Partner Reduction

Introduction

I. Definition of the Prevention Area

Partner reduction is a prevention strategy focused on decreasing overall number of partners in order to lessen the risk of becoming infected with or transmitting HIV. Increasingly, partner reduction efforts have focused not only on reducing the number of partners, but also the number of concurrent partners.

II. Epidemiological Justification for the Prevention Area

Partner reduction is one of the most effective HIV prevention strategies to date, with a large evidence base to support this intervention. During the HIV epidemics of the late 1980s and early 1990s, campaigns advocating partner reduction and fidelity among couples and other prevention strategies were launched in the United States and Uganda. Among these was Uganda's "Zero Grazing" campaign.

Surveys showed that the campaigns were at least modestly effective with some survey participants reducing both their concurrent sexual relationships and their total number of sexual partners. These changes were followed by declines in the incidence of new HIV infections, first in the United States among men who have sex with men, and later in Uganda among heterosexuals.

HIV incidence and/or prevalence has declined in other countries, such as Cambodia, Zambia, Zimbabwe, Thailand, Ethiopia, and Kenya, and most experts attribute these declines, at least in part, to partner reduction strategies.

III. Core Programmatic Components

Partner reduction strategies may be directed at specific risk groups, such as those who engage in commercial sex or men who have sex with men. In hyper-epidemics in Southern Africa, where HIV is prevalent among the general population, some experts have advocated more generalized strategies that address the entire population.

Partner reduction efforts must take into account complex, interrelated social, class, cultural, and economic factors. For example, social and gender norms play an important role in perpetuating attitudes and beliefs that encourage, or at least tolerate, men and/or women having multiple or concurrent partnerships. Researchers have found that despite a high level of knowledge about the mechanisms of HIV transmission and prevention, many people continue to engage in high-risk partnerships for a multitude of reasons, including poverty, economic "wants," and violence. Men who, often by necessity, take jobs at a distance from their families may engage in commercial sex. Impoverished women may be compelled to engage in transactional or commercial sex. Young girls may engage in intergenerational sex with older men--who are more likely to have HIV--to obtain gifts.

Partner reduction messages are often coupled with other prevention messages, such as abstinence, delay of sexual debut, correct and consistent condom use, and HIV testing. Programs may need to deliver difficult messages that individuals are put at risk of HIV not only by their own behavior but by their partners' behaviors. Another important message is that alcohol abuse is often associated with less cautious behavior that can lead to sexual activity with multiple partners, thereby increasing the risk of HIV infection.

IV. Current Status of Implementation Experience

It can be difficult to prove that partner reduction programs are the cause of declines in HIV prevalence because multiple simultaneous factors may play a role. Most experts agree, however, that the body of evidence, especially studies of regions where partner reduction strategies preceded other interventions, suggests that partner reduction strategies play an important role in reducing the incidence of HIV.

Surveys conducted in Uganda provide some evidence that the partner reduction campaigns of the 1980s and 1990s led to the decline in HIV prevalence that began in the early 1990s.

Educational activities alone may not be sufficient to change behavior, however. Some regions showed stable or escalating rates of high-risk behaviors despite widespread knowledge about HIV transmission. In these instances, structural changes are needed to allow people the freedom to make choices that can reduce their risk of HIV infection, such as the choice to leave a violent spouse with concurrent partners.

What we know

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Putting it into practice

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Tools and Curricula

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UNAIDS Combination Prevention Briefs

Joint United Nations Programme on HIV/AIDS (UNAIDS). (2008).

The Joint United Nations Program on HIV/AIDS (UNAIDS) published a series of briefs to provide an overview of combination prevention approaches in high-prevalence countries in Eastern and Southern Africa. The briefs contain background information, programmatic challenges, and recommendations for action with a focus on modes of transmission, multiple concurrent partnerships, vulnerabilities of women and girls, and male circumcision.

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"Know Your Epidemic, Know Your Response": A Useful Approach, If We Get It Right

Wilson, D. & Halperin, D. T. Lancet (2008), Vol. 372 No. 9637, pp. 423-426.

This commentary provides advice to the HIV prevention community for responding effectively to vastly differing HIV epidemics throughout the world without becoming overly complicated. Despite differences in concentrated, generalized, and mixed epidemic settings, partner reduction can help reduce HIV transmission in generalized epidemics. The authors argue that the response to AIDS has "given insufficient emphasis to aligning prevention priorities with epidemic transmission dynamics, compromising effective prevention with mismatched or unfocused responses." They conclude that much can be done to help curb HIV transmission around the world if the right approaches are taken, such as partner reduction and male circumcision.

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Outreach Guides: HIV/AIDS Prevention Programmes

Pact/Botswana. (2007).

This series of outreach guides developed in Botswana address many topics that HIV prevention programs can use for their efforts. The guides include participatory methods, and were developed to help promote changes in behavior. Ten guides include information and activities on abstinence promotion, alcohol abuse reduction, improving couple communication and parent-child communication, as well as partner reduction.

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Field Assessment of Emergency Plan Centrally-Funded HIV Prevention Programs for Youth

Speizer, I. & Lopez, C. (2007). MEASURE Evaluation Project, University of North Carolina at Chapel Hill, NC, USA.

This report evaluates "abstinence and be faithful for youth" (ABY) programs funded through The President's Emergency Plan for AIDS Relief. The researchers visited 20 sites in Ethiopia, Haiti, Kenya, Mozambique, and Tanzania to assess how program efforts had fared. The authors recommend how these programs can strengthen their work, and also provide an assessment tool that can be used by funders, program planners, and program managers to identify characteristics of strong ABY programs.

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