Multiple sex partners and the spread of HIV/AIDS in Africa
A growing number of studies single out such behavior -- in which men and women maintain two or more ongoing relationships -- as the most powerful force propelling a killer disease through a vulnerable continent.
This new understanding of how the AIDS virus attacks individuals and their societies helps explain why the disease has devastated southern Africa while sparing other places. It also suggests how the region's AIDS programs, which have struggled to prevent new infections even as treatment for the disease has become more widely available, might save far more lives: by discouraging sexual networks.
"The problem of multiple partners who do not practice safe sex is obviously the biggest driver of HIV in the world," said Ndwapi Ndwapi, a top government AIDS official in Botswana, speaking in Gaborone, the capital. "What I need to know from the scientific community is, what do you do? . . . How do you change that for a society that happens to have higher rates of multiple sexual partners?"
But the number of sex partners is not the only factor that increases the risk of HIV/AIDS in Africa:
The most potentially dangerous relationships, researchers say, involve men and women who maintain more than one regular partner for months or years. In these relationships, more intimate, trusting and long-lasting than casual sex, most couples eventually stop using condoms, studies show, allowing easy infiltration by HIV.
Researchers increasingly agree that curbing such behavior is key to slowing the spread of AIDS in Africa. In a July report, southern African AIDS experts and officials listed "reducing multiple and concurrent partnerships" as their first priority for preventing the spread of HIV in a region where nearly 15 million people are estimated to carry the virus -- 38 percent of the world's total.
Men and women in Botswana - a country of south-central Africa - contract HIV/AIDS faster than almost anywhere else on Earth:
Twenty-five percent of Batswana adults carry the virus, according to a 2004 national study, and among women in their early 30s living in Francistown, the rate is 69 percent.
Researchers increasingly attribute the resilience of HIV in Botswana -- and in southern Africa generally -- to the high incidence of multiple sexual relationships. Europeans and Americans often have more partners over their lives, studies show, but sub-Saharan Africans average more at the same time.
Nearly one in three sexually active men in Botswana reported having multiple, concurrent sex partners, as did 14 percent of women, in a 2003 survey paid for by the U.S. government. Among men younger than 25, the rate was 44 percent.
The distinction between having several partners in a year and several in a month is crucial because those newly infected with HIV experience an initial surge in viral loads that makes them far more contagious than they will be for years. During the three-week spike -- which ends before standard tests can even detect HIV -- the virus explodes through networks of unprotected sex.
This insight explained what studies were documenting: Africans with multiple, concurrent sex partners were more likely to contract HIV, and countries where such partnerships were common had wider and more lethal epidemics.
A model of multiple sexual relationships presented at a Princeton University conference in May showed that a small increase in the average number of concurrent sexual partners -- from 1.68 to 1.86 -- had profound effects, connecting sexual networks into a single, massive tangle that, when plotted out, resembles the transportation system of a major city.
In generations past, even people in Botswana with just one spouse rarely expected monogamy:
Husbands spent months herding cattle while their wives, staying elsewhere, tended crops, Mosojane said. On his return, a husband was not to be quizzed about his activities while he was away. He also was supposed to spend his first night back in an uncle's house, giving his wife time to send off boyfriends.
In Botswana, HIV/AIDS prevention campaigns have tended to favor comdoms over monogamy:
Fidelity campaigns never caught on in Botswana. Instead, the country focused on remedies favored by Western AIDS experts schooled in the epidemics of America's gay community or Thailand's brothels, where condom use became so routine it slowed the spread of HIV.
These experts brought not just ideas but money, and soon billboards in Botswana touted condoms. Schoolchildren sang about them. Cadres of young women demonstrated how to roll them on. The anti-AIDS partnership between the Bill & Melinda Gates Foundation and drugmaker Merck budgeted $13.5 million for condom promotion -- 25 times the amount dedicated to curbing dangerous sexual behavior.
But soaring rates of condom use have not brought down high HIV rates. Instead, they rose together, until both were among the highest in Africa.
The focus on condoms endured even after the arrival of internationally heralded "ABC" programs, named for their prescription of "Abstain, Be Faithful and Condomize." The middle concept -- fidelity -- often got lost.
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Part 5: Death and the Second Sex