Multiple concurrent partnerships

A Think Tank meeting on HIV prevention in the high HIV prevalence countries in southern Africa, convened by the Southern Africa Development Community (SADC) and UNAIDS in 2006, concluded that 'high levels of multiple and concurrent sexual partnerships by men and women with insufficient consistent, correct condom use, combined with low levels of male circumcision are the key drivers of the epidemic in the sub-region.' One of two 'key priority interventions' the meeting recommended was the need to "significantly reduce multiple and concurrent partnerships for both men and women."

Studies show that men and women in the region often have more than one sexual partner at the same time. These concurrent partnerships can overlap for months or years. The pattern of concurrent partnerships is different to the pattern of serial monogamy more common in the West and can result in much higher rates of HIV transmission across communities. Viral load and 'infectivity' is much higher during the three to four week 'acute infection' window period that initially follows HIV infection. The combined effects of sexual networking and the acute infection spike in viral load means that as soon as one person in a network of concurrent relationships contracts HIV everyone else in the network is placed at risk. Conversely, modeling suggests that a relatively small reduction in multiple concurrent partnerships in the population will have a disproportionate effect in reducing the extent to which individuals are linked in one sexual network.

In Southern Africa male and female motivations for seeking more than one partner include long absences away from home in the migrant labour system, female vulnerability, ease of opportunity and social, cultural and economic factors. Women are often not passive victims but active agents in pursuing concurrent partnerships, particularly with men older than themselves, in order to meet a range of needs. These include cash, various material resources and social status as well as sexual satisfaction, love and security.

Addressing multiple concurrent partnerships in HIV prevention requires targeted locally informed and culturally relevant messages to raise personal awareness of risk and change socio-cultural norms around sexual partnering. Increased effort and resources are also needed to directly engage young and older men.

Key resources

UNAIDS et al
Gender and multiple and concurrent sexual partnerships in Zambia (Powerpoint presentation), 2010

UNAIDS

Multiple concurrent partnerships - fact sheet


SAFAIDS

How to card series - multiple concurrent partnerships: Driving Southern Africa's HIV epidemic. 2009
 

Mah T., & Halperin D.T.
Concurrent sexual partnerships and the HIV epidemics in Africa: the evidence to move forward. 2010

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.

Family Health International
Gender and concurrent sexual partnerships in Zambia. Preliminary analysis findings. 2010

This study was designed to produce strategic information on determinants of sexual behavior, focusing particularly on social, economic, and cultural factors that promote concurrent sexual partnerships (concurrency). Its goal was to inform national gender interventions to prevent HIV.

Key findings:

  • Overlapping concurrency is prevalent
  • "Faithful" is not perceived to mean sexual ­fidelity
  • The use of crude measures of concurrency can result in misleading estimates of male and female concurrency

UNAIDS and Soul City Institute
Community of Practice on HIV prevention communications meeting - Johannesburg, 14-15 May 2009

On 14 and 15 May 2009, UNAIDS and Soul City Institute co-convened the second of a series of meeting of HIV prevention communications practitioners working on discussing comprehensive HIV prevention efforts with a particular focus on addressing multiple and concurrent partnerships in Eastern and Southern Africa.

Download the meeting presentations:

UNAIDS
Strategic considerations for communications on multiple and concurrent partnerships within broader HIV prevention in Southern Africa. 2009

This guidance document results from interactions with civil society in the region and collaboration between UNAIDS, the Harvard AIDS Prevention Research Project and the World Bank, including an expert meeting on MCP held on 28-29 January 2009 in Gabarone, Botswana. It arose from recognition of the need for regional guidance on the principles and good practice for MCP campaigning to assist national programmes, in particular, to strengthen HIV prevention efforts for MCP reduction.

UNAIDS
Addressing multiple and concurrent partnerships in Southern Africa: Developing guidance for bold action. Meeting report. 2009

This meeting built on two previous meetings to discuss MCP in the region: one held by UNAIDS RST ESA and Soul City in Johannesburg in September 2008, bringing together MCP practitioners to share experiences and ideas; and a second held by PEPFAR in Washington in October 2008 to share programmatic experiences from the region and to deepen understanding of the contribution of MCP to the hyper-endemic epidemics in southern Africa.

National AIDS Commission Lesotho, UNAIDS, and Family Health International
Gender and multiple concurrent partnerships in Lesotho. 2009

A qualitative study undertaken in five communities aimed at better understanding the social, economic and cultural considerations that influence individuals' decisions related to multiple sexual partnerships and the perception of HIV risk in such relationships.

This study provides strategic information on determinants of sexual behavior, focusing particularly on social, economic and cultural factors that promote multiple concurrent sexual partnerships, with the purpose to inform national gender interventions targeting prevention of HIV.

UNAIDS and Soul City Institute
Multiple concurrent partnerships campaigns and communications towards a coordinated regional response. Meeting report, 2008

In September 2008 UNAIDS and Soul City brought together communications practitioners to take stock and discuss practice and progress in the region in addressing the risk of multiple concurrent partnerships. The meeting focussed on ensuring commitment to greater sharing and coordination in communications addressing not only multiple concurrent partnerships but also broader combination prevention efforts.

UNAIDS
Parcerias sexuais múltiplas e concorrentes: Revisão de alguns instrumentos internacionais (Powerpoint presentation). 2008

UNAIDS
Multiple and Concurrent Partnerships. Strategic Considerations (Powerpoint presentation). 2008

CADRE
Concurrent sexual partnerships amongst young adults in South Africa. Challenges for HIV prevention communication. 2007

The present report explores both quantitative and qualitative data related to the 20-30 year age group with a focus on concurrent sexual relationships amongst heterosexual respondents. Much HIV prevention focus has emphasised risk amongst youth, with youth variously defined in terms of age range, including teenagers and post-teenage groups, but predominantly focusing on young people under 20. This focus on younger 'youth' has resulted in lesser emphasis being placed on understanding of young adults in the 20-30 year age group, as well as other older age groups vulnerable to HIV.

Christine L. Mattson, Robert C. Bailey, Kawango Agot, J. O. Ndinya-Achola and Stephen Moses
Nested case-control study of sexual practices and risk factors for prevalent HIV-1 infection among young men in Kisumu, Kenya - Sexually Transmitted Diseases, May 2007, Vol. 34, No. 5. 2007

To evaluate risk factors for prevalent HIV-1 infection, reserachers analyzed crosssectional data from a nested sample of 1337 uncircumcised men aged 18-24 years participating in the context of a randomized controlled trial (RCT) of male circumcision (MC) to reduce HIV-1 incidence in Kisumu, Kenya.

CADRE
Shifting sands. Knowledge, risk and genderin South Africa (Powerpoint presentation). 2007

Halpering D. T and Epstein H.
Why is HIV prevalence so sever n Southern Africa? The role of multiple concurrent partnershps and lack of male circumcision: Implications for AIDS prevention

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.

James D Shelton, Daniel T Halperin, David Wilson
Has global HIV incidence peaked? (Comment published in Lancet online, March 30 2006)

Article considering the decline in HIV prevalence in a number of African settings and elsewhere.

He' Le' Ne A. C. M Voeten, Omar B. Egesah and J. Dik. F Habbema
Sexual behavior is more risky in rural than in urban areas among young women in Nyanza province, Kenya. 2004

The goal of this study was to measure sexual risk behavior among young adults in Nyanza province in Kenya and to compare rural and urban areas. The study found that for women, sexual behavior was more risky in rural than in urban areas, also after adjusting for sociodemographic differences. Rural women reported less frequently being a virgin at marriage, a higher number of lifetime partners, and less consistent condom use with nonspousal partners. For men, sexual risk behavior was equally high in urban and rural areas.

Michael Carael, Mohamed Ali, John Cleland
Nuptiality and risk behaviour in Lusaka and Kampala - African Journal of Reproductive Health, Vol. 5, No. 1, Aug. 2001

This analysis assesses the link between partnership status and the probability of having one or more casual or non-regular sexual relationships in the past 12 months, using data from sample surveys conducted in Kampala and Lusaka in 1989/90 under the auspices of the Global Programme on AIDS. Non-regular sexual relationship was found to be much more common among individuals in relatively informal primary partnerships than among married individuals, and also more common among those with multiple primary partners.