Partner Reduction
Recent evidence links multiple, concurrent partnerships as strongly associated with HIV transmission (Epstein, 2007). “Concurrency can be defined as having sexual relations with more than one person within a specified period i.e., a new sexual relationship is initiated before the preceding one has ended…irrespective of whether those relationships were spousal or non-spousal” (Sandøy et al., 2008: para 2). Focusing on concurrent or simultaneous partnerships in an HIV prevention response is more important than focusing on all multiple partnerships, as concurrency is more efficient at raising HIV prevalence. Viral load and infectivity are higher in the early, acute stage of infection, so recently infected individuals with concurrent partners are more likely to transmit HIV to others than recently infected individuals that have one or no partners (Pilcher et al., 2004; Morris and Kretzchmar, 1997 cited in Carter et al., 2007).
Multiple Partnerships Are Common and Place Women At Risk of HIV Acquisition
Concurrent sexual partners are a common practice in many parts of the world where the epidemic has proliferated: A meta-analysis of 68 epidemiological studies from 1986 to 2006 with 17,000 HIV-positive people and 73,000 HIV-negative people found that women who reported three or more sex partners had three times as much likelihood of HIV acquisition versus women with up to two partners (Chen et al., 2007 cited in Vergidis et al., 2009); Studies showing that concurrent sexual partners are common were also found for Zimbabwe (Kasprzyk et al., 2008); Cameroon and Zimbabwe (Mishra and Assche, 2008); Botswana, with one of the highest prevalence rates in the world Carter et al., 2007; UNAIDS, 2008); Mali (Levandowski et al., 2008b); and South Africa (Mah, 2008).
When designing prevention interventions it is important to understand women’s various partnership patterns. A woman may be married with only one sexual partner. Or a young woman may be in a cross-generational sexual relationship, with an older male partner upon whom she relies for school fees. [See Chapter 5. Prevention for Young People] A woman may also have multiple partners to enable her to survive financially. Women may work as sex workers, an occupation that requires multiple sexual partners. [See Chapter 4. Prevention for Key Affected Populations] Men may also have multiple partnerships, which may place women at risk for HIV acquisition. In some societies, polygamy, where a man has multiple spouses, may place women at risk of HIV acquisition. Other factors, such as gender norms, violence, and income, may result in men having numerous sexual partners. [See Chapter 11. Strengthening the Enabling Environment]
Married Women Are Still At Risk for HIV Acquisition
Marriage is often portrayed to women and girls as a haven from the risk of HIV infection. In fact, the risk of HIV transmission between sexual partners is nonexistent when both partners are uninfected at the time of marriage and subsequently engage in sexual activity exclusively with each other. However, these conditions are often not met. In some countries, married women are at high risk of acquiring HIV (UNAIDS, 2006: 22; Hirsch et al., 2007; Hageman et al., 2009; Ugonnet et al., 2002 cited in Matovu et al., 2007), particularly in generalized epidemics. An estimated 55% to 92% of new heterosexually acquired HIV infections among sexually active adults in urban Zambia and Rwanda occur within serodiscordant martial/cohabitating relationships. Couples interventions to reduce transmission in serodiscordant relationships could have a large impact on the epidemic (Dunkle et al., 2008).
It is critical that partners know their serostatus and practice safe sex. Both married and unmarried women need basic knowledge of HIV and how to prevent transmission. However, married women are often not reached by prevention messages because married women “were not considered part of the so-called risk groups. Prevention efforts have been focused on pregnant women, sex workers, and IDUs. Therefore, the majority of women received a message of false security that women who are married and monogamous have no risk for acquiring HIV” (Ross Quiroga, 2006:1-2). Despite the fact that HIV transmission occurs within stable partnerships or marriage, a review of the literature on couples’ HIV prevention found that “couples-focused approaches to HIV prevention are still in an early phase of development” (Burton et al., 2008: para 8).
Changing Gender Norms On Multiple Partnerships is Critical
Multiple partnerships is closely tied to gender norms of masculinity, where men are required to have multiple sexual partnerships simultaneously, be unfaithful to their regular sexual partner and buy sex as proof of their masculinity (Peacock et al., 2008). Many women are unaware that their husbands or sexual partners may have other sexual partners. Married adolescent girls are particularly vulnerable and are often more at risk of HIV infection than unmarried sexually active girls. For example, a study analyzing Kenyan and Zambian data from 1997 and 1998 found that married adolescent girls living in urban areas had higher incidences of HIV infection than unmarried sexually active girls in the same age group. “Although married girls are less likely than single girls to have multiple partners, this protective behavior may be outweighed by their greater exposure via unprotected sex with partners who have higher rates of infection” (Clark, 2004: 149). In sub-Saharan Africa, both women and men may be the HIV-positive partner. Additional risks are posed by polygyny, i.e. legal or customary marriage with multiple wives, with low rates of condom use and unequal power relations (Bove and Valeggia, 2009).
Reducing Concurrent Partnerships Can Reduce HIV Transmission
Reduction of concurrent partnerships has been shown to effectively reduce HIV transmission; “there are, however, few demonstrated replicable approaches to reducing multiple sexual partnerships on a large scale” (Potts et al., 2008: 750). There is currently programmatic focus on partner reduction, yet this review identified few evaluations of interventions intended to promote fidelity, “be faithful,” or partner reduction, particularly among adult men. Furthermore, “The needs of the married and cohabitating population have been neglected... despite the fact that more than half of HIV infections in the severe epidemics of Southern and East Africa are occurring in this group” (Delvaux and Nöstlinger, 2007: 56).
Interventions to reduce concurrent partnerships that are gender transformative are urgently needed. Programs need to work with communities to address gender norms that put women at risk through expectations of fidelity, while encouraging multiple partnerships among men. Programs that do not incorporate a gender perspective are precisely what have placed women with only one sexual partner at risk for HIV acquisition. Increasing couple communication is a promising strategy to begin addressing these risks and raise awareness that married women are indeed at risk for acquiring HIV. A few areas regarding partner reduction still have major gaps that need to be filled, including interventions that address the risks of polygamous marriage (Sandøy et al., 2008), and the role of homophobia in leading men who have sex with men to feel they must hide their sexuality through concurrent partnerships with women, thus putting many at risk.