“Sexual desire and passion lead to sexual contact, but transmission of the [HI] virus only occurs if sex is part of a much larger network, and only under certain conditions.”⁽²⁾ HIV thrives on connections forged through sexual contact, but these contacts cannot be understood in isolation. By studying the structure of sexual relationships, and by extension sexual networks, a more advanced understanding of the relative risk faced and routes of transmission amongst sexually active groups can be developed.⁽³⁾

Multiple concurrent partnerships (MCP) is a term used to describe any situation where an individual engages in overlapping sexual contact with more than one person.⁽⁴⁾ This paper reflects on the nature and impact of sexual networks and MCP in Africa. The determinants and drivers of these networks are discussed. Also, the factors which catalyse the formation of MCP, which often characterise these networks, are explored. Finally, behaviour change communication and intervention methodologies developed in response are presented. The “One Love” campaign, among others, is used here to illustrate the concepts and implications of sexual networks and MCP programmes.

Defining sexual networks and key concepts

The term sexual network describes a group of people who are connected to one another through direct or indirect sexual contact.⁽⁵⁾ Sexual networks can take a number of configurations, some more complex than others. Ultimately however, all members of the sexually active population are members of at least one sexual network.

A number of factors have been said to influence and affect the nature of these networks. The size of the network and the number of partners of a given individual are important factors with regard to the risk of transmission of the virus,⁽⁶⁾ as the rate of transmission is closely linked to the number of exposures. Selection of partners is another critical factor to consider – by selecting partners of non-similar or random character, the likelihood of spreading the infection across demographic and socio-cultural groups is substantially increased.⁽⁷⁾ Core group members are those members of a network subpopulation characterised by particularly high risk behaviour profiles and may thus contribute disproportionately to the rate and risk of transmission.⁽⁸⁾

Within networks, assortative and disassortative interactions occur. The term assortative interaction primarily refers to partnerships between sexually active individuals with demographically similar risk profiles, whereas disassortative interactions occur when sexual partners are selected from a different group to the individual’s own.⁽⁹⁾ The former has been shown to result in a faster initial transmission of STIs including HIV, while the latter is characterised by a slower initial spread but development of a large-scale epidemic.⁽¹⁰⁾ These interaction types have been used to understand sexual partner selection based on other demographic and social characteristics. As will be discussed below, it appears that individuals are more likely to select sexual partners with similar characteristics or group membership to their own.

Determinants of sexual networks

With regard to the development and structure of sexual networks, three main types of determinants have been identified, namely societal determinants, social norms and physical spaces.⁽¹¹⁾ Societal determinants have been described as including socio-cultural, economic, industrial and political factors that have broad level implications on the formation of sexual networks.⁽¹²⁾ Social determinants refer to social norms and cultural factors guiding partnership behaviours. These are maintained at the societal level and supported by behaviours within the network. Finally, networks can span physical spaces and these are afforded a degree of importance in determining the development, growth and maintenance of sexual networks. Physical spaces include all the places in which people may meet and interact with their partners,⁽¹³⁾ and may include the workplace, social, cultural or community centres, and places of gathering (bars, taverns, clubs etc) amongst others.

What emerges here is the notion that people are connected to one another at numerous levels, and that each partnership generated is integral to the structure of sexual networks. For example, a Malawian study of young adults residing on Likoma Island, revealed that at least half the island’s young adult population were connected “through multiple independent chains of sexual relationships.”⁽¹⁴⁾ Where more than one partnership is entered into by an individual, which is often the case, the connection between sexual networks and multiple and concurrent sexual partnerships must be attended to.

Multiple concurrent sexual partnerships

Concurrent partnerships can be contrasted with serial or sequential ones which refer to no overlap of sexual contact and partners.⁽¹⁵⁾ At a 2006 think-tank convened by the Southern African Development Community (SADC), a number of social and structural drivers spurring the HIV & AIDS epidemic in the region were identified. Key among these were low-frequency and inconsistent condom use, low levels of male-circumcision and high numbers of multiple and concurrent sexual partnerships.⁽¹⁶⁾ Research has suggested that multiple sexual partners, and concurrent partnerships particularly, are core influences on the spread of the epidemic across the African continent.⁽¹⁷⁾

A study conducted in Lesotho revealed that rates of MCP are exceptionally high in the country. The study found, consistent with the SADC findings, that MCP both prior to and during marriage, coupled with insufficient condom use and low levels of full male circumcision, contribute significantly to fuelling Lesotho’s hyperendemic HIV situation.⁽¹⁸⁾ Interestingly, while African men do not report higher numbers of lifetime sexual partners than their global counterparts, they do report more frequent instances of long-term concurrent relationship cycles with two or more concurrent partnerships often lasting more than a year.⁽¹⁹⁾ In Lesotho, the reported incidence of concurrent partner relationships of men and women was 55% and 39% respectively (similar rates, although not as high, were reported in populations from Tanzania and Zambia).⁽²⁰⁾

Types and determinants of MCP: Evidence from the “One Love” campaigns and supporting research

In response to the findings of the abovementioned SADC think-tank, the Soul City Regional Programme (SCRP) embarked on a three-year, multi-region campaign known as “One Love”, which aims to reduce new infections by concentrating efforts on reducing levels of MCP in African sexual networks. Participants in a study conducted to evaluate the success of the One Love campaign were drawn from ten southern African countries, namely: Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Zambia and Zimbabwe.⁽²¹⁾ The study was extensive and findings addressed both forms of MCP and the reasons given by members of MCP sexual networks for engaging in these practices. A full review of the results is beyond the scope of this paper, however, the discussion which follows aims to provide a brief overview of these, supported by research evidence.

Four main types of MCP were identified in the study. These included steady vs. ‘side partners’, intergenerational sexual relationships, transactional relationships and polygamous partnerships.⁽²²⁾ In the first instance, a number of individuals acknowledged that in addition to their primary partner (whether a spouse, girl- or boy-friend or other committed partner), they will regularly enter into additional, concurrent sexual partnerships.⁽²³⁾ For example, one participant in the South African arm of the study stated: “Right in the home, she can refuse to sleep with you. And now, you have to understand that men are built a certain way: a woman can always say no, but when she does, you know it can only turn out this way – we go out there and find what we are looking for, because there is no way of stopping yourself when you want it.”⁽²⁴⁾ Motivations for entry into these partnerships included dissatisfaction in relationships, including with sexual aspects, insufficient or unsatisfactory communication, and intimate partner violence - including physical abuse and domestic discord.⁽²⁵⁾

Research has indicated that women and young girls are particularly at risk for infection. Halperin and Epstein have highlighted how African women in concurrent partnerships are exposed to or involved in relationships, which are characterised by “a powerful element of sexual-economic exchange, related to issues of gender and income inequality, sexual culture, poverty, and the globalisation of consumerism.”⁽²⁶⁾ The gendered power differentials which are implicit in such relationships add an important dimension to understanding these MCPs. There is compelling evidence to suggest that these disparities arise due to transactional partnerships, and ‘age-disparate’ (5-10 year age difference between partners) or ‘intergenerational’ relationships (more than 10 year age gap between partners).⁽²⁷⁾

Transactional partnerships are those driven by the exchange of sex for social or financial gain. A Zimbabwean participant in the One Love study noted, “We are talking of girls who just start prostitution which is caused by poverty or who have been divorced and the girl will just go to ‘shebeen’ to prostitute to get money to survive.”⁽²⁸⁾ This statement highlights the stark state of social and infrastructural inequality which characterises much of African life-norms and how MCP is driven by more than sexual needs. A Ugandan study noted rates of transactional sex as high as 90%.⁽²⁹⁾

Age-disparate and intergenerational relationships are closely related to transactional sexual partnerships and characterised by a relationship between a young woman and an older man (although this is not always the case).⁽³⁰⁾ The latter are often referred to as “sugar daddies”. A number of studies have shown that these relationships are common throughout sub-Saharan Africa and that they are associated with an increased HIV risk profiles and unsafe sexual practices including low condom use.⁽³¹⁾ An added complication of participation in intergenerational relationships is that risk is extended to both the younger and older participant populations.

Polygamy refers to the practice of having more than one spouse, and is a widely culturally-sanctioned practice in Africa. Respondents from a number of countries noted that polygamy is deeply entrenched in their cultural heritage and it is seen as normal for a man to have more than one wife.⁽³²⁾ A young Tanzanian respondent highlighted some of the risks to which polygamous partners are exposed, stating that: “Yeah, when you move from this wife to another wife in the next house, there are men behind you who are replacing your absence”.⁽³³⁾ Polygamous relationships can represent secure MCP scenarios, however should one member of this sexual network compromise one link, all members will be placed at risk.

Making it work: Intervention experiences

Developing an understanding of the nature of and relationship between sexual networks and MCP is key to the development of effective behaviour change interventions.⁽³⁴⁾ In order to structure intervention programmes strategically, it has been suggested that AIDS prevention programmes should allocate special consideration to focal actors in the sexual network. By targeting and achieving behaviour change amongst core network members, major pathways for transmission across the network may be impeded.⁽³⁵⁾

Following this thought, it has been suggested that community consultation and engagement should guide the development of MCP programmes. Also, MCP campaigns are now engaging a number of tailored communication tools and strategies ranging from interpersonal activities, mass media and community mobilisation, and social media.⁽³⁶⁾ For example Uganda’s One Love: “Get off the sexual network!” campaign has an active Facebook component.⁽³⁷⁾

It is important when constructing intervention targets to address all sectors. A useful forum for intervention is the workplace, a central location implicit to sexual networks. At a recent business sector conference hosted by the South African Business Coalition on HIV & AIDS in the Limpopo Province (SA), delegates from government and the health and business sectors engaged in rigorous and emotive debate on the topic of sexual networks and multiple concurrent partners. Conference coordinators reflected on the engagement of participants and highlighted the openness with which participants discussed this topic. Through the use of anonymous electronic voting technology, active assessment revealed that a majority of participants acknowledged having had multiple concurrent sexual partnerships in their lifetimes.⁽³⁸⁾ These networks often extended across familial, socio-cultural and workplace domains. Perhaps this implies that sexual networks are ecologically pervasive and may contribute to explaining the transmission of HIV across African sexual networks.

South Africa’s ‘Scrutinise’ campaign has been highlighted as an exemplary campaign. The programme’s “Undercover Lover” cartoon adverts or ‘animerts’ encourage South Africans to be aware of their sexual risk profiles and membership of sexual networks.⁽³⁹⁾ The campaign is supported by a number of private and public organisations, serving as an example of how inter-agency collaboration can produce a locally targeted, high quality campaign.⁽⁴⁰⁾

Concluding remarks

It is clear that sexual networks and the MCP behaviours which are often characteristic thereof are current and relevant concerns to the sexual health of the African continent. Different types of networks exist, and each has a unique risk profile which can be mitigated by psychosocial, economic and infrastructural factors. By understanding these networks and the way in which their members interact with one another, intervention efforts may be locally and appropriately designed. In doing so, efforts to change behaviours, and to “get off the sexual network” will allow for maximum risk reduction potential.

NOTES:

(1) Contact Deanne Goldberg through Consultancy Africa Intelligence's HIV & AIDS Unit (hiv.aids@consultancyafrica.com).
(2) R.J. Thorton, ‘Preventing AIDS: A new paradigm for a new strategy’, 2008, http://wiredspace.wits.ac.za.
(3) Reinking, D., et al., 1994. Social transmission routes of HIV: A combined and life course perspective. Patient Education and Counseling, 24, pp.289-297.
(4) ‘Sexual networks and STI: A brief overview’, Centre for Health Training, 2009, http://www.centerforhealthtraining.org.
(5) D. Wohlfeiler and J. Potterat, ‘How do sexual networks affect HIV/STD prevention?’, 2003, http://caps.ucsf.edu; Adimora, A.A., and Schoenbach, V.J., 2005. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. Journal of Infectious Diseases, 191(1), pp. 115-122.
(6) D. Wohlfeiler and J. Potterat, ‘How do sexual networks affect HIV/STD prevention?’, 2003, http://caps.ucsf.edu; ‘Sexual networks and STI: A brief overview’, Center for Health Training, 2009, http://www.centerforhealthtraining.org.
(7) D. Wohlfeiler and J. Potterat, ‘How do sexual networks affect HIV/STD prevention?’, 2003, http://caps.ucsf.edu.
(8) Liljeros, F., Edling, C.R., and Nunes Amaral, L.A., 2003. Sexual networks: Implications for the transmission
of sexually transmitted infections. Microbes and Infection, 5, pp.189–196.
(9) ‘Sexual Networks and STI: A Brief Overview’, Centre for Health Training, 2009, http://www.centerforhealthtraining.org.
(10) Liljeros, F., Edling, C.R. and Nunes Amaral, L.A., 2003. Sexual networks: Implications for the transmission
of sexually transmitted infections. Microbes and Infection, 5, pp.189–196.
(11) ‘Sexual networks and STI: A brief overview’, Center for Health Training, 2009, http://www.centerforhealthtraining.org.
(12) Ibid.
(13) Ibid.
(14) Mah, T., and Halperin, D., 2010. Concurrent sexual partnerships and the HIV epidemics in Africa: Evidence to move forward. AIDS and Behavior, 14(1), pp.11-16.
(15) Ibid.
(16) ‘Expert think tank meeting on HIV prevention in high-prevalence countries in southern Africa’, SADC, 2008, http://www.sadc.int.
(17) Shelton, J.D., 2009. Why multiple sexual partners? The Lancet, 374, pp.367-69; Kenyon, C., Boulle, A., Badri, M., and Asselman, V., 2010. “I don’t use a condom (with my regular partner) because I know that I’m faithful, but with everyone else I do”: The cultural and socioeconomic determinants of sexual partner concurrency in young South Africans. Journal of Social Aspects of HIV/AIDS, 7(3), pp.36-43.
(18) ‘Lesotho HIV prevention response and modes of transmission analysis’, Lesotho National AIDS Commission, 2009, http://www.nac.org.ls.
(19) Halperin, D.T.and Epstein, H., 2007. Why is HIV prevalence so severe in Southern Africa? The role of multiple concurrent partnerships and lack of male circumcision: Implications for AIDS prevention. The Southern African Journal of HIV Medicine, 8(1), pp.19-25.
(20) Ibid.
(21) ‘One Love: Multiple and concurrent sexual partnerships in Southern Africa: A ten country research report’, Soul City Regional Programme, 2008, http://www.onelovesouthernafrica.org.
(22) Ibid.
(23) Ibid.
(24) ‘Multiple and concurrent sexual partnerships in South Africa: A target audience research report - September 2008’, Soul City Institute of Health and Development Communication, 2008, http://www.onelovesouthernafrica.org.
(25) Ibid.
(26) Halperin, D.T. and Epstein, H., 2007. Why is HIV prevalence so severe in Southern Africa? The role of multiple concurrent partnerships and lack of male circumcision: Implications for AIDS prevention. The Southern African Journal of HIV Medicine, 8(1), pp.19-25.
(27) ‘Transactional and age-disparate sex in hyperendemic countries’, AIDSTAR-One, 2011, http://www.aidstar-one.com.
(28) ‘One Love: Multiple and concurrent sexual partnerships in Southern Africa: A ten country research report’, Soul City Regional Programme, 2008, http://www.onelovesouthernafrica.org.
(29) ‘Transactional and age-disparate sex in hyperendemic countries’, AIDSTAR-One, 2011, http://www.aidstar-one.com.
(30) ‘One Love: Multiple and concurrent sexual partnerships in Southern Africa: A ten country research report’, Soul City Regional Programme, 2008, http://www.onelovesouthernafrica.org.
(31) ‘Transactional and age-disparate sex in hyperendemic countries’, AIDSTAR-One, 2011, http://www.aidstar-one.com.
(32) ‘One Love: Multiple and concurrent sexual partnerships in Southern Africa: A ten country research report’, Soul City Regional Programme, 2008, http://www.onelovesouthernafrica.org.
(33) Ibid.
(34) Shelton, J.D., 2009. Why multiple sexual partners? The Lancet, 374, pp.367-69.
(35) Reinking, D., et al., 1994. Social transmission routes of HIV: A combined and life course perspective. Patient Education and Counseling, 24, pp.289-297.
(36) ‘Behavioral interventions: Multiple and concurrent sexual partnerships: Introduction’, 2011, AIDSTAR-One, http://www.aidstar-one.com.
(37) One Love, 2011, ‘Get off the Sexual Network: One Love’, http://www.facebook.com.
(38) Heynike, L., 2011. Reflections on sexual networks exercise conducted at SABCOHA Limpopo Business Sector Conference. [discussion] (Personal communication, 5 October, 2011).
(39) ‘Undercover Lover’, 2011, Scrutinize, http://www.scrutinize.org.za; ‘Behavioral interventions: Multiple and concurrent sexual partnerships: Introduction’, 2011, AIDSTAR-One, http://www.aidstar-one.com.
(40) Ibid.

Written by Deanne Goldberg ⁽¹⁾