . . . They will kill us."
An increasing number of studies have shown that the practice of men and women having multiple or concurrent sexual partners is the "most powerful force propelling" the spread of HIV in Southern Africa, the Washington Post reports. This new understanding of the effects of multiple sexual partners might help explain why HIV/AIDS has "devastated Southern Africa while sparing other places," the Post reports. In addition, it "suggests how the region's AIDS programs, which have struggled to prevent new infections even as treatment for the disease has become more widely available, might save far more lives" by "discouraging sexual networks," according to the Post. The "most potentially dangerous relationships" for spreading HIV are simultaneous, regular partners for months or years because people in long term relationships often stop using condoms at some point, according to studies. Another crucial factor fueling the spread of HIV in Southern Africa is low rates of male circumcision (Timberg, Washington Post, 3/2). According to final data from two NIH-funded studies conducted in Uganda and Kenya published in the Feb. 23 issue of the journal Lancet, routine male circumcision could reduce a man's risk of HIV infection through heterosexual sex by 65% (Kaiser Daily HIV/AIDS Report, 2/28). The findings help explain why in countries in predominantly Muslim North Africa, where circumcision is the norm, HIV prevalence is low. Also in these countries, societies discourage sex outside of marriage. The dual factors of high rates of multiple sex partners and low rates of male circumcision in Southern, as well as Eastern, Africa have led to a "lethal cocktail" that is fueling the epidemic in those regions, Daniel Halperin, a former AIDS prevention adviser in Africa for the U.S. government, said. He added, "There's no place in the world where you have very high HIV and you don't have those two factors" (Washington Post, 3/2).
Reprinted from kaisernetwork.org. You can view the entire Kaiser Daily HIV/AIDS Report, search the archives, and sign up for email delivery at www.kaisernetwork.org/dailyreports/hiv . The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org, a free service of The Henry J. Kaiser Family Foundation. © 2009 Advisory Board Company and Kaiser Family Foundation. All rights reserved.