The Washington Post catches on to something I've been writing about for three years: AIDS is so bad in Africa in part because it has a different sexual structure than much of the rest of the world. One of Africa's big AIDS causes is not Castro Street-style promiscuity, but multiple concurrent partners.
Speeding HIV's Deadly Spread
Multiple, Concurrent Partners Drive Disease in Southern Africa
By Craig Timberg
FRANCISTOWN, Botswana -- … A growing number of studies single out such behavior -- in which men and women maintain two or more ongoing relationships -- as the most powerful force propelling a killer disease through a vulnerable continent.
This new understanding of how the AIDS virus attacks individuals and their societies helps explain why the disease has devastated southern Africa while sparing other places. It also suggests how the region's AIDS programs, which have struggled to prevent new infections even as treatment for the disease has become more widely available, might save far more lives: by discouraging sexual networks.
"The problem of multiple partners who do not practice safe sex is obviously the biggest driver of HIV in the world," said Ndwapi Ndwapi, a top government AIDS official in Botswana, speaking in Gaborone, the capital. "What I need to know from the scientific community is, what do you do? . . . How do you change that for a society that happens to have higher rates of multiple sexual partners?" …
But the number of sexual partners is not the only factor that increases the risk of AIDS. The most potentially dangerous relationships, researchers say, involve men and women who maintain more than one regular partner for months or years. In these relationships, more intimate, trusting and long-lasting than casual sex, most couples eventually stop using condoms, studies show, allowing easy infiltration by HIV.
Researchers increasingly agree that curbing such behavior is key to slowing the spread of AIDS in Africa. In a July report, southern African AIDS experts and officials listed "reducing multiple and concurrent partnerships" as their first priority for preventing the spread of HIV in a region where nearly 15 million people are estimated to carry the virus -- 38 percent of the world's total.
But for many Batswana, as citizens of this landlocked desert country of 1.6 million call themselves, it is a strategy that has rarely been taught.
… International experts long regarded Botswana as a case study in how to combat AIDS. It had few of the intractable social problems thought to predispose a country to the disease, such as conflict, abject poverty and poor medical care. And for the past decade, the country has rigorously followed strategies that Western experts said would slow AIDS.
With its diamond wealth and the largess of international donors, Botswana aggressively promoted condom use while building Africa's best network of HIV testing centers and its most extensive system for distributing the antiretroviral drugs that dramatically prolong and improve the lives of those with AIDS.
But even though the relentless pace of funerals began to ease in recent years, the disease was far from under control. The national death rate fell from the highest in the world, but only to second-highest, behind AIDS-ravaged Swaziland. Men and women in Botswana continued to contract HIV faster than almost anywhere else on Earth. Twenty-five percent of Batswana adults carry the virus, according to a 2004 national study, and among women in their early 30s living in Francistown, the rate is 69 percent.
Researchers increasingly attribute the resilience of HIV in Botswana -- and in southern Africa generally -- to the high incidence of multiple sexual relationships. Europeans and Americans often have more partners over their lives, studies show, but sub-Saharan Africans average more at the same time.
Nearly one in three sexually active men in Botswana reported having multiple, concurrent sex partners, as did 14 percent of women, in a 2003 survey paid for by the U.S. government. Among men younger than 25, the rate was 44 percent.
The distinction between having several partners in a year and several in a month is crucial because those newly infected with HIV experience an initial surge in viral loads that makes them far more contagious than they will be for years. During the three-week spike -- which ends before standard tests can even detect HIV -- the virus explodes through networks of unprotected sex.
This insight explained what studies were documenting: Africans with multiple, concurrent sex partners were more likely to contract HIV, and countries where such partnerships were common had wider and more lethal epidemics.
A model of multiple sexual relationships presented at a Princeton University conference in May showed that a small increase in the average number of concurrent sexual partners -- from 1.68 to 1.86 -- had profound effects, connecting sexual networks into a single, massive tangle that, when plotted out, resembles the transportation system of a major city.
… These factors, researchers say, explain how North Africa, where Muslim societies require circumcision and strongly discourage sex outside monogamous and polygamous marriages, has largely avoided AIDS. They also explain why the epidemic is far more severe south of the Sahara, where webs of multiple sex partners are more common, researchers say.
West Africa has been partially protected by its high rates of circumcision, but in southern and eastern Africa -- which have both low rates of circumcision and high rates of multiple sex partners -- the AIDS epidemic became the most deadly in the world. "That's the lethal cocktail," said Harvard University epidemiologist Daniel Halperin, a former AIDS prevention adviser in Africa for the U.S. government, speaking from suburban Boston. "There's no place in the world where you have very high HIV and you don't have those two factors."
… "It explains why Africa is hardest hit" by AIDS, Mosojane said. "The way we contract for sex is different from how others do it."
Polygamy once was common in the region, and in some parts still is; Swaziland's king has 13 wives. In generations past, even Batswana with just one spouse rarely expected monogamy. Husbands spent months herding cattle while their wives, staying elsewhere, tended crops, Mosojane said. On his return, a husband was not to be quizzed about his activities while he was away. He also was supposed to spend his first night back in an uncle's house, giving his wife time to send off boyfriends.
An anthropologist friend who spent years in Botswana talks about how once he and some of the tribesmen went off on a trip. On the way home to the village, they were making better than expected time, so he proposed driving through the evening and arriving about midnight, rather than the next day as they had announced upon leaving. The tribesmen were aghast at his proposing such a social faux pas. No gentleman would arrive home early, likely surprising his wife in flagrante delicto with her lover. It would be most embarrassing for all concerned. No, a polite husband never comes home early.
In Setswana, the national language, "the word 'fidelity' does not even exist," Mosojane said.
The few checks that traditional villages had on sexual behavior dwindled during the development frenzy after 1967, when diamonds were discovered. Batswana increasingly moved to cities for school or work. Plentiful television sets delivered a flood of Western images, including racy soap operas and music videos featuring lightly clad women vying for the attention of wealthy, bejeweled men.
The key is that African husbands tend to be more tolerant of their wives having a long term lover or two than is the norm elsewhere. The thought of one's wife becoming pregnant by another man is intolerable to most husbands around the world, but tends to be less infuriating in Africa.
That probably stems from women doing most of the farm work in rural Africa. (That's why you are always hearing about men in Africa working away from home in mines or wherever for months -- the men aren't often needed around the farm because most of the work is just hoeing weeds, which women can do at least as well as men.)
So, the husbands don't have as much leverage over their wives' behavior as in places where husbands are work-a-daddies bringing home the bacon. And African husbands don't have as much motivation to enforce fidelity on their wives since they won't be investing as much money in their wives' children's upbringing as they would elsewhere.
Another contributor to the high rates of AIDS in Southern/Eastern Africa besides multiple concurrent partners and lack of circumcision is the bizarre fetish for "dry sex," which I would guess doesn't exist among West Africans because (thankfully) you never hear about it among their African-American cousins.