James Shelton
Publication Date
August 1, 2009

Bureau for Global Heath, United States Agency for International Development (USAID)

In this article from The Lancet, James D. Shelton examines behavioural components of multiple concurrent sexual partnerships (MCPs), identified as a driver of HIV infection in southern and eastern Africa. As stated by Sheldon: "Understanding why people have multiple partnerships is key to efforts to change behaviour, with the realisation that behaviours range from polygamy itself, to longer term quasi-polygamy (sometimes described as having a “small house”), to sporadic sexual encounters. A superficial view is that men are driven by uncontrollable sexual urges and the cultural legacy of polygamy, while women are trapped by economic necessity and male domination - a daunting prospect for behavioural change. Although this picture undoubtedly reflects some truth, an emerging and rich sexual ethnographic literature, notably including a ten-country study from South Africa’s The Soul City Institute for Health and Development Communication, reveals considerable individual autonomy and basis for interventions to change behaviour." [Editor's note: Footnotes have been removed throughout the quoted passages.]

In addition to relationship dissatisfaction, the perceived benefits of transactional sex can motivate behaviours related to MCPs. This is particularly relevant when transactional sex is associated with gifts and economic support from men as part of a sexual relationship, which "seems mainly related to social status and economic advancement more broadly" than to survival. "Other reasons described for multiple partnerships include: insurance against loss of one’s main partner; a multi-pronged strategy to find the “right” life partner; physical separation especially because of work; peer pressure; revenge in response to partner’s infidelity; and, for women ironically, the perception that modernity allows freedom to behave more like men by having multiple partners. Culture also contributes, including the backdrop of polygamy, belief that men’s sexual drives are poorly controllable and reflect prowess, women’s traditional passive role in sex, and general reluctance to talk about sex. Alcohol clearly facilitates risky sex."

According to the article, people faced with the prospect of contracting HIV/AIDS will sometimes take deliberate actions to protect themselves. For example, " Malawi, couples have adopted a specific communication strategy to discourage outside sexual relationships. Rather than accusing the partner of infidelity, they invoke the importance of protecting the family against HIV so as not to leave children parentless." However, as stated here, awareness of the role of concurrent partners in spreading the HIV virus and the fact that concurrency is often a long-standing and personally and culturally accepted practice prevents people from viewing it as an entrée to risky sexual networks.

Two efforts to provide education and communicate behaviour change on concurrency are: Soul City's nine-country communication initiative called “One Love” and Johns Hopkins University’s effort in South Africa called “Scrutinize”. Another is the “O Icheke - Break the Chain - campaign” in Botswana, led by the National AIDS Coordinating Agency with help from Population Services International and other partners. "On the basis of sound epidemiology and audience research, the targets of O Icheke (which means “check yourself” or “think about it”, and which was also the title of a popular song about multiple partners) include mobile men typically aged 25-34 years and younger women. Initial efforts emphasise knowledge about the risks of multiple concurrent partners. Visual portrayal of sexual networks with the potential for the virus to spread through them and testimonials from people living with HIV seem particularly effective approaches for heightening the perception of personal risk. Changing social norms is also key, including presenting positive models of men and masculinity, promoting better communication about sex and cultivating more sexually satisfying primary relationships. Mass-media approaches encompass billboards, printed advertisements, and television and radio, including call-in shows. Community-level discussions, by various partners including non-governmental and faith-based organisations, also allow for consistent but much richer messaging and influence on social norms." Counselling at HIV clinical sites and school curricula are arenas for communication in the planning stages.

Shelton concludes by suggesting that behaviour change projects on MCPs, along with the promotion of male circumcision and use of condoms, especially for high-risk sex, appear to be the most promising way forward for preventing hyper-epidemic HIV transmission.


The Lancet, August 2009.