HIV Prevention Knowledge Base
Behavioral Interventions: Multiple and Concurrent Sexual Partnerships
USAID, Synergy Project: What Happened in Uganda? A Case Study—Declining Prevalence, Behavior Change and the National Response
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
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
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.