Multiple and Concurrent Sexual Partnerships in Generalized HIV Epidemics
To support the expansion of multiple concurrent partnerships (MCP) programming, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) Technical Working Group (TWG) for General Population and Youth Prevention, in collaboration with AIDSTAR-One, convened a technical consultation in Washington, DC, October 29–30 2008, entitled Multiple and Concurrent Sexual Partnerships in Generalized HIV Epidemics. The objectives of this meeting were to: (1) deepen understanding of the role of MCP in the spread of HIV; and (2) share emerging programmatic approaches and build consensus on promising strategies to address MCP. This report offers a brief summary of key themes that emerged from the meeting and looks at what is known about MCP, what still needs to be learned, and what can be done now to advance efforts to address MCP.
According to the report, addressing concurrency is difficult, but is likely necessary to reduce HIV incidence in the generalised epidemics of southern and East Africa. MCP messages and interventions will need to complement other effective prevention interventions. Partner reduction messages will continue to play an important role in prevention communication programmes, but addressing concurrency requires that new messages be integrated into HIV programmes. Because the behavioral patterns that support the occurrence of MCP are deeply embedded within cultural and social systems, communication programmes will need to ground their messages in an understanding of the local context that supports these types of relationships.
Based on the presentations and discussions at the meeting, several conclusions and recommendations were made (extracted directly from the report):
"The Relationship between MCP and HIV Transmission
Mathematical models provide strong support for a relationship between concurrent sexual partnerships and HIV, but additional empirical evidence is needed to establish a causal relationship. Models suggest that small reductions in the prevalence of concurrency could have a large impact on reducing HIV transmission. Experts at the meeting called for at least one carefully controlled study to measure the effects of program activities to reduce MCP on HIV incidence. Additional research is warranted to determine the magnitude of change in concurrency that is needed to reduce incidence at a population level.
Current population-based surveys have a limited ability to explain the relationship between MCP and HIV because many do not include appropriate measures. Concurrent sexual partnerships can be measured in surveys through a short series of questions, but many surveys to date have not incorporated these measures. Until better data become available, researchers and practitioners must be aware of the limitations of population-based survey data in measuring concurrency. In particular, caution should be used when correlating HIV prevalence - or HIV cases that have accumulated in a population over a long period of time - and MCP, which is often captured only at the time of the survey. An assessment of HIV incidence and its relationship to MCP has yet to be performed. A clear operational definition of MCP is needed as the basis for standardized measures that can be used to accurately assess the prevalence of MCP and evaluate the impact of program interventions to reduce MCP.
Core Components of MCP Programs
Given low awareness of the risks associated with concurrent sexual partnerships, programs can begin by working to increase people’s perception of these risks. Programs have for many years developed “partner reduction” messages aimed at discouraging people from having multiple sexual partners, though these messages may not have been as widespread as necessary. In many places, people are aware that having multiple partners increases their risk of HIV. However, people are less aware of the risks associated with having two or three long-term concurrent partners. Programs can start with a focus on increasing people’s perceptions that concurrent sexual partnerships increase their risk of HIV by, for example, communicating that “even two is too many.” Early program experience suggests that it is possible to convey the risks associated with concurrent sexual partnerships.
Programmatic experience suggests that framing a “call to action” around concurrency can be challenging, and that communities need to be involved in framing these messages. Program experiences to date raise an important question: What is the call to action for MCP campaigns? Programs will need to address the complicated social and cultural drivers of MCP to be effective, including transactional and intergenerational sex, knowledge of one’s partner’s status, and trust within longstanding relationships and its implications for condom use. There may not be one universal call to action; communities should be supported to frame their own calls to action in ways that reflect their local context, epidemic, and drivers.
MCP programs should feature multilevel communication campaigns that encourage people to adopt safer sexual behaviors and that are tailored to the specific needs and circumstances of groups at risk. Programs will need to employ multiple communication channels, from mass media to community-level interventions and interpersonal communication (including in clinical settings) to achieve scale-up. These efforts should all be based on sound formative research and the local social and cultural context and incorporate mutually reinforcing messages. To sustain communication efforts over time, programs should work to build the capacity of local organizations to produce more effective behavior change communication strategies and to mobilize resources.
Programs should integrate MCP messages as one element of a comprehensive approach to prevention. Programs need to build and maintain effective systems to link people to other vital HIV interventions. Special attention should be given to promoting fidelity within a context where partners know each other’s HIV status, and where couples HIV counseling is accessible. Links to condom programming are important for discordant couples, people living with HIV, and individuals who continue to engage in high-risk behavior. Prevention programs must continue to address other risks relevant to the epidemic, and include male circumcision services and programs for most-at-risk populations (MARPs).
Engendering Community Support for MCP Activities
Coordination - at all levels of the response - is essential to bring programs to scale and to use limited resources for maximum effect. National programs may need to expand their strategies and integrate MCP-related prevention activities into their existing health program priorities. Health sector personnel at all levels will need to coordinate integration of MCP behavior change within a full range of health and HIV activities, such as counseling and testing, prevention of mother-to-child transmission (PMTCT), care and treatment programs for people living with HIV, and male circumcision. MCP messaging—from the national program to facilities and communities—should be mutually reinforcing.
Programs need to listen and learn from local communities and identify audience-centered solutions. Prevention messages must be nonjudgmental and non-stigmatizing. Because singling out groups (or individuals) can be stigmatizing, programs can instead target the behaviors that put people at risk of HIV. In every community, some people manage to avoid MCP-related risks, and programs can build on these examples of positive behaviors to encourage people to adopt safer sexual practices. The involvement of affected communities throughout program planning and implementation stages helps to develop strong approaches. Programs should also work to build the capacity of communities and support them with the tools to initiate this type of dialogue.
Measuring Program Outcomes
Program planners and managers should employ data to guide program and message development. Given the diversity of epidemic contexts, countries need to know their epidemics and modes of transmission, identify their target audiences, and understand the different patterns of sexual partnerships. In each context, programs need to understand the reasons why people engage in MCP and the factors that contribute to this type of sexual behavior (e.g. low risk perception, denial, alcohol, and gender and social norms). Ethnographic and other qualitative assessments provide essential information for designing effective prevention activities and complement epidemiological data.
Programs need improved methods to monitor MCP activities. Since program experience in addressing MCP is recent, there are few programmatic or evaluation data on which to judge effective approaches. Every opportunity should be taken by programs to collect rigorous data on the effectiveness of these programs in changing behavior and, when feasible, on the impact on HIV incidence. Routine measures to monitor population-level outcomes as well as specific MCP-related program activities would enable better program monitoring. For example, there are no standard metrics for measuring MCP program outputs that are analogous to those commonly used in other program areas, such as the number of bed nets distributed as a common output measure for malaria programs. Finally, it is essential that the HIV community continue to develop an evidence base and establish promising practices for MCP programs."
AIDSTAR-One website on July 10 2009.