The role of concurrent relationships in the spread of HIV in Africa

I'm Courtney Sanders.

According to the 2008 UNAIDS Report on the Global AIDS Epidemic, countries in Sub-Saharan Africa continue to bear a disproportionate share of the global HIV/AIDS burden. In all, an estimated 67% of people living with HIV reside in Sub-Saharan Africa. In 2007, three-quarters of all deaths resulting from AIDS occurred in Sub-Saharan Africa. Though the first HIV cases in the United States were noted in 1981, HIV was not seen in African countries until the late 80s. From its first appearance, the infection rate has soared with unequivocal momentum. Currently, the infection rate in Sub-Saharan Africa falls in the range of 15-28%. Just to give you a point of comparison in understanding the magnitude of this statistic, the HIV infection rate in the United States has never exceeded 1%.

Nevertheless, public health officials will never be able to tackle the problem in Africa using methodologies which have proven successful in the United States. Rather, they must craft a solution tailored specifically to causes of the epidemic in Africa. With the statistics which I mentioned above, I think that we can all agree that there is more to the problem than simply poverty. There are a number of theories which have been proposed in trying to explain the astronomical infection rate, the majority of which pertain to African sex practices.

One theory, which initially seemed quite logical hypothesized that African people had a unique “sexual system” which was characterized by high rates of casual and premarital sex. Though this theory initially seemed intuitive given the polygamous traditions and the cultural pressure to bear many children, it gave rise to much controversy. Contrary to many stereotypes regarding African sexual behavior, studies have shown that Africans are no more promiscuous than men and women in the Western world. Children in Africa, Europe and the United States usually become sexually active around the same age—late teens. In addition, African males usually report fewer lifetime sexual partners than do heterosexual men in the west. Because African heterosexual men and women are no more promiscuous than men and women in the west, this theory raises doubt.
Another theory supposes that Africans’ weakened immune systems as a result of malnutrition and infection (common among the poor) cause them to be more vulnerable to HIV infection. This theory received attention in the wake of a study in 2006 which discovered that malaria enhances the transmission of HIV. The major weakness in the theory is that it does not explain why many poorer countries have lower rates of infection. For example, the supposition fails to explain why some of Africa’s most impoverished, worn-torn and parasite-infested countries like Ethiopia and Somalia have lower rates of infection than the richer, more peaceful countries like Botswana and Zambia.

The most widely accepted theory for explaining Sub-Saharan Africa’s disproportionate share of the global AIDS burden is the model of “concurrent partnerships.” Literature defines concurrency as having “multiple relationships which overlap in time.” According to many informed sources, having many ongoing relationships at one time is fairly common among African men and women, regardless of their marriage status. Unlike the “serial” or “sequential” nature of sexual relationships common to polygamous men and women in the United States, African men and women may have sex with the same man or woman in addition to their marriage partner for a lifetime. The serial nature of the sexual practices in the United States may actually help to protect men and women from contracting the virus since the likelihood of infection when having sex with an HIV positive person is only about 1 in 100 acts.

The theory of concurrency has been defended by numerous studies and was even touted in the most recent edition of the UNAIDS Report on the Global AIDS Epidemic. A few studies, the first of which debuted in 1992, attempt to use mathematical modeling to investigate the effect of concurrency on the prevalence of HIV infection. The majority of these studies have concluded that, when the number of sexual partners is held constant, concurrent relations are associated with higher rates of HIV infection than serial relationships. According to one author, these concurrent relationships are incredibly dangerous since they “link people in a giant web of sexual relationships that create ideal conditions for the rapid spread of HIV” (from The Invisible Cure by Helen Epstein).

Recognizing how exactly the sexual practices of Africans contribute the incredible rate of HIV/AIDS infection in Sub-Saharan African is a vital part of implementing a successful plan to combat the pandemic.

The reality of HIV/AIDS: It hasn't gone away

In a recent episode of the television show South Park, one of the main characters is infected with HIV. In an attempt to find a cure, he must continually deal with the public opinion that AIDS is no longer a threatening condition. He is told that his disease is “a disease of the 80s and 90s” and even that he is “retro” for being infected with HIV. But has this retrovirus truly become retro to Americans? If we take South Park as a social barometer, then it seems that the disease has been marginalized in the public eye. Public interest on the Internet regarding AIDS is declining as well. A recent government blog about Google search hits for the terms “HIV” or “AIDS” shows a declining trend over the past four years. Each year, fewer people searched for the terms “HIV” or “AIDS” on December 1st (World AIDS day) than the previous year. Why has the US public marginalized this disease, which twenty years ago was the terror of the nation?

Searches for “AIDS” and “HIV” have decreased for four years running now. Have Americans stopped caring about this disease? Photo courtesy of Google, Inc.

A simple reason may be that the media sensationalism of the disease has settled down. As people become accustomed to news, it ceases to be news, no matter how horrible the reality of the situation may be. The early media coverage of the AIDS epidemic focused on the fact that the disease seemed to infect only gay men. Some even believed that AIDS was the punishment for the lifestyles of gay men, and AIDS became known as the “gay cancer” by many after its initial discovery. In this way, AIDS aided U.S. society in demonizing the gay population in the early 1980s. AIDS was deemed a gay problem, and the rest of society could forget about it. Ryan White’s struggle against the disease helped dispel some of these myths, but many fallacies have persisted regardless, even to the present day. Many choose to ignore the AIDS epidemic, as they believe that they will not come in contact with the disease if they are not homosexual.

AIDS may also be ignored because its prevalence in the U.S. is perceived to be decreasing. In South Park, the public seems surprised when the main character is newly infected with AIDS. In many regions of the U.S., taboo prevents open discussion about AIDS, and if people aren’t hearing about a problem, they tend to imagine that it is going away. In reality, 56,000 new cases of AIDS are diagnosed in the U.S. every year. This figure only represents the number of cases detected; the true occurrence is likely higher. Why does the public believe, then, that AIDS is on the decline?

The apparent decrease of infection rate is caused by the fact that infected individuals generally live longer and healthier lives than they would have in the 80s, when the average lifespan following diagnosis was approximately three months. This fact is largely due to the success of many drugs in delaying the onset of AIDS after exposure to HIV. AIDS advocates are victims of their own success, then, as the myth has arisen that AIDS will no longer kill infected individuals. This belief is wrong; AIDS is a lethal disease. Drugs do a great deal these days to slow its progress, but HIV has the uncanny ability to develop resistance to these drugs and overwhelm the body’s immune system, which invariably leads to death.

One additional aspect of fading public interest in AIDS, sadly enough, may be the lack of infection of a public figure. The movie star Rock Hudson was a famous AIDS victim in his time, and his death helped shock the nation into action against HIV. Rock Hudson is relatively unknown by today’s youth, who grew up after the passing of the star. These days, when most people think of celebrities with AIDS, Magic Johnson is the first name that pops to mind. This former basketball superstar retired after being diagnosed with HIV and began working towards a cure for the deadly virus. Indeed, in the South Park episode, the character with AIDS must travel to find Magic Johnson who may have the cure for AIDS. Magic Johnson faded from public view when his basketball career ended. The fact that no Hollywood star or public figure of great significance has recently been diagnosed with AIDS means that the disease is no longer the vogue disease it once was.

Rock Hudson (left) and Magic Johnson (right) are two of the most famous AIDS patients. Neither are well-known by much of today’s younger generation. Photos courtesy of Wikipedia.

As is typical for the satirical style of South Park, the characters discover that the cure for AIDS is to inject large quantities of cash directly into the bloodstream. While there is no real cure for AIDS, the biting commentary of this cartoon is telling. Wealthy AIDS patients, like Magic Johnson, often live the longest and healthiest lives following their infection. Many AIDS patients do not have access to the resources that Magic Johnson enjoys, and are therefore much more susceptible to the disease. The average cost of a year’s supply of antiretroviral drugs is between $10,000 and $15,000, which means that those living near the poverty line with AIDS must devote an enormous portion of their income to their drug regimen. Some of the hardest hit regions of the world with regards to AIDS are also the poorest. Sub-Saharan Africa is among the worst regions, with up to 30% infection rates in the population. The disease is therefore easier to ignore for U.S. citizens, who are more likely to be wealthy enough to afford treatment.

South Park offers one final shot at society, stating, “Americans have forgotten that AIDS is a serious disease.” Decreasing public interest in the AIDS epidemic is apparent, which is unfortunate both for affected individuals and the general public alike. AIDS continues to rage as a fearsome epidemic, and the number of infected individuals continues to grow. Society needs to wake up again and face the reality that AIDS is still here, and is still a terrible disease.