I have been reading a lot of Helen Epstein’s journalism on HIV/AIDS (she’s also here at Princeton at the Center for Health and Well-Being. While I disagree with her assessment that large-scale foreign assistance programs are doomed to failure (see my comments here), I found her work on “concurrency” or the profusion of long-run polygamous relationships in sub-Saharan Africa to be extremely interesting. Her basic argument is that faithfulness programs have gotten short shrift in AIDS prevention programs. While the right has embraced abstinence and the left condoms, the B in ABC programs, ‘be faithful’, has been neglected. She thinks that a “partner reduction” program like Uganda’s Zero Grazing campaign of the 1990s can reduce risky sex outside of monogamous relationships and cut down on the risk of HIV transmission.
In a 2004 essay in the New York Times, she writes that:
Studies show that people in southern Africa don’t have nearly as many sexual partners as, say, homosexual men in San Francisco did in the 1980’s, when reports of hundreds of sexual partners a year were not uncommon. Such behavior is rare in Africa, but many people — like the boyfriends of Thokozile and Mcha — do have a small number of longer-term, simultaneous or ”concurrent” sexual relationships that may overlap for a few months or even years. This ”concurrency” links sexually active people up in a giant network, not only to one another but also to the partners of their partners’ partners — and to the partners of those partners, and so on — via a web of sexual relationships that can extend across huge regions. If one member contracts H.I.V., then everyone else in the web may, too .
Long-term concurrency is far more common in Africa than in Asia and in the West, where heterosexual people tend to practice ”serial monogamy.” Martina Morris, a sociologist at the University of Washington, has shown that concurrency is more of a public-health danger than serial monogamy because it permits the virus to spread to others quickly, rather than trapping it in a single relationship for months or years. In addition, a recently infected person is much more likely to transmit the virus than a person who has been infected for a while. Thus, when a serially monogamous H.I.V.-positive person eventually finds a new partner, his ability to infect has been reduced. Someone at the hub of a network of concurrent relationships, however, is likely to infect all of his partners very rapidly when he is first infected.
She’s elaborated these ideas with scientists in a series of short essays, one in the Lancet with Daniel Halperin of USAID in a special issue on HIV/AIDS from July 2004. In that article, they write that:
Of increasing interest to epidemiologists is the observation that in Africa men and women often have more than one—typically two or perhaps three—concurrent partnerships that can overlap for months or years.
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, is much higher during the initial weeks or months after infection. 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 relationship for months or years.
She and another co-author, Stewart Parkinson, have commented elsewhere on the importance of these high viral loadings early in infection and concurrency. They noted that models of disease transmission seemed to underpredict the incidence of disease in Uganda:
What the researchers did not consider at first was that a person is much more likely to transmit HIVduring the first month or so after infection. (YES, going back to the short-term nature of encounters in asia. During this time a person’s immune system has not yet responded to the presence of the virus, and it proliferates rapidly in the blood. The Rakai researchers later reanalyzed their data and found that people who had been recently infected were much more likely to pass the virus on to their other partners than someone who had been infected for a long time. Myron Cohen at Johns Hopkins University has estimated that during this early or “viremic” stage-also known as the “window period”- the likelihood of transmission is actually much higher than one in a thousand, and may even be as high as 7 – 24 percent. After that, cells and antibodies emerge which reduce the concentration of the virus in the blood and this in turn reduces the risk of transmission. Typically the presence of HIV in an individual is assessed not by checking for the virus, but rather for the antibodies produced in response to infection.
Ironically, sex with an infected prostitute may actually be safer than sex with someone in a network of long term concurrent relationships. This is because there is a good chance that the prostitute has been infected for a while, and
will thus have passed out of the “window period”- unless she has only recently begun to practice sex work, or unless it is very early in the epidemic in general. Thus the chances that she will transmit the virus during a given sexual act are often quite low.
They think this might explain why Thailand never developed such a bad AIDS problem as sub-Saharan Africa. Indeed, China and India may never develop the feared “Next Wave” of AIDS problems that the CIA warned of several years ago. That said, the absolute numbers of AIDS sufferers in India and China are likely to be large, given the countries’ large populations, but the overall prevalence of the disease will remain low. They write that this is because:
Surveys of sexual behavior in the “New Wave” countries of China, India and Russia suggest that while men do have affairs, they tend to be short-term liaisons with prostitutes, rather than ongoing relationships with co-wives or concubines. Such short-term relationships are generally safer -when it comes to HIV-because they involve only a single act of sex, rather than an ongoing relationship involving repeated exposure to any pathogens either partner may carry. In addition, condoms are increasingly used in such short-term relationships, but they are seldom used in longer-term relationships.
I find this topic fascinating and hope this gets policy-makers to focus on the most effective means to deal with the disease that are culturally appropriate as Helen suggests. The recent PEPFAR report talks a fair amount about faithfulness so I wonder if they got the message. That said, they lump abstinence and be faithful funding into the same category in their reporting. Here’s an extract:
Be faithful programs encourage individuals to practice fidelity in marriage and other sexual relationships as a critical way to reduce risk of exposure to HIV. Once a person begins to have sex, the fewer lifetime sexual partners he or she has, the lower the risk of contracting or spreading HIV or other STIs. Some of the most significant gains in Uganda’s fight against HIV are a result of specific emphasis on, and funding of, programs to promote changes in behavior related to fidelity in marriage, monogamous relationships, and reducing the number of sexual partners among sexually active unmarried persons. Uganda’s President Museveni, along with local religious groups and other nongovernmental organizations (NGOs), promoted a consistent message of partner reduction and fidelity, which contributed to a significantdecline in the number of sexual partners among both men and women in Uganda.
Filed under: Politics and Policy
I’ve been working in HIV prevention in Botswana for the last five months and have also been struck by the prevalence of long term concurrent partnerships and casual attitudes towards infidelity. This is a precarious topic, since it treads close to negative stereotypes of African sexuality–one reason for the hesitancy of African leaders to address the issue. But the logic of Epstein’s argument (and the evidence I’ve seen) suggests that changing social norms around multiple sexual partners would go a long way to reducing HIV incidence.
In my work, I’ve found crafting fidelity- based prevention messages to be a major challenge. The problem is simple: you can, in good faith, tell people that if they abstain or condomize (correctly and consistently) then they are protecting themselves from HIV. But fidelity is not foolproof, since partners may not be faithful in turn. (Hence the appeal of A and C for donors).
In low trust situations (e.g. cultures where multiple partnerships are the norm), individuals will not rationally choose fidelity as a tool for prevention, instead perceiving a choice between A, C, and unprotected sex. As Epstein points out, there is a huge positive social externality to an individual’s fidelity; but since, in low trust situations, this benefit is not fully captured by individuals choosing to be faithful, fidelity will be “under-consumed.”
In other words, people can be motivated to choose A and C on the basis of a rational response the threat of HIV to themselves as individuals. People will only choose fidelity on a large scale if they can identify with a larger project of social change. This is what is so fascinating about the uganda case, and why people interested in public health should be interested in the politics of collective action.
[…] Behavior change campaigns for years in the African region have targeted high-risk sexual behaviors in attempts to prevent HIV infection. The discourse at times has veered into culturally naive assumptions of sexual exceptionalism. Yet, as some researchers have observed, some fundamental measures human sexual behaviors appear consistent across cultures and geographies -i.e. average lifetime number of partners. Granted, distinct regional patterns emerge on closer look – i.e. long-term concurrent partnerships and serial monogamy are alternatively dominant in different regions of the world (see April ‘06 post “Concurrency and a Campaign for Serial Monogamy”). […]