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Behavioral Interventions: Multiple and Concurrent Sexual Partnerships
I. 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.
II. 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.
III. 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.
IV. 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.
Updated: March 2011
Debate: Is Sexual Partner Concurrency Driving the Spread of HIV in Africa?
Mah and Halperin’s 2010 article in AIDS and Behavior, “Concurrent Sexual Partnerships and the HIV Epidemics in Africa: The Evidence to Move Forward,” sparked passionate debate around the impact of sexual concurrency on the HIV epidemic in Africa. Critics assert that the lack of consistent data on multiple and concurrent partnerships (MCP) calls into question whether MCP is a true driver of HIV in Africa. Proponents of the concurrency thesis acknowledge the inconsistencies in definition and measurement methods, but maintain the relevance of MCP to the spread of HIV in the region and argue that programming to address MCP remains an important element of a prevention response. Here, AIDSTAR-One summarizes a series of articles and commentaries responding to Mah and Halperin.
Concurrent Sexual Partnerships and the HIV Epidemics in Africa: The Evidence to Move Forward
Mah, T. & Halperin, D.T. AIDS and Behavior (2010), Vol. 14 No. 1, pp. 11-16.
Concurrent sexual partnerships are thought to contribute to the generalized HIV epidemics in sub-Saharan Africa. Such relationships may be particularly risky in part because they are likely to expose individuals to a partner with HIV during the highly infectious month immediately following infection. Concurrency is said to be more common in Southern Africa than elsewhere, fueled in part by migrant work that separates spouses. However, research about rates of concurrency can produce conflicting results depending on the survey method used. The authors discuss the pros and cons of the calendar method of questioning versus direct questioning.
Concurrent Partnerships as a Driver of the HIV Epidemic in Sub-Saharan Africa? The Evidence is Limited
Lurie, M.N. & Rosenthal, S. AIDS and Behavior (2010), Vol. 14 No. 1, pp. 17-24.
The authors assert that current measures and definitions for concurrency are not consistent, casting doubt on the assumption that concurrency is a key driver of the African HIV epidemic. Citing a 2001 study, they comment that concurrency should be “higher in countries with high HIV prevalence compared to those in low prevalence countries, but they were not,” and conclude that Mah and Halperin’s claim that concurrency can play a critical role in HIV transmission is not the same as empirical evidence showing that it does. They suggest that more targeted research with consistent methodology is needed before public health specialists can draw definite conclusions about the relationship between concurrency and the African epidemics.
The Evidence for the Role of Concurrent Partnerships in Africa’s HIV Epidemics: A Response to Lurie and Rosenthal
Mah, T. & Halperin, D.T., AIDS and Behavior (2010), Vol. 14 No. 1, pp. 25 -28.
The authors challenge the assertion by Lurie and Rosenthal that there is insufficient data to conclude that concurrency is any more common in Southern Africa than elsewhere. Mah and Halperin say that survey data they cited are from World Health Organization surveys that support the idea that African populations studied have higher rates of concurrency. They cite surveys showing that in Lesotho, where HIV prevalence is the third highest in the world, 55 percent of men and 39 percent of women report concurrency. They compare this to the 3 percent and 0.2 percent rates of concurrency among women in Thailand.
The Mathematics of Concurrent Partnerships and HIV: A Commentary on Lurie and Rosenthal, 2009
Epstein, H. AIDS and Behavior (2010), Vol. 14, No. 1, pp. 29-30.
Epstein responds to Lurie and Rosenthal, who assert there are insufficient empirical data to support the claim that concurrency is driving the HIV epidemic in Southern Africa. The author defends mathematical modeling exercises that support concurrency as a central factor in the spread of HIV, and criticizes one mathematical model that didn’t support the concurrency concept on the grounds that the researchers failed to distinguish between concurrency and serial monogamy.
Barking up the Wrong Evidence Tree. Comment on Lurie & Rosenthal, "Concurrent Partnerships as a Driver of the HIV Epidemic in Sub-Saharan Africa? The Evidence is Limited"
Morris, M. AIDS and Behavior (2010), Vol. 14 No. 1, pp. 31-33.
The author asserts that Lurie and Rosenthal make several mistakes with regard to their assertion that concurrency is not a proven driver of the HIV epidemic. First, she states that measuring concurrency in the index person who acquires HIV is a mistake since “concurrency increases your risk of transmitting infection, not acquiring it.” Second, the use of HIV prevalence is an improper message, according to the author, since prevalence is a cumulative measure over time, while concurrency is generally measured over a limited time period, such as 12 months. Only when both prevalence and concurrency are in equilibrium for some years can the effects of concurrency be measured, says the author. For this reason, HIV incidence should be measured instead of prevalence and it should be measured during time window matched to measures of concurrency.
The Concurrency Hypothesis in Sub-Saharan Africa: Convincing Empirical Evidence is Still Lacking. Response to Mah and Halperin, Epstein, and Morris
Lurie, M.N. & Rosenthal, S. AIDS and Behavior (2010), Vol. 14 No. 1, pp. 34-37.
Lurie and Rosenthal respond to authors who are critical of their contention that concurrency is not a proven driver of the HIV epidemic in Southern Africa. They note that their critics agree that the evidence is “limited” and that further research is needed. They assert that even if their critics can point to correlates between concurrency and high HIV prevalence, that association is not causation. The authors say that one study that assessed the temporal relationship between concurrency and the development of HIV did not find a causal link. The authors object to the assumption that in the face of uncertainty about concurrency that “nothing is lost” by discouraging concurrency since, they say, some forms of concurrency, such as polygyny, appear to be protective.
A Framework of Sexual Partnerships: Risks and Implications for HIV Prevention in Africa
Green, E.C., Mah, T.L., Ruark, A. et al. Studies in Family Planning (2009), Vol. 40, No. 1, pp. 63-70.
The authors of this commentary state that “many standard HIV prevention strategies have not proven effective,” such as the medically based triad of condom promotion, HIV testing, and treatment of sexually transmitted diseases in the generalized epidemics of East and Southern Africa. They cite the successful reduction of HIV transmission in concentrated epidemics following a campaign promoting condom use among sex workers in Thailand. The authors cite concurrency as a significant contributor to the generalized epidemics of East and Southern Africa and say that campaigns to reduce multiple partners in several African nations have been effective since they have been followed by measurable reductions in multiple partners, which in turn have been followed by reduced HIV prevalence.
Relatively Low HIV Infection Rates in Rural Uganda, But with High Potential for a Rise: A Cohort Study in Kayunga District, Uganda
Guwatudde, D., Wabwire-Mangen, F., Eller, L. et al. PLoS ONE (2009), Vol. 4 No. 1, pp. e4145.
Studies have explored the determinants of HIV infection in Uganda. Using a community-based cohort of 2,025 volunteers from Kayunga, Uganda, researchers administered a questionnaire about participants’ sexual behavior and other HIV risk factors every six months. Blood samples were collected simultaneously. At baseline, approximately one of every 10 individuals tested positive for HIV-1. Within one year, 13 new cases of HIV were detected. HSV-2 (genital herpes) was strongly associated with HIV-1 infection. The most significant behavioral risk factor associated with new HIV infection was the number of times in the last six months that a participant had sex with partners whom they thought or knew were having sex with someone else.
Cultural Scripts for Multiple and Concurrent Partnerships in Southern Africa: Why HIV Prevention Needs Anthropology
Leclerc-Madlala, S. Sexual Health (2009), Vol. 6 No. 2, pp. 103-10.
From October 2007 to November 2008, 228 members of nongovernmental organizations in seven Southern African countries were interviewed to understand the role of culture and contextual factors in relation to MCP. Common patterns in cultural scripts regarding sexuality emerged. These scripts (such as “male sexuality is by nature un-restrainable” or “sexual violence sometimes demonstrates caring”) affirm and legitimatize MCP and need to be addressed to better orient messages to the population.
Why Multiple Sexual Partners?
Shelton, J. The Lancet (2009), Vol. 374 No. 9687, pp. 367-369.
In this commentary, individual, social, economic, and cultural factors underlying multiple concurrent partnerships are discussed. Understanding the causes of sexual concurrency in a given geography and with a given group is an important step toward developing effective HIV prevention programming. “High-quality multilevel (mass media, community, clinical setting, individual) approaches” are called for. One Love, Scrutinize, and O Icheke are cited as exemplary.
Young People's Sexual Partnerships in KwaZulu-Natal, South Africa: Patterns, Contextual Influences, and HIV Risk
Harrison, A., Cleland, J., & Frohlich, J. Studies in Family Planning (2008), Vol. 39 No. 4, pp. 295-308.
The study authors conducted a household survey to examine the sexual behaviors of young people, aged 15-24 years in KwaZulu-Natal, South Africa. The region is one of that nation’s poorest provinces and has the nation’s highest HIV prevalence. The researchers found that one third of men reported MCPs and one quarter of women had partners who were five years older than themselves. Nonparticipation in school or civic organizations correlated with higher-risk partnerships for women. Relationships, on average, lasted more than a year and were defined as “serious” by the participants. Partnerships were both sequential and overlapping. Mobility and the distance between workplace and home greatly affected the kinds of relationships that were formed and sustained.
Age-disparate and Intergenerational Sex in Southern Africa: the Dynamics of Hypervulnerability
Leclerc-Madlala, S. AIDS (2008), Vol. 22 Suppl. 4, pp. S17-S25.
Age-disparate (age gap >5 years between partners) or intergenerational (>10 years) sexual partnerships are thought to disproportionately contribute to high HIV rates among young women aged 15-24 years. Most such partnerships are transactional in nature, rooted in cultural beliefs that men demonstrate affection by providing for women, and that women’s bodies are assets for transactions. Pairing of older men and younger women is further fueled by men’s preference for young, presumably disease-free, partners. Although these partnerships are often mutually advantageous rather than victimizing, women are usually not empowered to negotiate condom use. Along with partner reduction messages, interventions must address education and financial independence in order to empower women to protect themselves. Programs should also foster male norms that discourage exploitative relationships.
Reassessing HIV Prevention
Potts, M., Halperin, D.T., Kirby, D., et al. Science (2008), Vol. 320 No. 5877, pp. 749 – 750.
This commentary challenges several assumptions about HIV epidemiology, including the idea that poverty is an important factor in the spread of HIV. The authors cite data from recent Demographic and Health Surveys (DHS) to suggest that within Africa, high HIV prevalence is not associated with high levels of poverty or conflict, but instead correlates with high rates of MCP, and low levels of male circumcision. The authors also cite evidence that microbicides, vaccines, and HIV testing and treatment of sexually transmitted diseases have little effect on HIV transmission. They conclude that male circumcision (which can reduce a man’s risk of contracting HIV by more than one half) and reduction in sex partners are the most effective interventions for generalized epidemics.
Small House, Hure, Sugar Daddies, and Garden Boys: A Qualitative Study of Heterosexual Concurrent Partnerships Among Men and Women in Zimbabwe
Taruberekera, N., Kaljee, L., Astatke, H., et al. 17th International AIDS Conference (2008), Aug 13-18; 17 Abstract No. MoAc0203.
2006 study about the nature of sexual partnerships in Zimbabwe found that nearly one third of men and over one quarter of women had more than one regular sexual partner. These concurrent partnerships ranged from short-term casual relationships to longer-term emotional relationships. Short-term relationships included intergenerational sex and transactional sex in which money or goods were exchanged for sex. Sex workers engaged in short- and long-term relationships as some sex workers had long-term boyfriends or regular clients. Long-term relationships included those with spouses, girlfriends, and “small house” relationships in which a man supports his partner and possible children but is not formally married.
Why Is HIV Prevalence So Severe in Southern Africa? The Role of Multiple Concurrent Partnerships and Lack of Male Circumcision: Implications for AIDS Prevention
Halperin, D.T. & Epstein, H. The Southern Africa Journal of HIV Medicine (2007), Vol. 8 No. 1, pp. 19–25.
The combination of high rates of concurrent sexual partnerships with low rates of male circumcision seems to distinguish Southern Africa from other regions affected by HIV, and to fuel the world’s largest generalized HIV epidemics. Although African men and women do not have more sex partners than people do elsewhere, their partnerships are more likely to overlap for months or years, creating stable overlapping networks of sexual relationships through which HIV can spread rapidly. In contrast to serial monogamy, HIV can spread more rapidly through concurrent partnerships, in part due to the greater likelihood of contact during the highly infectious month immediately following infection. Consistent condom use can be achieved in casual partnerships, but consistent use is much more difficult to attain in longer-term “trusting” relationships, due to low risk perception.
Sexual Network Structure and the Spread of HIV in Africa: Evidence from Likoma Island, Malawi
Helleringer, S., & Kohler, H.P. AIDS (2007), Vol. 21 No. 17, pp. 2323–2332.
In generalized HIV epidemics, such as those of Southern and East Africa, infections occurring among low-risk individuals account for the majority of new HIV cases. In a study in Likoma Island, Malawi, the prevalence of HIV infection was higher among women than men. Researchers found that half of the island’s sexually active, young adult population was linked in a giant network, rendering them highly effective in spreading HIV among lower-risk groups. The structure of the networks observed in Likoma appears compatible with a broad diffusion of HIV among lower-risk groups.
Measuring Sex Partner Concurrency: It's What's Missing That Counts
Nelson, S.J., Manhart L.E., Gorbach P.M., et al. Sexually Transmitted Diseases (2007), Vol. 34 No. 10, pp. 801-807.
Measures for concurrency are not consistent, leading to conflicting study results. In order to assess the different results obtained by two common survey methods, the researchers conducted a study in which both methods (the calendar method and direct questioning) were used to query 680 young adults in three U.S. cities. Although the total rates of concurrency (over one half of participants) were similar using both methods, nearly one third of individuals reporting concurrency in one measure did not do so in the other. The researchers conclude that despite the greater detail provided by the calendar measure, direct questioning might better identify those at greatest risk for HIV infection.
Ten Myths and One Truth about Generalised HIV Epidemics
Shelton, J.D. The Lancet (2007), Vol. 370, Issue 9602, pp. 1809–1811.
The author of this commentary states that common misperceptions impede HIV prevention efforts. For example, he says, commercial sex workers are not the problem since formal sex work is uncommon in generalized epidemics. Nor are men the problem since there is a high proportion of discordant couples in which women, not men, are HIV positive. The author comments on other perceived myths related to HIV, such as those surrounding condoms, HIV testing, and youth. He concludes that concurrency is central to generalized epidemics and that behavioral interventions are effective.
Concurrent Sexual Partnerships amongst Young Adults in South Africa: Challenges for HIV Prevention Communication
Parker, W., Makhubele, B., Ntlabati, P., et al. CADRE (2007).
This 51-page report examines concurrent sexual partnerships (defined in this survey as a person who has “two or more sexual partners in the past month”) among young people aged 20-30 years old in South Africa. The researchers found that for these young people, the concepts of sex and love are often separated; sex with love is reserved for a ‘main’ partner, while sex without love is common with ‘other’ or concurrent partners. This duality is widely accepted as normative and results in a definition of faithfulness whereby keeping infidelity secret is a sufficient criterion for considering oneself to be faithful. Among people with concurrent partners, condom use declined rapidly with a main partner, and was inconsistent with other partners. The authors conclude that in the South African context, high overall HIV prevalence in conjunction with concentrated sexual networks suggest the need for programs that focus on reducing concurrency. Condom promotion remains an important cornerstone to HIV prevention, and programs need to increase their efforts to promote correct and consistent condom use. HIV testing is a useful complementary strategy for people in established relationships, or for those considering establishing them.
Brief but Efficient: Acute HIV Infection and the Sexual Transmission of HIV
Pilcher, C.D., Tien, H.C., Erron, J.J. Jr., et al. The Journal of Infectious Diseases (2004), Vol. 189 No. 10, 1785-1792.
Empirical biological data suggests that individuals who are acutely infected with HIV (during the first several months) are more likely to infect others than they are during a later phase of their disease, when their viral load is likely to be lower. Using blood and semen samples from 30 patients with acute and long-term HIV-1 infection, the researchers modeled the effect of changes in viral concentration in semen on the probability of transmission per coital act and found that the probability of heterosexual transmission of HIV increases by 8-10-fold during the acute phase of infection compared to infection during the chronic phase of HIV.
Concurrent Partnerships and the Spread of HIV
Morris, M. & Kretzschmar, M. AIDS (1997), Vol. 11 No. 5, pp. 641-648.
Mathematical models comparing the spread of HIV in two populations—one in which serial monogamy was the norm and one in which long-term concurrency was common—indicate that concurrent partnerships amplify the rate of HIV spread. 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 about 10 times greater.
Exploring the Potential Impact of a Reduction in Partnership Concurrency on HIV Incidence in Rural Uganda: A Modeling Study
McCreesh, N., K. O'Brien, R.N. Nsubuga, et al. 2012. Sexually Transmitted Diseases Vol. 39 No. 6, pp. 407-13.
The study modeled the effects of reducing concurrency in a rural Ugandan population as a means to reduce HIV incidence while keeping the amount of sex constant. The behavioral, biological, and demographic data used in the model was collected on an annual basis in the rural South-West area in Uganda. There were three measures of concurrency in the model—long-term, short-term and total concurrency—and it was found that men’s rates were higher than women’s. About 10 percent of men reported a total concurrency level, 4 percent were long-term, and 2 percent were short-term. Less than one percent of women reported any type of concurrent behaviors. The model explored the effects of a 20 percent and 50 percent reduction in concurrency on HIV incidence. It was found that a 20 percent reduction in concurrency would reduce HIV incidence in 2020 by 4.1 percent in men, 9.2 percent in women, and 7.1 percent overall. A reduction of 6.0 percent in men, 16.2 percent in women, and 11.9 percent overall was found in HIV incidence in 2020 if concurrency was reduced by 50 percent. It was also found that reducing concurrency in one gender caused reductions in HIV incidence in the other gender. The authors conclude that countries with high levels of concurrency could benefit from a behavioral campaign targeting sexual concurrency, and that women’s rates of HIV incidence would be reduced if their male partners reduced their levels of concurrency.
Symposia Meeting Report: Addressing Multiple and Concurrent Partnerships in Southern Africa: Developing Guidance for Bold Action
Harvard University and UNAIDS, Gabarone, Botswana (2009).
This 19-page report provides an overview of a regional meeting held in Gabarone, Botswana, that was organized by Harvard, the World Bank, and UNAIDS. Approximately 40 representatives from various regional and international organizations participated. Topics include the theory, implementation, and evaluation of MCP programs in the region. The report provides links to the AIDS Prevention Research Project at Harvard, which in turn links to meeting symposia documents, prior meeting reports, such as the XVII International AIDS Conference in Mexico City, PowerPoint presentations, videos, and poster session reports.
Strategic Considerations for Communications on Multiple and Concurrent Partnerships within Broader HIV Prevention in Southern Africa (draft)
This eight-page guidance is the result of the joint UNAIDS/Harvard AIDS Prevention Research Project and the World Bank meeting, with input from civil society in Southern Africa. Intended as an aid to national programs and implementers, the draft document offers a rationale for its focus on concurrent relationships, strategic goals for communications around multiple and concurrent partnerships (MCP), and guidance regarding appropriate types of messages regarding MCP.
UNAIDS Consultation on Deﬁnition and Measurement of Concurrent Sexual Partnerships (April 20-21, 2009)
This brief, preliminary report on the meeting of the UNAIDS Reference Group on Estimates, Modelling, and Projections, in Nairobi, Kenya, provides an overview of the meeting goals and outcomes. Thirty-five experts addressed the problem of inconsistent definitions of concurrent sexual relationships and how information about concurrency can be obtained during surveys. The experts reached consensus on the following definition of concurrency: “Overlapping sexual partnerships where sexual intercourse with one partner occurs between two acts of intercourse with another partner.” A final set of specific recommendations for survey questions to capture information about concurrency is here.
UNAIDS Meeting Report: Multiple Concurrent Partnerships Campaigns and Communications, Towards a Coordinated Regional Response (September 17-18)
Crooks-Chisano, K. UNAIDS, (2008)
This 24-page meeting report builds on the earlier October 2006, SADC Regional Consultation. The document provides an executive summary, statement of goals, and includes sections on Research on Emerging Evidence; Updates on Experiences and Lessons learned from MCP; Effective Social Change Communication; and Building a Community of Practice.
M&E for MCP Programmes and Consultation on Concurrent Sexual Partnerships
UNAIDS & World Bank (2009).
The first of this two-part document is a 54-page guidance on monitoring and evaluation (M&E) for MCP programs, which is intended for use by National AIDS Commissions, HIV M&E officials and organizations in Eastern and Southern Africa. Definitions, epidemiologic evidence, and goals are provided along with guidance for measurement, measurement tools, and ways to incorporate M&E into existing efforts. Four appendices include guidelines and tools for qualitative research and options for measuring concurrency. The second part of this document is an 18-page Consultation on Concurrent Sexual Partnerships, which recommends the following definition of concurrency: “Overlapping sexual partnerships where sexual intercourse with one partner occurs between two acts of intercourse with another partner.” Due to confusion about the acronym, MCP, and its implications, experts recommend that when referring to concurrency, terms such as “concurrent partnerships,” or simply “concurrency,” should be used. If an acronym is desired, they suggest using "CP."
Policy Brief: Sexual Risk Behaviour among Men with Multiple, Concurrent Female Sexual Partners in an Informal Settlement on the Outskirts of Cape Town
Medical Research Council, South Africa (2008)
This two-page brief highlights a respondent-driven survey of 421 hard-to-reach men living in an informal, urban settlement in South Africa. Sponsored by the U.S. Centers for Disease Control and Prevention, the study authors developed a surveillance system to measure key risk behaviors and HIV prevalence in a population of men who have multiple and concurrent sexual partners. Key findings were that the men used condoms inconsistently, engaged in “high levels of transactional sex and intimate partner violence,” and frequented establishments where alcohol consumption is high in order to find sexual partners. The researchers recommend interventions based on those findings.
Multiple and Concurrent Partnerships: A Support Document for Advocacy Actions and Decision Making Process in Mozambique
Streel, E. (2008)
The brief web document provides an overview of study results of MCP in Mozambique and the reasons individuals engage in MCP. The study found that MCP is common between certain populations such as young girls and older men and men who have sex with women of the same age and/or younger. The report recommends that MCP interventions focus on certain target populations. Contact information is provided to obtain the full 18-page report, which is published by the Johns Hopkins Bloomberg School of Public Health Centre for Communication Programs.
Report on a PEPFAR technical consultation on “Addressing Multiple and Concurrent Sexual Partnerships in Generalized HIV Epidemics,” Washington, DC (October 29-30, 2008)
Stash, S. & Roseman, D. AIDSTAR-One (2008)
The 54-page report summarizes a technical consultation on MCPs held in Washington, DC. The meeting convened researchers, government representatives and program implementers from several nations, including the U.S. and Southern Africa, to address four themes: 1) the relationship between MCP and HIV transmission; 2) core components of MCP programs; 3) engendering community support for MCP activities; and 4) measuring program outcomes. The consultation concluded with group work and discussion on next steps. The report includes appendices with additional resources and a list of participants.
The Invisible Cure: Africa, the West, and the Fight Against AIDS
Epstein, H. Farrar, Straus and Giroux (2007), New York
The author of this book, Helen Epstein, relates the story of her discovery of a long-forgotten study of Ugandan sexual behavior in the late 1980s and early 1990s. The study, conducted by Maxine Ankrah, an African American researcher, explored the myth that condoms were central to the decline in HIV prevalence in Uganda. Ankrah’s research demonstrated that the decline was preceded by a successful campaign to reduce MCP in Uganda. Epstein examines the risks of concurrent sexual relationships and the social and economic upheavals that gave rise to an "earthquake" in gender relations in Africa, contributing to the spread of HIV.
SADC Expert Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern Africa Report. Maseru, Lesotho, (May 10-12, 2006)
Southern Africa Development Community (2006)
This 18-page report provides an overview of the 2006 meeting’s stated goals to “reflect on the key drivers of the epidemic in the region and to provide suggestions for accelerating HIV prevention.” The 35 expert participants set priorities, including promotion of interventions to: reduce the number of multiple and concurrent partnerships; increase male circumcision; encourage male involvement and responsibility for sexual and reproductive health; promote HIV prevention and support; increase consistent and correct condom use; and continue programs to encourage delay of sexual debut along with programs for condom use and reduced partnerships.
USAID, Synergy Project: What Happened in Uganda? A Case Study—Declining Prevalence, Behavior Change and the National Response
Hogle, J., Green, E., Nantulya, V., et al. USAID (2002)
This 13-page report focuses on Uganda as one of the first success stories of the HIV epidemic. HIV prevalence in that country peaked in 1991 and decreased through the early 2000s. The U.S. Census Bureau/Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that national prevalence peaked at around 15 percent in 1991 and fell to 5 percent in 2001. Although the authors of this 20-page report say that the factors that led to the decline "are complex and not yet completely understood," they discuss a variety of observations that a key factor in the decline was the reduction of sexual partners.
PSI's Mass Media Campaign: Reducing Multiple Concurrent Partnerships in Botswana
MCP is thought to be one of the main drivers of the HIV epidemic in Botswana. In 2008, PSI (Population Services International)/Botswana launched a multimedia campaign using billboards, radio, print media and personal communications to raise awareness about the risks of concurrency (distinct from the number of partners that one has). The issue was given prominence when the government of Botswana announced its “National Operational Plan for Scaling Up HIV Prevention in Botswana, 2008-2010,” which calls for a single, high-profile national prevention campaign, initially focused on MCP.
Under the slogan “O ICHEKE – Break the Chain” (O Icheke means “check yourself” and is the name of a popular song in Botswana), the campaign will initially focus on increasing knowledge and risk perception around concurrency, before shifting to focus on the values and norms that cause people to engage MCP and create new values and norms that discourage MCP. The campaign will use mass media and community mobilization efforts, such as community theater and interpersonal communications at schools and churches, as well as messages integrated into Botswana’s HIV-related services (counseling and testing; the delivery of health services such as antiretroviral therapy and the treatment of sexually transmitted infections) and education sector.
C-CHANGE. Lesotho Multiple Concurrent Partner Program
C-CHANGE, launched in February 2009 in Lesotho, works to reduce the “widespread practice” of MCP, which the project states “will contribute to 65 percent of all new infections in Lesotho in the next 12 months.” The program addresses intergenerational sex, transactional sex, and gender norms. The project works in partnership with CARE-Lesotho, Phela Communication and Health Institute, and national and local nongovernmental organizations. The media component of the program is organized under the regional OneLove campaign and focuses on adults 18-50 years old. The interpersonal component includes tools and training materials for group discussions. The program will be evaluated through a national behavior survey that will measure the number of MCP.
Soul City's OneLove Kwasila! Project, Zambia
Soul City is implementing a new 10-part mini-series drama called Club Risky Business, which is part of the Kwasila! Campaign in Zambia. Several episodes of the show, which was first broadcast in June 2009, can be seen on YouTube. The primary target audience of the campaign is married men aged 25 to 50 years and the secondary target audience is women aged 15 to 45 years (the wives and girlfriends of the primary target audience).
The story line of Club Risky Business centers on the relationships of three Lusaka men who frequent a local bar, Club Risky Business, and how their involvement in multiple and concurrent partnerships exacerbate the HIV pandemic in Zambia. The central character, David, uses his wealth to attract women and frequently exchanges gifts for favors. The second man, Sachi, thinks that he is safe because he only has one other partner besides his wife, and the third character, Charlie Lucky, has multiple sexual partners but maintains that he is safe because he always uses condoms.
Social, cultural, and gender dynamics surrounding MCP, the riskiness of the sexual network, and the idea that a lifelong relationship can be happy and fulfilling, are all integrated into the story lines.
Other aspects of the campaign include multimedia projects involving radio, television talk shows, a feature length film, print materials, and a website.
PSI’s Reducing Multiple Concurrent Partnerships in Mozambique
Addressing MCP is a priority for the Mozambican Ministry of Health and National AIDS Council (CNCS) and is part of the accelerated HIV prevention plan for 2009. Accordingly, PSI/Mozambique initiated a community-based communication program of 30 community agents in Maputo and Gaza Provinces in May 2008 to conduct face-to-face sessions to increase awareness of the risks of MCPs. These efforts are part of a participatory discussion group module that is implemented by the existing network of 180 community agents, and the integration of MCP themes into the activities and discussions of 12 community theater groups.
Interpersonal communication sessions generally consist of 15-20 adults who sit around a blackboard with pictures of men and women. The participants are asked to identify the sexual networks in their communities. The community agents visually demonstrate with lines linking the men and women on the blackboard how having just one or more additional concurrent partner(s) can put everyone at greater risk of infection by building an overlapping network of sexual relationships across which HIV can spread.
PSI/Mozambique also conducts research. In 2008, PSI undertook a large-scale, population-based survey to assess the levels and determinants of condom use and MCP within three provinces. Over 40 percent of men in Gaza, 30 percent of men in Sofala, and 20 percent in Zambezia provinces reported having more than one sexual partner during the past month. Condom use was very low among individuals in long-term, concurrent partnerships.
PSI is currently working with USAID, PEPFAR, Johns Hopkins University and Mozambican partners FDC and N'weti (the local affiliate of Soul City) to develop a mass media, TV, radio, and print campaign with similar behavior-change messages to increase risk perceptions of MCP and HIV.
Is Concurrency Driving HIV Transmission in Sub-Saharan African Sexual Networks? The Significance of Sexual Partnership Typology
Kretzschmar, M. & Caraël, M. AIDS and Behavior (October 2012), Vol. 16 No. 7, pp. 1746-52.
There has been strong disagreement in the past few years about the role that concurrent partnerships play in HIV transmission. With few empirical studies to back up the mathematical modeling that supports the concurrency theory, particularly in regions of very high HIV prevalence such as Southern Africa, the authors explore the difficulties of testing the “seemingly simple hypothesis” of concurrency as a primary driver of HIV transmission. First, they question whether mathematical modeling efforts—which abstract sexual behavior and thus create idealized factors to explain the spread of epidemics—are sufficiently sensitive to assess the real-world complexities of sexual networking at the population level. The authors also cite the difficulties inherent in defining quantities that can be measured in fieldwork and in HIV incidence, and in working without a universal standard definition of concurrency. They recommend developing a typology of concurrent partnerships that classifies by social determinants and sexual behavior within partnerships to better analyze sexual network structure and, ultimately, the impact of concurrency. In their conclusion, the authors argue that, while concurrent partnerships in theory play an important role in HIV transmission, concurrency has not yet been proven to be a “driving force” in the epidemic. They urge epidemiologists and mathematical modelers to work together to improve methods of investigating the impact of concurrency.
Social and Cultural Contexts of Concurrency in a Township in Cape Town, South Africa
Mah, T.L. and B. Maughan-Brown. 2012. Culture, Health, and Sexuality [Epub ahead of print].
The goal of some prevention interventions in South Africa is to reduce concurrent sexual relationships as a means to decrease HIV incidence. This qualitative study explored individuals’ perceptions of the prevalence of concurrency in their communities and what terms they use to describe this behavior. It also investigated why individuals engage in these partnerships as well as participants’ understanding on the link between concurrency and HIV infection. The participants were selected using a disproportionate stratified sampling methodology among a township in Cape Town with a reportedly high level of concurrency (17 percent). Six gender-specific small group discussions were conducted in the local language and then transcribed into English. It was found that the most common term for concurrent sexual partnerships was “roll-on,” which referred to underarm deodorant and something to be hidden. These types of partners were viewed as common and equally practiced by both men and women. The predominate reasons given for having concurrent sexual partnerships was for material or financial gain/exchange and sexual dissatisfaction with a main partner. Other reasons that were given for having concurrent sexual relationships were separation from the main partner, revenge on the main partner for having another partner, alcohol, and “human nature.” Reasons for remaining monogamous were trust that the main partner was also faithful, being sexually satisfied, religion, and fear of being infected with sexually transmitted infections. Participants stated that the knowledge of the link between concurrency and HIV acquisition did not stop people from engaging in such relationships. The authors conclude that increasing condom use within concurrent partnerships and increasing sexual satisfaction among couples could be effective prevention strategies in this population.
The Scrutinize Campaign: A Multi-Level Communication Program to Address Concurrency in South Africa
The Scrutinize campaign, created in partnership with USAID, the Johns Hopkins Health Education in South Africa (JHHESA), and Levi's®, helps young people change their sexual behavior in order to reduce their risk of HIV infection. The campaign uses social networks (peers and friends), community (community leaders) and societal influences (policy and services) to disseminate messages about MCPs and the correct use of condoms. Seven “Animerts” or cartoon commercials are central to the Scrutinize media campaign. The cartoons are specifically tailored for young South Africans, aged 18-32 years old.
Characters featured in the campaign mimic South African celebrities, and mirror local stereotypes in the community that many can relate to, from taxi-drivers to sugar daddies. The Scrutinize Campus Campaign is active at five higher educational institutions, where peer educators are identified and trained to communicate through art, drama, song and dance.
A Scrutinize Live Event features South African celebrities and musicians who interact with the audience. Campus-based radio disk jockeys have developed a Scrutinize magazine program. The campaign promotes linkages to HIV counseling and testing services provided by a partner organization. A “Scrutinize on-line” Website draws attention to Animerts. Cell phone numbers collected during events are used to disseminate campaign updates.
Marketing research shows that the campaign has reached 98% of the target audience and Animerts were seen as relevant, educational, and depicting contexts and situations that were familiar to the viewers. Over time, the two primary messages that the audience associated with the campaign were: (1) having multiple and concurrent sexual partners increases the risk of HIV, and (2) inconsistent condom use with all partners increases the risk of HIV infection.
OneLove: Multiple and Concurrent Sexual Partnerships in Southern Africa: A Ten Country Research Report
This 40-page report is an analysis of earlier reports from Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia, and Zimbabwe, where 179 focus groups were conducted after a research design workshop held in May/June 2007. The focus groups were followed by 116 in-depth interviews with men and women of all ages and various backgrounds who were, or had been, involved in MCPs.
The groups were part of the OneLove campaign, which is sponsored by the Soul City Regional Programme and which focuses on reducing MCP. The focus groups provided insight into attitudes and practices regarding sexual relationships in the context of HIV prevention among individuals in the ten southern African nations. Findings were consistent across the ten nations and included a low level of condom use among those involved in MCP and superficial knowledge about risks associated with MCP.
Cultural norms, gender inequality, poverty, transactional sex and alcohol were identified as significant contributors to MCP. The report authors recommend educational messages about the risks of MCP; the problems related to female subservience and male dominance; the correct use of condoms; and the concept that a lifelong relationship can be happy and fulfilling.
SAfAIDS, Changing the Rivers Flow Series: Challenging Gender Dynamics in a Cultural Context to Address HIV (2009)
The Changing the River’s Flow Series is a project that addresses "harmful cultural practices" that can feed into the transmission of HIV. The project includes an 89-page "best practices" document, two community education handbooks, a training manual, booklet, poster, banner, and sticker. Separate links are provided for each.
CADRE, Tsha Tsha, 2008
Tsha Tsha is an award-winning television series consisting of 78 half-hour episodes that were broadcast between 2003 and 2006. The educational/entertainment drama series focuses on young people and how they live with HIV/AIDS while coping with poverty and other social issues. A DVD companion discussion guide about strategies for the effective management of HIV and a facilitator’s guide to the first segment of Tsha Tsha are available.
HIV Peer Education Picture Codes
McLellan, I. CARE (2008).
A set of picture codes produced in Botswana is available for a variety of topics, including abstinence, alcohol abuse reduction, sexual behavior choices, gender and sexual abuse reduction, better couple communication, and values and goal setting.
SAFAIDS, Inter-linkages between Culture, Gender Based Violence, HIV and AIDS and Women’s Rights: Training Manual (2008)
This 85-page training manual provides information for a four-day training program on the linkages between gender-based violence (GBV), culture, women’s rights and HIV/AIDS. The project was developed for community-based workers and volunteers, HIV implementers, and others. The manual includes a section on creating an action plan and provides handouts that can be used during the program.
Outreach Guides: HIV/AIDS Prevention Programs
CARE (December 2007)
PACT Botswana has developed 10 outreach guides to assist HIV program implementers. The guides use participatory methods and focus on promotion of behavior change, especially for at-risk groups, taking co-factors such as alcohol abuse, sexual violence, and intergenerational sex into consideration. Each guide can be downloaded by topic or as a single large packet. Topics include: Organizing and Conducting Outreach; Abstinence Promotion; Assertiveness and Peer Pressure; Values and Goal Setting; Sexual Behavior Changes; Alcohol Abuse Reduction, Gender Roles and Sexual Abuse Reduction; Better Couple Communication; Enhancing Parent-Child Communication; and Partner Reduction and Protection
OneLove. Loving with Respect: A Guide for Men Who Care
This 16-page guide for men addresses myths that interfere with positive relationships and that may contribute to MCP. Such myths include the idea that a woman can’t say "no" to sex after going on a date or that it is in men’s "biology" to have more than one partner. The guide lists the phone numbers for various regional offices of the National AIDS Council (NAC).
OneLove. Loving Carefully: A Guide for Women
This 16-page guide for women uses a variety of scenarios to encourage women to speak openly with the men they love to reduce their chances of contracting HIV. Issues from rape to pregnancy are included and the guide concludes with a list of phone numbers for various regional offices of the National AIDS Council (NAC).
OneLove, Multiple and Concurrent Sexual Partners: What’s culture got to do with it? A Handbook for Journalists
Soul City developed this 22-page handbook for journalists in order to improve reporting on HIV. Terms are defined and research summaries are provided regarding MCP, concurrency, lack of condom use, interpersonal violence and certain cultural norms. The handbook offers a number of questions and potential stories for journalists to pursue. Reference articles and links are included. An extensive list of resources with contact information is also provided.
The HIV Superhighway
The HIV Superhighway is a two-part educational film on concurrent partnerships and HIV prevention. The film was produced by DKT-Ethiopia and is intended for any audience at risk, especially young people. It could be shown in school- or work-based programs, anti-AIDS clubs or in community-based organizations and NGOs.
Part I uses animated drawings to explain how HIV spreads faster via concurrency than via serial monogamy, even though serial monogamists may have more sexual partners.
Part II describes Uganda's successful "Zero Grazing" AIDS campaign that urged people to stay faithful to one partner, reduce their sexual partners and helped break up the HIV Superhighway that encouraged the virus to spread.
UNAIDS, Talking about OneLove in South Africa (2009)
This webpage provides a brief overview of the South African OneLove campaign.
Left Behind - Black America: A Neglected Priority in the Global AIDS Epidemic
Black AIDS Institute (2008)
For more information about the role of concurrency in the U.S. HIV epidemic and its impact on black populations, this 56-page report offers a review of the socioeconomic and epidemiologic aspects of HIV among black individuals in the U.S.
View Full Text (PDF, 1.5MB)
C-Change Picks 5: Focus on Multiple Concurrent Partnerships
C-Change program is a project of the Communication Initiative and USAID. The fifth issue of C-Change Picks, an electronic journal, focuses on MCP and provides links to a variety of articles on MCP in Southern Africa.
Zimbabwe HIV Prevention e-Toolkit
The toolkit offers a selection of different resources including research papers, books, training materials, and behavior change communication materials across the spectrum of HIV prevention topics. Readers can access materials and resources on behavior change communication, condom use, family planning and HIV service integration, male circumcision, multiple and concurrent partners, prevention of mother-to-child transmission, and voluntary counseling and testing.
Related AIDSTAR-One Case Studies