Friday, November 21, 2008

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.


Anonymous said...

Dear Ms Sanders

As a South African, I am distressed and offended at the overt racist overtones in your article above. Unfounded belief in Africans’ voracious sexual appetite has been on of the driving factor of Western paternalism for centuries. And yet, it is baseless: have you paused to reflect that you are making sweeping generalizations about hundreds of millions of people, of thousands of different ethnicities, and a great variety of customs? Yet you easily sweep all into the same box. Would you ever dare make the same blanket statements about Asians, or even South Americans?
Furthermore, the actual epidemiological evidence does not support your claims. Please see this authoritative article, one among many surveys of the medical literature: sexual activity cannot account for the high rate of HIV in Africa:

"There is substantial dissonance between much of the epidemiologic evidence and the current orthodoxy that nearly all of the HIV burden in sub-Saharan Africa can be accounted for by heterosexual transmission and the sexual behaviour of Africans. The mounting toll of HIV infection in Africa is paralleled by a mounting number of anomalies in the many studies seeking to account for it. We propose that existing data can no longer be reconciled with the received wisdom about the exceptional role of sex in the African AIDS epidemic."

-Gisselquist et al, INTERNATIONAL JOURNAL OF STD & AIDS, Volume 14: Pages 144-147, March 2003.

You write: “public health officials will never be able to tackle the problem in Africa using methodologies which have proven successful in the United States.” – Please then account for the tens of millions of new cases of STD’s in the USA every year? What exactly has been the campaign that has been so successful in averting an “Aids epidemic” in the States?

Interestingly, you further write that “…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.” – The number of relationships is hypothesized, and assumed, and the number of concurrent relationships is extrapolated from there.

Last, I would like you to explain how even the lusty savages of the dark Continent can achieve such a high rate of seropositivity, when the largest and best-conducted studies in heterosexuals, including the European Study Group (European Study Group (1989), "Risk factors for male-to-female transmission of HIV", Brit. Med. J. 298:411-414), have shown that, for women, the only sexual practice leading to an increased risk of becoming HIV-antibody-positive is anal intercourse. The unidirectional transmission of "HIV" observed in OECD countries is supported by Nancy Padian's 10-year study of heterosexual couples (1986-1996). There were two parts to this study: one cross-sectional, the other prospective.

In the cross-sectional study, "The constant per-contact infectivity for male-to-female transmission was estimated to be 0.0009 [1 in 1,111]". The risk factors for the women were: (i) anal intercourse; (ii) having partners who acquired this infection through drug use (Padian says this means the women may also be IV drug users); (iii) the presence of STDs (antibodies to their causative agents may react in an "HIV" antibody test). Of the HIV-negative male partners of 82 HIV-positive female cases, only two became HIV-positive - but under circumstances that Padian considered ambiguous.

In the prospective study, starting in 1990, 175 HIV-discordant couples were followed for approximately 282 couple-years. At entry to the study, one third used condoms consistently and, in the six months prior to their last follow-up visit, 26 per cent of couples consistently failed to use condoms. There were no seroconversions after entry, including the 47 couples not using condoms consistently. Based on the 2 in 86 men who became HIV-positive in the early study, the risk to a non-infected male from his HIV-positive female partner was reported to be in the order of 1 in 9,000 per contact. From this statistic one can calculate that, on average, a male would need to have 6,000 sexual contacts with an infected female to achieve a 50 per cent chance of becoming HIV-positive. If sexual intercourse were to commence at age 20 and average three times weekly, this would occupy a lifetime.
Padian, N. and Pickering, J., "Female-to-male transmission of AIDS: a re-examination of the African sex ratio of cases", JAMA 256:590
Padian, N.S., Shiboski, S.C., Glass, S.O., Vittinghoff, E. (1997), "Heterosexual transmission of human immunodeficiency virus (HIV) in northern California: Results from a ten-year study", Am. J. Epidemiol. 146:350-357.

I await your speedy reply,

Best regards
Jason Hart
Cape Town
South Africa

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