Definition of the Prevention Area
Partner reduction is a prevention strategy focused on decreasing overall number of partners in order to lessen the risk of becoming infected with or transmitting HIV. Increasingly, partner reduction efforts have focused not only on reducing the number of partners, but also the number of concurrent partners.
Epidemiological Justification for the Prevention Area
Partner reduction is one of the most effective HIV prevention strategies to date, with a large evidence base to support this intervention. During the HIV epidemics of the late 1980s and early 1990s, campaigns advocating partner reduction and fidelity among couples and other prevention strategies were launched in the United States and Uganda. Among these was Uganda’s “Zero Grazing” campaign.
Surveys showed that the campaigns were at least modestly effective with some survey participants reducing both their concurrent sexual relationships and their total number of sexual partners. These changes were followed by declines in the incidence of new HIV infections, first in the United States among men who have sex with men, and later in Uganda among heterosexuals.
HIV incidence and/or prevalence has declined in other countries, such as Cambodia, Zambia, Zimbabwe, Thailand, Ethiopia, and Kenya, and most experts attribute these declines, at least in part, to partner reduction strategies.
Core Programmatic Components
Partner reduction strategies may be directed at specific risk groups, such as those who engage in commercial sex or men who have sex with men. In hyper-epidemics in Southern Africa, where HIV is prevalent among the general population, some experts have advocated more generalized strategies that address the entire population.
Partner reduction efforts must take into account complex, interrelated social, class, cultural, and economic factors. For example, social and gender norms play an important role in perpetuating attitudes and beliefs that encourage, or at least tolerate, men and/or women having multiple or concurrent partnerships. Researchers have found that despite a high level of knowledge about the mechanisms of HIV transmission and prevention, many people continue to engage in high-risk partnerships for a multitude of reasons, including poverty, economic “wants,” and violence. Men who, often by necessity, take jobs at a distance from their families may engage in commercial sex. Impoverished women may be compelled to engage in transactional or commercial sex. Young girls may engage in intergenerational sex with older men—who are more likely to have HIV—to obtain gifts.
Partner reduction messages are often coupled with other prevention messages, such as abstinence, delay of sexual debut, correct and consistent condom use, and HIV testing. Programs may need to deliver difficult messages that individuals are put at risk of HIV not only by their own behavior but by their partners’ behaviors. Another important message is that alcohol abuse is often associated with less cautious behavior that can lead to sexual activity with multiple partners, thereby increasing the risk of HIV infection.
Current Status of Implementation Experience
It can be difficult to prove that partner reduction programs are the cause of declines in HIV prevalence because multiple simultaneous factors may play a role. Most experts agree, however, that the body of evidence, especially studies of regions where partner reduction strategies preceded other interventions, suggests that partner reduction strategies play an important role in reducing the incidence of HIV.
Surveys conducted in Uganda provide some evidence that the partner reduction campaigns of the 1980s and 1990s led to the decline in HIV prevalence that began in the early 1990s.
Educational activities alone may not be sufficient to change behavior, however. Some regions showed stable or escalating rates of high-risk behaviors despite widespread knowledge about HIV transmission. In these instances, structural changes are needed to allow people the freedom to make choices that can reduce their risk of HIV infection, such as the choice to leave a violent spouse with concurrent partners.