HIV Prevention Knowledge Base
Behavioral Interventions: Partner Reduction
Alcohol Abuse, Sexual Risk Behaviors, and Sexually Transmitted Infections in Women in Moshi Urban District, Northern Tanzania
This study found that among nearly 1,000 women living in an urban district of northern Tanzania, those who abused alcohol were more likely to report having been a victim of physical abuse or sexual violence. They were also more likely to report having more than one sexual partner in the previous three years. There was no significant association between alcohol abuse and sexually transmitted infections (STIs). The authors concluded that alcohol abuse was not directly associated with prevalence of STIs but was indirectly associated through its association with multiple partners. The authors suggest that the subordinate status of women may lead some women to stay with men who are unfaithful and violent and that such women may use alcohol to “self-medicate” underlying problems. They conclude that alcohol use screening should be a part of comprehensive STI and HIV prevention programs.
Role of Widows in the Heterosexual Transmission of HIV in Manicaland, Zimbabwe, 1998–2003
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.
Changes in Sexual Behaviour Leading to the Decline in the Prevalence of HIV in Uganda: Confirmation from Multiple Sources of Evidence
Seven diverse sources of information— including historical documents, newspaper articles, and multiple small- and large-scale surveys from 1988 through 1995—provided evidence about changes in sexual behavior following a campaign launched in 1986 to reduce sexual partners in Uganda. According to these varied sources, the dramatic decline in HIV prevalence in Uganda during the 1990s was preceded by a reduction in sexual partners. Furthermore, they indicate that increases in condom use did not take place until the early 1990s, after HIV prevalence was already declining. The author concludes that concurrently emphasizing partner reduction and condom use is “much more effective than primarily promoting condom use (or abstinence).”
Gender Differences in the Risk of HIV Infection Among Persons Reporting Abstinence, Monogamy, and Multiple Sexual Partners in Northern Tanzania
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.”
Trends in HIV-related Behaviors and Knowledge in Uganda, 1989-2005: Evidence of a Shift Toward More Risk-Taking Behaviors
According to several large-scale surveys of adult Ugandans, knowledge about HIV peaked in 2001 and then remained stable while self-reported behaviors both improved and worsened. At the same time that the proportion of men who were abstinent increased, the number of men who had sex with multiple partners also increased, rising from one in four men in 2001 to one in three in 2005. The authors suggest that two factors may underlie increases in sexual risk-taking behaviors: complacency as antiretroviral drugs have become widely available between 2000 and 2005, and a shift in funding away from behavior change programs to medical access programs.
Sexual Risk Factors for HIV Infection in Early and Advanced HIV Epidemics in Sub-Saharan Africa: Systematic Overview of 68 Epidemiological Studies
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.
Evidence for Population Level Declines in Adult HIV Prevalence in Kenya
National survey data show that HIV prevalence in Kenya peaked at about 10 percent in the late 1990s and declined to 7 percent by 2003. Age at first sex and use of condoms increased while the percentage of adults with multiple partners fell. Gonorrhea, chlamydia, and syphilis all declined in young women attending an antenatal clinic in Nairobi. The researchers concluded that HIV prevalence decreased in some but not all areas of Kenya and that some of the decline was due in part to high levels of AIDS deaths. Prior to 2000, there were more new infections than deaths—a situation that reversed after 2000. Prevention interventions increased after 2000, too late, say the authors, to explain the earlier decline in HIV prevalence.
HIV Decline Associated with Behavior Change in Eastern Zimbabwe
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.”
A Typology of Groups at Risk of HIV/STI in a Gold Mining Town in Northwestern Tanzania
HIV prevention interventions have generally targeted risk groups such as migrant laborers and commercial sex workers in mining communities in sub-Saharan Africa. In 2002, the authors conducted several hundred informal interviews of women who openly engaged in commercial sex, and of women who engaged in less visible forms of transactional sex, such as shopkeepers or barmaids, who made most or part of their income by selling sex. They concluded that traditional epidemiological categories of “general,” “bridging,” and “core” populations did not adequately describe the range of HIV risk. The lure of economic opportunity in mining towns led to dislocation and travel that facilitated spread of HIV among seemingly low-risk individuals. Interventions, say the authors, should focus on decreasing income disparities and providing housing for mineworkers’ families.
Masculinities and Multiple-Sexual-Partners in Historical Perspective in KwaZulu-Natal: The Making and Unmaking of Isoka
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.
Barriers to Preventing Human Immunodeficiency Virus in Women: Experiences from KwaZulu-Natal, South Africa
The authors of this study surveyed women in KwaZulu-Natal, South Africa, from 1991 to 1993, and found that nearly 9 out of 10 women were sexually active. Virtually all of the women understood the role of condoms in HIV prevention, but only a little over 1 in 10 had ever used a condom. Many women said they did not insist on using a condom because their partners would get angry if they did. Unlike other researchers, these authors found that high levels of knowledge about HIV transmission did not influence safer-sex behavior changes for several reasons, including threats of violence against women, alcohol abuse, financial dependence on men, and women’s status as child bearers.
Changes in Sexual Behavior and a Decline in HIV Infection Among Young Men in Thailand
The prevalence of HIV among commercial sex workers in Thailand is 50 percent or higher, leading Thai officials in the 1990s to promote condom use for commercial sex workers. This study evaluated the effects of that and other HIV prevention programs in Thailand. Five cohorts of 21-year-old male army conscripts in Northern Thailand were evaluated. There were modest declines in HIV prevalence between 1991 and 1995. The percentage of men who had sex with a commercial sex worker declined while condom use increased. The authors concluded that active monitoring of brothels to “encourage and enforce” condom use are critical to the success of HIV prevention.
The Role of Partner Reduction and Faithfulness in HIV Prevention in Sub-Saharan Africa: Evidence from Cameroon, Rwanda, Uganda, and Zimbabwe
This study used national-level data to explore the association between risk of HIV infection, multiple sexual partnerships, and partner faithfulness among men, women, and cohabiting couples in the HIV epidemics in Cameroon, Rwanda, Uganda, and Zimbabwe. M ultiple sexual partnerships varied among countries, but tended to be common in these countries. In general, men reported having more partners than did women, and were less faithful (lifetime faithfulness and recent faithfulness) than were women. As one would expect, the higher the number of lifetime sexual partners, the greater the likelihood of HIV infection. Similarly, those who reported being faithful to their partners were less likely to be infected with HIV than those who were unfaithful.