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Concurrent sexual partnerships help to explain Africa’s high
HIV prevalence: implications for prevention

See Seminar page 69
As Kiat Ruxrungtham and colleagues describe in today’s Lancet, What might account for this pervasive discrepancy? The HIV transmission in most Asian countries remains strongly strong association between lack of male circumcision and HIV associated with particularly high-risk activities—ie, injection-drug risk8–10 helps explain the 4–5-fold difference in HIV rates use, male-male sex, prostitution and, in China, paid donation of between southern and western Africa discussed by Asamoah- plasma. Although there is understandable concern that the virus Odei and colleagues. However, that association does not could soon spread widely through the general population,1,2 HIV explain why HIV has spread so much more extensively in has been present in Asia for nearly two decades and such southern Africa than in India, or in Europe, where circumcision extensive spread has yet to occur . For example, analysis of trends is similarly uncommon. Although sexual cultures do vary from in India suggests that HIV prevalence, both in high-risk groups region to region,11 the differences are not so obvious.
and in the generally low-risk antenatal clinic population, has Demographic surveys and other studies suggest that, on probably stabilised in recent years.3 It is possible that large-scale average, African men typically do not have more sexual partners heterosexual epidemics will never emerge in most of Asia, except than men elsewhere. For example, a comparative study of perhaps on the island of Papua.4–6 Furthermore, in some of the sexual behaviour found that men in Thailand and Rio de Janeiro world’s most populated countries—Pakistan, Bangladesh, Indo- were more likely to report five or more casual sexual partners in nesia, and the Philippines, home to some one billion people— the previous year than were men in Tanzania, Kenya, Lesotho, nearly all men are circumcised, further restricting the potential or Lusaka, Zambia. And very few women in any of these countries reported five or more partners a year.12 Men and See Articles page 35
In chilling contrast, as Emil Asamoah-Odei and colleagues women in Africa report roughly similar, if not fewer, numbers of report, also in today’s Lancet, HIV rates remain very high in much lifetime partners than do heterosexuals in many western of east and especially southern Africa. The overwhelming burden countries.13–15 Of increasing interest to epidemiologists is the of HIV/AIDS is still concentrated in this region, which accounts observation that in Africa men and women often have more for only 3% of the global population yet some 50% of global HIV than one—typically two or perhaps three—concurrent partner- cases.1 For example, infection rates in adults in South Africa, ships that can overlap for months or years (figure). This pattern Botswana, Zimbabwe, and western Kenya range from 20 to 40%, differs from that of the serial monogamy more common in the roughly an order of magnitude higher than anywhere else in the west, or the one-off casual and commercial sexual encounters Vol 364 July 3, 2004
Morris and Kretzschmar16 used mathematical modeling to com- pare the spread of HIV in two populations, one in which serial monogamy was the norm and one in which long-term concurrency was common. Although the total number of sexual relationships was similar in both populations, HIV transmission was much more rapid with long-term concurrency—and the resulting epidemic was ten times greater. The effect of such concurrency on the spread of HIV is exacerbated by the fact that viral load, and thus infectivity,10 is much higher during the initial weeks or months after infection.17 Therefore, as soon as one person in a network of concurrent relationships contracts HIV, everyone else in the network is placed at risk. By contrast, serial monogamy traps the virus within a single Morris subsequently studied sexual networks in Uganda, Thai- land, and the USA.14 She found that Ugandan men reported fewer lifetime sexual partners than Thai men, but while the Thais mainly had one-off encounters with prostitutes, the Ugandanmen’s relationships tended to be of much longer duration. Given that the per-act probability of heterosexual HIV transmission is, on average, quite low, the much higher number of cumulative sexual acts—and hence the likelihood of transmission—within any given relationship was much greater in Uganda than in Thailand or the USA. In addition, except for prostitutes, very few Asian women have concurrent partners, whereas a larger proportion of African women do. Even though the Ugandan women in Morris’ study reported fewer concurrent relationships than Ugandan men, the multiple partnerships that some of them did have helped maintain the extensive interlocking sexual networks which facilitate the generalised spread of HIV.14 Although most African women in concurrent partnerships are not prostitutes, such relationships often include a quasitrans- actional aspect, related to issues of gender inequality, poverty,and the globalisation of consumerism.18,19 These patterns of sexual behaviour might have important implications for HIV prevention. As Ruxrungtham and colleagues Figure: Frequency of concurrent and suspected concurrent sexual relationships
discuss, consistent use of condoms has been effectively prom- Percentage of 15–49-year-olds reporting more then one regular partner or spouse oted in Asia’s organised brothels, particularly in Thailand and (bottom), and percentage of those who believe that their partner has other regularpartners (top). NA=data not available, CAR=Central African Republic. Redrawn Cambodia, and, for example, in the Sonagachi project in Cal- cutta20 and among west-African sex workers in Abidjan andSenegal.21–23 Yet from the gay communities of Australia and San Although no simple solution exists to this complex problem, Francisco to the market towns of Uganda, it has proved much we believe that in addition to condom availability and other pre- more challenging for people in ongoing longer-term relation- vention approaches in Africa, there needs to be franker ships to consistently use condoms.19,22–25 Unfortunately in discussion and concerted public-health efforts addressing the Africa—unlike in most of Asia—such longer-term relationships dangers of having more than one long-term sexual partner at a are often the ones in which HIV transmission takes place. For time. Because most Africans do not have exorbitant numbers of years, condom promotion has been a mainstay of donor-funded partners, they may not fully realise how dangerous, especially in HIV prevention in Africa, but a recent review commissioned by regions of high HIV-prevalence, such behaviours actually are. In UNAIDS22 concluded that, although condoms are highly effective southern Africa, even people with only two lifetime partners— when used correctly and consistently, “no clear examples have hardly high-risk behaviour by western standards—need to emerged yet of a country that has turned back a generalized appreciate just how risky that one extra partner can be if the epidemic primarily by means of condom promotion”. Condom relationships are long-term and concurrent. The now famously See Comment page 13,
availability remains a concern, especially in rural areas, but successful Zero Grazing (partner reduction and faithfulness) about condoms another serious problem is that although people worldwide, campaign in Uganda,19,22,23,28,29 coupled with encouraging including Africans, are likely to use condoms during casual and evidence from other places such as Zambia,25,29 Addis Ababa,1,29 commercial sexual encounters, condoms are seldom used con- and Kenya,23 suggests that fundamental society-wide changes in sistently in longer-term relationships in which there is a sense of sexual norms can occur in Africa, just as in other regions faced Vol 364 July 3, 2004
*Daniel T Halperin, Helen Epstein Meeting Published Abstracts, Anaheim, California, Aug 18–21, 2002: session Office of HIV-AIDS, US Agency for International Development, Pettifor AE, Rees, HV, Steffenson A, et al. HIV and sexual behavior among Washington, DC 20523, USA (DTH); and Center for Health and young South Africans: a national survey of 15–24 year olds. University of Wellbeing, Princeton University, Princeton, New Jersey, USA (HE) Witwatersrand, Johannesburg: Reproductive Health Research Unit, 2004: (accessed June 24, 2004).
Morris M, Kretzschmar M. Concurrent partnerships and the spread of HIV.
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for their input to this commentary, and Petr Petr for the graphic.
Pilcher CD, Tien HC, Eron JJ, et al. Brief but efficient: acute HIV infection and UNAIDS. AIDS epidemic update 2003. Geneva: UNAIDS. http://www.unaids.
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United States, Thailand and Uganda. American Sociology Association Annual Seizing the opportunity to capitalise on the growing access
to HIV treatment to expand HIV prevention

Access to antiretroviral therapy is expanding in resource-poor current level of 5 million, treatment programmes will be un- settings. This long-awaited action has the potential to able to keep pace with the number of people in need, and will improve the health of millions of HIV-infected people and stabilise societies in regions hardest hit by HIV/AIDS. Little However, there is a dynamic tension between the provision discussed, however, is the fact that expanded access to of HIV prevention and treatment. The scale-up of HIV pre- treatment also offers critical new opportunities to simul- vention and treatment must be carefully coordinated and taneously strengthen HIV-prevention efforts.
integrated to ensure the maximum synergistic effect. In- More widespread access to treatment has the potential to creased availability of antiretroviral therapy can bolster attract millions of people into health-care settings, in which prevention efforts by significantly enhancing incentives for HIV-prevention messages can be delivered and reinforced.
voluntary testing,1 reducing the stigma associated with HIV,2 The availability of HIV treatment will provide new incentives and potentially lowering the infectivity of HIV-positive for HIV testing, which in turn will increase opportunities for counselling on HIV prevention. And increased knowledge of But treatment access will also present new prevention serostatus will enable prevention programmes to develop challenges. As antiretroviral therapy reduces AIDS deaths in interventions that are specifically tailored to the different areas where treatment is available, the number of people needs of HIV-positive, HIV-negative, and untested indi- living with HIV will grow. As HIV-infected people on anti- retroviral therapy become healthier, they are likely to become To achieve a sustainable response to HIV/AIDS, prevention more sexually active, potentially creating additional oppor- and treatment services must be brought to scale simul- tunities for HIV transmission to occur. Although knowledge taneously. Unless annual HIV incidence falls sharply from its of HIV infection prompts most people to take steps to avoid Vol 364 July 3, 2004


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