Dangerous Practice of Taking Concurrent Partners Fueling Epidemic

GABORONE – There's a Setswana proverb, "Monna poo ga a agelwe mosako," that says a bull cannot be contained in a single kraal. It is taken to mean that men cannot be expected to stick to one sexual partner.

But is that really the case in Botswana?

Results from a paper published earlier this year in the journal AIDS and Behavior indicate that nearly one in four Batswana questioned had been in sexually active relationships with more than one partner at the same time, and among men questioned it was one in three. This is a practice called concurrency, a pattern that can speed up the transmission of HIV through the network of sexual partners caught up in its web.

Public health scientists say concurrent relationships may be one reason why HIV prevalence in Botswana and other southern African countries is so high. Understanding this complex practice, they say, will help inform a more comprehensive response to the epidemic.

The Botswana concurrency data was from the Makgabaneng Radio Serial Drama Listenership Survey, a population-based survey conducted in 2003 of people aged 15-49 years from seven of the most populous health districts in Botswana.

Out of the 546 sexually active respondents, 23 percent (nearly one in four) reported having sex with another person at some point during their relationships with recent sex partners. Men and non-religious people were more likely to say they had concurrent partners than women or Christians, respectively, but marital status, education, and area of residence did not point to any differences in reported concurrency.

Concurrency was measured for all the respondents who had sex in the past 12 months before the survey. These respondents were asked about their last three sexual partners in the past 12 months. Interviewers asked, "While sexually active with this person, did you have other sexual partners?" Those who said "yes" were coded as having had a concurrent sexual partnership.

Dr. Marion Carter, a program officer for the Behavior Change Communication (BCC) section at BOTUSA and one of the authors of the paper, explains that concurrency means having more than one -- perhaps two or three -- sexual partnerships at a time, which may overlap for days, months or years. This pattern differs from the "serial monogamy" more common in some other parts of the world.

"What's so risky about concurrency, even as compared to other multiple partnerships, is that it basically makes the sexual networks that sustain HIV transmission much tighter," Carter says.

The network puts everyone at risk -- not just those who engage in concurrent relationships themselves but anyone who is roped into the network, including monogamous men and women whose partners engage in concurrent relationships or did so in the past.

Another reason for the danger, Carter says, is that when someone gets infected with HIV, his viral load rapidly increases for a short time after exposure. So if he has sex with more than one person during that specific time period -- which someone with concurrent partnerships may do -- he is much more likely to transmit the virus.

This pattern of behavior has a powerful historical, social and economic basis, Carter says, but its exact roots are not easy to trace.

"A history of polygamy; a relatively low prevalence of marriage that reflects perhaps more fluid relationships here; some women's use of sexual relationships to obtain lifestyle and livelihood goods and money; some men that get social status by having many lovers -- all of it could be at work here," she says. "It's a very complex behavior. We are keen to understand multiple and concurrent partnerships better, as it's thought to be a major reason that HIV prevalence is high in Botswana."

Perhaps surprisingly, most respondents in the survey (88%) considered fidelity "extremely" important, even those who had reported being in a concurrent partnership. However, 40 percent suspected that one of their recent partners had other partners at the same time, and a third (33.3%) disagreed that most people they care about are faithful.

Carter says these results were heartbreaking.

"It sounds like many relationships have elements of mistrust and surely must be fragile. Few people really want that for themselves," she says. "Clearly fidelity is valued by many people, which is a helpful finding for thinking about how we can promote fidelity and partner reduction."

Social scientists would like to address this problem in a comprehensive way, but there are few program models in the world that currently address concurrency. It's the B (Be Faithful) in the ABC approach to prevention, and any response here will be one started practically from scratch.

"We've got to try to help make people more aware of the risks of concurrent and other multiple partnerships and benefits of partner reduction and fidelity," Carter says. "We also must promote community dialogue and find out what communities, families, and couples really want for themselves; and try to provide the skills and services to help them achieve that. What's for sure is that it is not the kind of thing that can change overnight."