THEORETICAL FRAMEWORK
CHAPTER 3 LITERATURE REVIEW
3.4. Concurrent multiple sexual partners
While circumcision can be used to explain the disparity between infection rates in West Africa and Southern African region, it cannot be used to rationalize the disparity between Southern
Africa and Europe and America where majority of males are not circumcised. ‘Multiple concurrent partnerships by men and women with low consistent condom use, and in the context of low levels on male circumcision’ (SADC, 2006), has been identified by researchers (Halperin, & Epstein, 2007; Kalichman, et al., 2007; Hannah, Pfeiffer, Torian, & Sackoff, 2008) and SADC as the two major driving forces in the exacerbation of the pandemic in Africa, more so in the Southern African regions.
Concurrency in sexual relationship has been defined by many authors as ‘sexual relationships that overlap in time’ (Adimora, et al., 2003; Helleringer & Kohler, 2007). It refers to people who have high levels of sexual partner turnover and concurrency; that is, having more than one sexual partner during the same period of time. Epidemiologists have observed that in Africa men and women often have more than one sexual partner at the same time. Sometimes, they have two or more concurrent sexual partners that can overlap for months or even years (Halperin, & Epstein, 2007). This pattern differs from that of serial monogamy that is more common in the West, or the one-off casual and commercial sexual encounters that occur everywhere (Morris, 2002; (Halperin & Epstein, 2004)). In their mathematical modelling, Morris and Kretzchmar (1997) compared the spread of HIV in two populations, where the norm of one is serial monogamy and the other is longer term concurrency. The total number of sexual relationships was similar yet HIV transmission was much more rapid with longer-term concurrency, and the resulting epidemic was projected to be ten times greater than in serial monogamous relationships. Quinn, et al. (2000) further established that the viral load and infectivity in concurrent relationships is much higher than the ‘acute infection’ window period
(typically about three weeks long) after HIV infection. This is because as soon as one person in a network of concurrent relationships contracts HIV, everyone else in the network is exposed to risk because of the combined effects of sexual networking and the acute infection spike in viral load whereas in serial monogamy, virus only traps within a single relationship for months or years (Pilcher, Tien & Eron, 2004).
Many people involved in multiple sexual relationships find it difficult to change and may not see any convincing reasons to change their behaviour because of a number of social, cultural, and economic reasons. Many Africans go into polygamous relationships because of fame, wealth or power. Many African young girls and women, because of poverty or greed, fall prey to the intrigues of richer and privileged men and go into multiple relationships for money or for position (Smith, 2007; Lewis, Lee & Patrick, 2007; Sabone, et al., 2007). Such women lack the power to negotiate timing for sex or for use of condom.
The sustained high prevalence of HIV/AIDS in Africa is thus associated with concurrent multiple sexual partnerships among Africans, single or married. For example HIV has been present in Asia for two decades yet the spread rate is still limited (Park, et al., 2010). Except for prostitutes, very few Asian women have concurrent sexual partners whereas a large proportion of African women do (Morris, 2002). In this study on the sexual networks in Uganda, Thailand and USA, Morris (2002) discovered that Ugandan men report fewer life-time sexual partners than Thai and USA men who engage in one-off encounters with prostitutes. However, HIV rates remain very high in much of Eastern and Southern African countries. Even though these regions
account for only 3% of the global population yet 50% of global HIV cases are located in the region. This is probably as a result of concurrent multiple sexual partners involving males and females among other reasons. Infection rates in South Africa, Botswana, Zimbabwe and Western Kenya range from 20-40% in 2003, roughly an order of magnitude higher than anywhere else in the world (UNAIDS, 2003). Jewkes, et al. (2006) declared, in their studies, that those that engaged in multiple concurrent sexual partners are regarded as heavy carriers of the epidemic, especially in cases where the males are much older than the females.
Shelton, et al. (2004) confirmed that without multiple sexual partnerships, HIV epidemic would not have occurred and that partner reduction, which serves as a way of preventing the spread of HIV, was being neglected. Partner reduction is the potential centre-piece of a unified ABC approach, which is regarded as good common sense and good epidemiology. For example the decline of HIV prevalence among pregnant women in Uganda (Genuis & Genuis, 2005), Thailand (Cohen, 2003), Ethiopia (Tsegaye, et al., 2002), Zambia (Fylkesnes, et al., 2001) and Tanzania (Kwesigabo, et al., 1998) was due to change in behaviour which included sexual partner reduction and fidelity in monogamy by men, especially older men. Fewer sex partners remain the key to curbing HIV. Thom (2008) also identified reduction in multiple sexual partnerships (and male circumcision) as the cornerstone of HIV prevention strategy in Africa if any positive impact is to be made on the pandemic.
Although it is obvious from the above analyses that multiple sexual partners is an important risk factor in the spread of HIV (e.g. Chen, et al., 2007; Mishra, et al., 2007), a few studies in sub-
Saharan Africa have found no association between concurrency and HIV prevalence level (Lagarde, et al., 2001; Hellenringes & Kohler, 2007). Multiple concurrent relationships are often associated with mobility, particularly labour-related mobility in Africa that necessitates people to have different partners at different locations (Coffee, Lurie & Garnett, 2007).