Partner Reduction

Reduction in concurrent sexual partnerships may have contributed to the recently observed decline in HIV prevalence in Zambia. While the proportion of women engaging in concurrent partnerships was less than 2%, there was a significant decline in concurrent partnerships for young urban men and older rural men. Men were 7 times more likely than women to report several ongoing relationships in both 1998 and 2003 in the young age group and 6 to 17 times more likely in the age group 25 to 49. Polygamy was common among older rural men (12%). The percent of rural men aged 15 to 24 who reported concurrent sexual partners declined from 58% in 1998 to 3.5% in 2003; among urban male youth aged 15 to 24 from 7.1% in 1998 to 1.9% in 2003 and among rural men aged 25 to 49 from 17.8% in 1998 to 11.9% in 2003. In addition, reported condom use increased during the most recent sexual intercourse both with the spouse and with the latest non-cohabitating partner increased from 1998 to 2003. An important predictor of concurrency was early sexual debut and early entry into marriage, as well as absence from home.

A study from 2003 to 2007 of women and men presenting for VCT at a community-based AIDS service organization in Moshi, Tanzania found that the number of partners was strongly associated with rates of HIV seropositivity for both men and women. However, even women reporting lifetime monogamy had a high risk for HIV infection. Of 6,549 clients, 3,067 were female, with 25% of the women and 10% of the men HIV-positive. Among 1,244 monogamous females, 34% were HIV-positive. Among 423 monogamous males, 4% were HIV-positive. A monogamous female with a partner who had other partners (as is the case for polygamy) or who did not know if the partner had other partners was 36% more likely to be HIV-positive than an otherwise identical female who reported no partners with other partners. The risk increased up to 45% for women with five or more partners and 15% for men with five or more partners. In a multivariate analysis, HIV seropositivity among monogamous women was associated with reporting a partner with other partners; among monogamous men, with age. Women having more than one lifetime sexual partner reported fewer total partners, with a median of three, as compared to a median of four among men.

Sixteen focus group discussions with 200 women and men, aged 32-55 held in 2007 in Zimbabwe to discuss underlying factors and programs in 1992, 1999 and 2006-2007 mirrored epidemiologic survey findings from 2000 to 2005: social norms changed to reduce acceptability of casual sex and payment for sex. In addition, between 2006 and 2009, 24 in-depth interviews were held with key AIDS experts in Zimbabwe, along with a review of 120 publications. As one man in a focus group discussion said, “These days when a man is said to have two or more wives, he is seen as uncivilized” (Muchini et al., 2011: 491). Participants mentioned messages concerning fidelity and increased availability of condoms. Growing poverty also reduced men’s ability to afford multiple partners (Muchini et al., 2011). Evidence from surveys, qualitative research and expert opinion indicates that the drop in national HIV prevalence in Zimbabwe is due in part to a reduction in multiple and concurrent partnerships and to changes in norms regarding such partnerships. HIV prevalence has declined in Zimbabwe by around 50 percent and data from national surveys indicate an approximate 30 percent reduction in the proportion of men reporting extramarital partners between 1999 and 2005/06. A national stakeholders meeting concluded that the reduction in multiple partnerships was “the most likely proximate cause of the most recent decline in HIV risk” (Halperin et al., 2011: 2). HIV programs have incorporated these new norms into messages by more assertively warning against multiple and concurrent partners and fidelity, in addition to other programming.