Behavioral Interventions: Partner Reduction

AIDS is the most common cause of young widowhood in southern Africa and was found among 11% of women in this rural population. This study of over 900 widowers found HIV prevalence rates at follow up to be 54% among ever-widowed men and 63% among ever-widowed women. HIV infection was largely acquired prior to widowhood, however. While 50% of 48 sexually active widows reported engaging in transactional sex, only 3% of married women reported doing the same. Widows were significantly more likely to use condoms than married women, however (53% vs. 8%, respectively). The authors used their findings in a mathematical model, estimating that between 8% and 17% of HIV infections over 20 years could be attributed to widow/widower sexual activity. Although widowers were more likely to transmit HIV to their partners, the greater prevalence of widows contributes to their higher overall transmission of HIV. The authors conclude that increasing the financial independence of widows through employment opportunities may reduce their reliance on new sexual partners for financial support.

Data from over 6,500 clients attending a HIV testing and counseling center in northern Tanzania between November 2003 and December 2007 found that one-fourth of females and one-tenth of males seeking testing were living with HIV. As expected, an increased number of sexual partners was associated with increased risk for seropositivity for men and women alike. Monogamous women who reported that their partner had other sex partners (or did not know) were 36% more likely to be infected with HIV than a monogamous woman whose partner was also monogamous. Furthermore, monogamous women were more likely than monogamous men to become infected with HIV. Despite study limitations, the authors concluded that their research demonstrates the limited protection of monogamy for women and highlights the role of male partner concurrency in infecting women. The authors suggest that the “overly simple formulation” of the ABC prevention strategy (if not abstinence, then be faithful, and if not faithful, then use condoms) is misguided. They argue that HIV prevention efforts that promote abstinence, partner reduction, and mutual monogamy take place concurrently with efforts to empower women to “better control their exposure risk.”

Multiple partners, paid sex, and sexually transmitted infections (STIs) are considered risk factors for HIV infection at the early stages of the HIV epidemic when HIV is concentrated among high-risk groups. These risk groups are assumed to be less important once the epidemic has spread into the general “low risk” population. The study authors used 68 epidemiological studies from 18 countries in sub-Saharan Africa from 1986 to 2006 to test this common assumption. The general trends over time indicate that these risk factors are also strong predictors of HIV infection in high-prevalence settings, where epidemics were considered generalized. Contrary to common wisdom, multiple partners, paid sex, and STI infection remain important risk factors in countries with high HIV prevalence. The authors recommend reexamination the UNAIDS definition of a “generalized” epidemic and the recommendation that STI treatment in countries with advanced epidemics is likely to have a low impact. This analysis indicates that prevention efforts should focus on vulnerable groups, regardless of where the trajectory of the HIV epidemic lies.

Researchers followed a cohort of nearly 10,000 adults in Manicaland over three years to assess the trajectory of the HIV epidemic. Overall HIV prevalence declined among men and women, with steepest declines taking place among men ages 17-29 (23%) and women ages 15-24 (49%). At baseline, nearly half of 17- to 19-year-old males reported being sexually active; three years later, only one-fourth of such males reported the same. Women ages 15-17 also reported declines in sexual debut (21% to 9% over three years). Furthermore, there was a significant decrease in the number of casual partners that men and women reported in the previous year. Similar declines in HIV prevalence took place in areas with and without partner reduction interventions. Because these findings mirror national HIV and local antenatal clinic HIV prevalence rates, the researchers concluded that there is a trend toward a declining prevalence of HIV in Zimbabwe. This decline may follow a pattern similar to Uganda’s—driven by delay of onset of sexual debut, partner reduction, with some contribution of consistent condom use with casual partners. Because prevalence estimates “reflect accumulation of infections over a period of more than 10 years,” however, the researchers state that HIV prevalence is “insensitive to behavior change.”

Perceptions of masculinity change over time and within various social and political contexts, according to this doctoral dissertation of a student describing his assessment of male behaviors in KwaZulu-Natal. South Africa, says the author, has been greatly influenced by capitalism, migrant labor, and Christianity. In the 1970s, high rates of unemployment affected men’s ability to marry, establish an independent household, and become the head of a household. Multiple partners were a means by which men could express their masculinity since traditional customs were more difficult to achieve. The author closes with critical assessments of groups that are currently challenging old concepts of masculinity.

The ‘Be a Man’ campaign is one component of the Young Empowered and Healthy (Y.E.A.H) initiative that is being implemented in Uganda to address cross-generational sex. The campaign was initiated in 2006 to challenge traditional male norms, attitudes, and behaviors. Objectives of the campaign included improving gender equtable beliefs and attitudes, and redefining what a “respectable” African male is in modern day society.

The campaign used a combination of television, radio, small media, and community channels. A qualitative evaluation was conducted in 2007. It found that the target group favored responsible men who did not have multiple partners, drink or use violence against women. However, respondents also identified certain circumstances when a man was justified in not performing these behaviors.

The Sikia Kengele (“Listen to the Bell”) campaign uses community opinion leaders known as “Bell Ringers” to initiate talks on the risks of multiple partners and the benefits of knowing one’s HIV status. The campaign is conducted in high-risk areas of Tanzania such as major transportation corridors, mining communities, and plantations. The Bell Ringers initiate discussions in bars, stadiums, churches, mosques, farms, and bus stations, and they prepare “Giant Bell” road shows in which a high profile team of influential individuals and educators (and large bell) travel to communities, using music, dance, dramas, and cinema to encourage people to reduce the number of sexual partners.

This fact sheet reviews effective strategies to prevent all three routes of HIV transmission: sexual, blood-borne, and mother-to-child. The interventions are listed by route of transmission. Although effective interventions have been identified over the past two decades, access to these interventions is low. Researchers with UNAIDS and the World Health Organization estimate that increased program access could avert half of the 62 million new HIV infections that are expected to occur between 2005 and 2015.