The authors of this commentary state that “many standard HIV prevention strategies have not proven effective,” such as the medically based triad of condom promotion, HIV testing, and treatment of sexually transmitted diseases in the generalized epidemics of East and Southern Africa. They cite the successful reduction of HIV transmission in concentrated epidemics following a campaign promoting condom use among sex workers in Thailand. The authors cite concurrency as a significant contributor to the generalized epidemics of East and Southern Africa and say that campaigns to reduce multiple partners in several African nations have been effective since they have been followed by measurable reductions in multiple partners, which in turn have been followed by reduced HIV prevalence.

From October 2007 to November 2008, 228 members of nongovernmental organizations in seven Southern African countries were interviewed to understand the role of culture and contextual factors in relation to MCP. Common patterns in cultural scripts regarding sexuality emerged. These scripts (such as “male sexuality is by nature un-restrainable” or “sexual violence sometimes demonstrates caring”) affirm and legitimatize MCP and need to be addressed to better orient messages to the population.

The study authors conducted a household survey to examine the sexual behaviors of young people, aged 15-24 years in KwaZulu-Natal, South Africa. The region is one of that nation’s poorest provinces and has the nation’s highest HIV prevalence. The researchers found that one third of men reported MCPs and one quarter of women had partners who were five years older than themselves. Nonparticipation in school or civic organizations correlated with higher-risk partnerships for women. Relationships, on average, lasted more than a year and were defined as “serious” by the participants. Partnerships were both sequential and overlapping. Mobility and the distance between workplace and home greatly affected the kinds of relationships that were formed and sustained.

This commentary challenges several assumptions about HIV epidemiology, including the idea that poverty is an important factor in the spread of HIV. The authors cite data from recent Demographic and Health Surveys (DHS) to suggest that within Africa, high HIV prevalence is not associated with high levels of poverty or conflict, but instead correlates with high rates of MCP, and low levels of male circumcision. The authors also cite evidence that microbicides, vaccines, and HIV testing and treatment of sexually transmitted diseases have little effect on HIV transmission. They conclude that male circumcision (which can reduce a man’s risk of contracting HIV by more than one half) and reduction in sex partners are the most effective interventions for generalized epidemics.

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. Consistent condom use can be achieved in casual partnerships, but consistent use is much more difficult to attain in longer-term “trusting” relationships, due to low risk perception.

Measures for concurrency are not consistent, leading to conflicting study results. In order to assess the different results obtained by two common survey methods, the researchers conducted a study in which both methods (the calendar method and direct questioning) were used to query 680 young adults in three U.S. cities. Although the total rates of concurrency (over one half of participants) were similar using both methods, nearly one third of individuals reporting concurrency in one measure did not do so in the other. The researchers conclude that despite the greater detail provided by the calendar measure, direct questioning might better identify those at greatest risk for HIV infection.

This 51-page report examines concurrent sexual partnerships (defined in this survey as a person who has “two or more sexual partners in the past month”) among young people aged 20-30 years old in South Africa. The researchers found that for these young people, the concepts of sex and love are often separated; sex with love is reserved for a ‘main’ partner, while sex without love is common with ‘other’ or concurrent partners. This duality is widely accepted as normative and results in a definition of faithfulness whereby keeping infidelity secret is a sufficient criterion for considering oneself to be faithful. Among people with concurrent partners, condom use declined rapidly with a main partner, and was inconsistent with other partners. The authors conclude that in the South African context, high overall HIV prevalence in conjunction with concentrated sexual networks suggest the need for programs that focus on reducing concurrency. Condom promotion remains an important cornerstone to HIV prevention, and programs need to increase their efforts to promote correct and consistent condom use. HIV testing is a useful complementary strategy for people in established relationships, or for those considering establishing them.

This eight-page guidance is the result of the joint UNAIDS/Harvard AIDS Prevention Research Project and the World Bank meeting, with input from civil society in Southern Africa. Intended as an aid to national programs and implementers, the draft document offers a rationale for its focus on concurrent relationships, strategic goals for communications around multiple and concurrent partnerships (MCP), and guidance regarding appropriate types of messages regarding MCP.

This 24-page meeting report builds on the earlier October 2006, SADC Regional Consultation. The document provides an executive summary, statement of goals, and includes sections on Research on Emerging Evidence; Updates on Experiences and Lessons learned from MCP; Effective Social Change Communication; and Building a Community of Practice.

This two-page brief highlights a respondent-driven survey of 421 hard-to-reach men living in an informal, urban settlement in South Africa. Sponsored by the U.S. Centers for Disease Control and Prevention, the study authors developed a surveillance system to measure key risk behaviors and HIV prevalence in a population of men who have multiple and concurrent sexual partners. Key findings were that the men used condoms inconsistently, engaged in “high levels of transactional sex and intimate partner violence,” and frequented establishments where alcohol consumption is high in order to find sexual partners. The researchers recommend interventions based on those findings.

The 54-page report summarizes a technical consultation on MCPs held in Washington, DC. The meeting convened researchers, government representatives and program implementers from several nations, including the U.S. and Southern Africa, to address four themes: 1) the relationship between MCP and HIV transmission; 2) core components of MCP programs; 3) engendering community support for MCP activities; and 4) measuring program outcomes. The consultation concluded with group work and discussion on next steps. The report includes appendices with additional resources and a list of participants.

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.

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.