Definition of the Prevention Area
Individuals who have multiple sexual partners increase their risk of contracting HIV as each new relationship introduces another pathway for HIV transmission. Concurrent sexual partnerships, defined as having two or more partnerships that overlap in time, also increase risk and have been recently identified as a likely driver of the spread of HIV.
Sexual practices vary widely, and individuals who have multiple sexual partners may or may not engage in concurrent sexual partnerships. Researchers distinguish serial monogamy, in which an individual may have multiple sexual partners without any overlapping partnerships, from concurrency. Individuals who are involved in concurrent relationships may or may not have a high number of lifetime sexual partners since some concurrent partnerships are long-term, stable, or "closed" relationships, such as polygamy. There is some controversy about the nature of various cultural norms and the risks entailed by these relationships.
At a time when HIV rates are declining in other parts of the world, HIV prevalence in East and Southern Africa remains high and is thought to be due to several factors: high rates of multiple and concurrent sexual partnerships (MCP), low rates of male circumcision, and inconsistent and/or incorrect condom use.
Epidemiological Justification for the Prevention Area
Since MCP clearly increase the risk of HIV transmission, partner reduction strategies have been undertaken in countries such as Uganda, Thailand, Kenya, and Zimbabwe. These programs have been followed by reductions in HIV incidence and/or prevalence. However, no large-scale population-based surveys have been able to directly link reductions in MCP with a decrease in HIV epidemics.
Although these types of partnerships are not mutually exclusive, different risks are associated with multiple versus concurrent sexual partnerships. The risks of multiple partnerships versus concurrent partnerships are different. For the individual with multiple partners (but not concurrent partners), their risk of acquiring HIV is directly related to the number of sexual partners they have over time. However, in concurrent partnerships the partner’s behavior or participation in concurrent sexual relationships has a profound effect on their role as a transmitter of HIV. Because of this, an individual’s risk cannot be calculated solely on the basis of his or her behavior, but can only be assessed in light of their partner’s behavior. For example, an individual may have only one sexual partner, but if that partner is connected to a wider sexual network through concurrent sexual relationships, then the individual is at higher risk of acquiring HIV.
Concurrency is also thought to be an important driver of HIV transmission because those involved in concurrent relationships may be more likely to be exposed to a sexual partner during the month-long period immediately following infection, known as the acute phase of HIV, while they are most infectious.
Intergenerational and transactional sexual relationships are closely entwined with MCP and gender dynamics. Women who engage in intergenerational and transactional sex in order to survive or to obtain gifts are at higher risk of HIV infection than women who are not dependent on older men for money or gifts. Information about local culture and behavior can be used to shape messages to communicate the risks associated with MCP and to target behaviors that place individuals at increased risk of HIV.
Core Programmatic Components
MCP programs constitute a new area of work. As of yet, there are insufficient data to evaluate which approaches are most effective. However, several approaches appear to show promise. Programs that increase awareness of MCP as a risk factor, followed by assistance in helping individuals estimate their personal risks based on their own and their partners' behavior, appear to be useful.
Communities should be involved in framing MCP messages so they do not stigmatize or place blame on specific groups. MCP programs should use a variety of approaches, such as mass media messages, community mobilization, or interpersonal and one-on-one activities that encourage people to adopt safer sexual behaviors, and activities that are tailored to the specific needs and circumstances of groups at risk.
Finally, programs should integrate MCP messages as one element of a comprehensive approach to prevention. Promoting the use of condoms remains important, since MCP is unlikely to be eliminated entirely. Links to counseling and testing, male circumcision, prevention of mother-to-child transmission, and treatment services will be essential, and it will be important to take all opportunities to integrate consistent messages about MCP.
Current Status of Implementation Experience
Over the last several years increased support for MCP interventions has led to innovative programs. One promising program is the Scrutinize Campaign in South Africa, which uses "animerts," or cartoon ads, to widely disseminate MCP messages. The campaign also uses art, drama, song, dance, and interpersonal activities to reinforce those messages. Scrutinize is supported by private and public organizations, demonstrating that such agencies can work together to produce a high-quality, targeted campaign that is accepted by the local population.
UNAIDS has recently proposed a standardized method of data collection and definition of the term concurrency in order to promote more reliable research regarding the effects of MCP, which in turn will allow better quantification of program outcomes. Larger societal questions such as how programs can address gender inequity and social tolerance for MCP have yet to be answered.