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.