August 15, 2006

Multiple Partnerships Fueling AIDS Epidemic

By Terri Coles

TORONTO -- In Swaziland they are called "lishendes" -- multiple concurrent sexual partners -- and they are the driving factor behind the HIV epidemic in southern Africa, said researchers on Monday at the 16th International AIDS Conference in Toronto.

Instead of casual sexual encounters with multiple partners, established partnerships outside of marriage are fueling a generalized epidemic in southern African countries. These partnerships often involve inconsistent condom use and occur in the context of low rates of male circumcision.

At the conference in a presentation titled "Prevention Works: What's The Evidence," researchers put forward evidence for various HIV prevention programs aimed at increasing education, reducing stigma and changing behavior.

"In southern Africa and a country like Swaziland we're talking about a very generalized epidemic," said Dr. Daniel Halperin of the US Agency for International Development's Southern Africa HIV-AIDS Program in Mbabane, Swaziland.

Halperin described the HIV infection rate in Swaziland as "astonishingly high." The prevalence rate for the general adult population was 33.4 percent in 2005. Multiple concurrent sexual partnerships are a main driver of the generalized epidemic in Swaziland, Dr. Halperin said. These partnerships are not casual sexual encounters or polygamy, but are instead longer-term relationships outside of marriage.

"Data worldwide consistently shows that people with a higher number of partners have a higher prevalence of HIV," Halperin said. Partner reduction can be one important element of HIV prevention, but it's not the only factor to consider.

Men in countries like Thailand and the United States report more lifetime sexual partners than men in some African countries, but have a lower prevalence rate of HIV infection. The problem is not that Africans have more sexual partners, Halperin said, but that concurrent partnerships lead to villages becoming linked up in sexual networks, aiding the spread of the virus. Having two or three regular sexual partners leads to an increase in the risk of HIV infection.

A large majority of those who responded to a baseline survey of 2000 adults in 12 randomly selected communities -- done before the start of a sexual behavior communication campaign in Swaziland -- agreed that lishendes were common or very common in their communities.

During the study, many respondents said that multiple partnerships were harmful to the fight against HIV/AIDS. Females in particular felt that choosing to have only one sexual partner at a time was important for prevention and the fight against HIV/AIDS in Swaziland.

A government-led campaign was launched in June 2005, and a follow-up survey of 2000 adults was conducted in the same 12 communities a year later, along with three rounds of focus group discussions with men and women in each of the communities.

The campaign focused on a message of abstinence and monogamy. Advertisements aimed at young people promoted waiting to have sex, while those for adults presented messages like "I choose to have only one sex partner" and "I'm circumcised, proud of it...and I'm still faithful to my partner."

Another group of advertisements had fear-based messages highlighting the risks of multiple partnerships, with messages like "Why kill your family?"

The advertisements were controversial in their approach, going against a belief by some NGOs and activist groups that fear-based messages are not effective, Halperin said.

"Many of people in the (focus) group said 'You should show people dying of AIDS, you should scare people'," Halperin said. "We're seeing a bit of a disconnect between what people in the community say and what we, as experts, believe is the right way to do AIDS prevention."

The controversial advertisements were widely discussed in Swaziland, where they were subject to heavy public and media attention. In their surveys after the fact, researchers found that more than 80 percent of respondents were aware of the campaign. Anecdotally, he said that the advertisements were widely discussed in the general population.