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.