Away matches and spare tyres

HIV prevention experts now know that one of the main drivers of the HIV epidemic in Africa is due to multiple concurrent sexual partnerships. As opposed to the West, where the majority of relationships take the form of serial monogamy - one relatively long-term partner after the other - here, there is a high prevalence of overlapping relationships, whereby men - and women - have more than one regular sexual partner at one time, overlapping for weeks or months or even years. According to the 2004-2005 Uganda HIV/AIDS Sero-Behavioral Survey, 4% of women and 29% of men report having more than one partner in the last 12 months (maybe not the best indicator of overlapping partnerships, but the best we have). This is up from 2000/2001, where 2% of women and 25% of men reported the same. The result of this is the creation of sexual networks, whereby many people are connected through their sexual partners.

Experts also now know that people living with HIV are most likely to infect others in the first 3-4 weeks of infection, when there is a huge spike in the amount of virus in the blood (the green line below), and when they are least likely to know they are infected, as the test will not yet detect the antibodies in the blood.

The combination of these two phenomena - overlapping partnerships, and high infectivity in the initial stages of infection - means that as soon as one person in a network of concurrent relationships contracts HIV, the entire network is placed at risk. This includes those who are just starting a sexual relationship, as well as those who are monogamous, but whose partners are not. Thus, it is not just those with "risky" sexual behavior that are at risk of infection.

Multiple concurrent partnerships has become a new hot topic in the HIV prevention world, and a large chunk of funding is going toward interventions that aim to reduce such partnerships. "Even modest reductions in concurrent partnerships could substantially dampen the epidemic dynamic" (Jim Shelton, Bureau for Global Health, USAID). It has become an area of emphasis in several projects that I'm working on, and each time we present this, we're met with the same reaction - silence. People seem to enter a state of shock and disbelief, as it sinks in that, yes, just that one other partner means that they're linked into this network, and therefore at risk.

Earlier this week, I gave a presentation on multiple concurrent partnerships for a group of young people developing scripts for the 5th year of our radio serial drama, Rock Point 256. I had the research side, the graphs, diagrams, and the scientific explanation down pat, but was lacking on the qualitative side. So, in preparation, I sent an email around to HCP staff to brainstorm common terms for outside partners. The flurry of responses was simultaneously funny and frightening. If "multiple concurrent sexual partnerships" doesn't float your boat, try one of these:

• "Away match"
• "Balanced diet"
• "Side dish"
• "Pre-testing"
• "Spare tyre"
• "Left hand"
• "Suitcase"
• "Side mirror"
• "Extra time"
• "Panadol" (aka: aspirin - when one is giving you a headache, you go to another)
• "Take-away"
• "Side kick"

Yup.

Another part of the presentation was on the barriers to behavior change. In other words, the reasons why young people (in this case) don't reduce their number of partners. Here are some of the ones that grabbed my attention (taken from focus group discussions conducted with young people in 2007, and retaining the wording from young people themselves in most cases):

Barriers to partner reduction:

• It is impossible to be sexually satisfied by just one woman
• Men have a biological need to have sex often in order to stay healthy
• It is good to change diet - how can you eat the same food every day?
• A girl will treat you well if she knows there's competition
• We do not want to wait for sex from one girlfriend so we seek for other girls who are ready for sex when we want it
• Women have all different hobbies, interests, and characters, and we enjoy this variety
• We are gaining experience so we know how to satisfy future partners and handle relationships with different types of women
• If you stick with one girlfriend, you may miss out on finding the love of your life
• Girls of today are not trustworthy, so there's no point in sticking with one girl
• Even when you do your best to show her all your love, the rich men in town will snatch her from you
• To avoid all the disappointment and heartache, it is better not to be committed to any one but have as many of them as possible
• We don't want any one woman to become too dependent on us
• Sometimes you make an appointment to be with one girl and she fails to escape from her home, so you must have a plan B
• Not all women are good in bed
• When you come across one that is more beautiful, you have to go for that one
• When one girlfriend is in school, you get a part-time girlfriend to occupy you as you wait for them to break off school
• The belief by both young men and women that there are certain circumstances when it is acceptable for a young man to have multiple partners at the same time, including when the wife is barren, when the girlfriend is arrogant, abusive, or generally ill-behaved, when the wife is pregnant, or when the girl is sexually weak

Let's just say we've got our work cut out for us.