Why multiple sexual partners?

Printeremail

Multiple sexual partnerships—particularly overlapping or concurrent partnerships—by both men and women lie at the root of the generalised epidemic of HIV in southern and eastern Africa.1 Accordingly, earlier this year the UNAIDS regional office for eastern and southern Africa, along with the World Bank and Harvard University, held a technical meeting and issued recommendations about communication interventions to address multiple sexual partnerships.2 Understanding why people have multiple partnerships is key to efforts to change behaviour, with the realisation that behaviours range from polygamy itself, to longer-term quasi-polygamy (sometimes described as having a “small house”), to sporadic sexual encounters. A superficial view is that men are driven by uncontrollable sexual urges and the cultural legacy of polygamy, while women are trapped by economic necessity and male domination—a daunting prospect for behavioural change. Although this picture undoubtedly reflects some truth, an emerging and rich sexual ethnographic literature,3–10 notably including a ten-country study from South Africa’s The Soul City Institute for Health and Development Communication,3 reveals considerable individual autonomy and basis for interventions to change behaviour.

Interestingly, both women and men prominently cite dissatisfaction with their primary partnerships, sexually and otherwise.3–9 Such relationship dissatisfaction is ascribed to lack of communication and romance, partner’s lack of skill in lovemaking, monotony, domestic discord, and desire for variety in partners and sexual practices.

Clearly, economics is important for women. But the role of economics is complicated and calls for understanding transactional sex, which arguably reflects the norm for sexual relationships in the region.7,8 Rather than a specific fee-for-service, transactional sex describes a social norm of expectation of gifts and economic support from men as part of a sexual relationship, in part expressing value, commitment, love, and respect. Such economic support might be vital to survival in many cases, but often seems mainly related to social status and economic advancement more broadly. In younger women, relationships with older men seem particularly often to be related to luxury goods and status.3,8,11

Other reasons described for multiple partnerships include: insurance against loss of one’s main partner;3,5,7 a multipronged strategy to find the “right” life partner;3 physical separation especially because of work;3–5 peer pressure;3,5 revenge in response to partner’s infidelity;3,7 and, for women ironically, the perception that modernity allows freedom to behave more like men by having multiple partners.6 Culture also contributes, including the backdrop of polygamy,3,6 belief that men’s sexual drives are poorly controllable and reflect prowess,3,5,8 women’s traditional passive role in sex,3 and general reluctance to talk about sex. Alcohol clearly facilitates risky sex.3,5,9

Nevertheless, generally, people seem not completely compelled by economics, culture, or circumstance to have multiple sexual partners.6,9 Indeed, many people realise that having multiple partners (though not necessarily concurrent partners) is risky, and, faced with the dire prospect of AIDS, sometimes take deliberate action.4,6,9 Thus in Malawi, couples have adopted a specific communication strategy to discourage outside sexual relationships. Rather than accusing the partner of infidelity, they invoke the importance of protecting the family against HIV so as not to leave children parentless.12 Similarly, people from several highly affected countries report substantial decreases in numbers of partners, often associated with declines in HIV incidence.13

But specific knowledge about the role of concurrent partners remains low. Part of the pernicious nature of concurrent partnerships is that they are often longstanding, familiar, comfortable, and not perceived as risky, although they entail entrée to risky sexual networks.

What is the best way to address multiple sexual partnerships? For too long, any such eff orts have been uncoordinated, too indirect, too diluted by other messages, and have failed to address sexual networks head on. What is needed are high-quality multilevel (mass media, community, clinical setting, individual) approaches to reinforce behavioural change on the basis of sound intensive research with the audience.

Fortunately, serious efforts are now beginning. Among them are Soul City’s nine-country communication initiative called One Love and Johns Hopkins University’s effort in South Africa called Scrutinize (figure).14 Another prominent national example is the recently launched
O Icheke—Break the Chain—campaign in Botswana led by the National AIDS Coordinating Agency with help from Population Services International and other partners.15

On the basis of sound epidemiology and audience research, the targets of O Icheke (which means “check yourself” or “think about it”, and which was also the title of a popular song about multiple partners) include mobile men typically aged 25–34 years and younger women. Initial efforts emphasise knowledge about the risks of multiple concurrent partners. Visual portrayal of sexual networks with the potential for the virus to spread through them (figure) and testimonials from people living with HIV seem particularly effective approaches for heightening the perception of personal risk. Changing social norms is also key, including presenting positive models of men and masculinity, promoting better communication about sex and cultivating more sexually satisfying primary relationships. Mass-media approaches encompass billboards, printed advertisements, and television and radio, including call-in shows. Community-level discussions, by various partners including nongovernmental and faith-based organisations, also allow for consistent but much richer messaging and influence on social norms. Additional arenas planned are one-on-one discussions in HIV clinical sites (eg, treatment, counselling, and testing centres), and integration into school-based life-skills curricula. The entire effort is reinforced through common O Icheke branding. Empirically, in some countries many people have reduced partners even in the absence of state-of-the-art programmes for behavioural change, but it is too early to tell if these new campaigns will be successful. Yet in concert with promotion of male circumcision and use of condoms, especially for high-risk sex, it appears we are finally embarking on the right road to prevent hyperepidemic HIV transmission.