Africa’s AIDS fight: Fresh focus on issue of multiple partners

New research is leading to new prevention programs focused on cultural change.

In the latest season of the popular South African television show, Soul City, Zanele presents her husband with a box of condoms when she discovers he's been cheating.

If he won't be faithful, she says, they'll have to use protection.

When he storms out, Zanele's mother chides her for making a fuss, saying all men have other women.

"Well, times have changed, Ma," says Zanele. "There is a thing called HIV now."

The show, produced by a South African nongovernmental organization, is representative of a revolutionary new generation of AIDS prevention campaigns that reflect a growing recognition that condoms aren't enough and that slowing the epidemic will require widespread cultural change. The new approach, which is being pioneered in South Africa, targets initial practical steps on route to that broader goal. It is based on new research about the driving forces of the epidemic – specifically the common practice in many hard-hit African countries of having multiple, long-term sexual partners at the same time.

These new AIDS prevention messages are also blurring the often-rancorous divide between largely secular advocates of condom-based messages and religious organizations that emphasize abstinence and fidelity.

The US President's Emergency Fund for AIDS Relief (PEPFAR), George W. Bush's multibillion-dollar global HIV/AIDS program, was initially heavily criticized by many secular AIDS activists for its requirement that a third of all prevention funds be spent on abstinence-until-marriage programs.

"We've moved beyond ABC," says John Molefe, a senior executive at the Soul City Institute that produces the Soul City drama, referring to the traditional Abstinence-Be Faithful-Condomize model that has shaped AIDS prevention for decades. "We've learned that behavior change is a lot more complex than we thought."

New research, new programs

South Africa's approach is catching on: on Nov. 28, UNAIDS called on countries to bring their HIV/AIDS prevention programs in line with new research. On Monday, the United Nations marks World AIDS Day for the 20th year.

AIDS prevention has been on the back burner in recent years, as attention – and money – shifted to providing treatment to those already infected.

Many had lost faith in prevention programs, which seemed to be a black hole that sucked up millions of dollars of funding but did little to slow the epidemic's growth. But now many experts believe the messages didn't fail, they just didn't target the right behaviors.

Traditionally, AIDS prevention messages were driven by the belief that if people knew about HIV/AIDS, they would take steps to protect themselves. Now, there's new understanding that knowledge isn't enough and condoms alone won't stem the tide.

Condom use has grown dramatically

Research shows that condom use in Africa has grown dramatically, especially in casual sexual encounters.

One study, by the Center for AIDS Research, Development and Evaluation (CADRE), showed that 65 percent of South Africans ages 20 to 30 reported using a condom in their last sexual encounter and that 86 percent were afraid to have a one-night-stand without using protection.

But studies have also found that many people stopped using condoms with long-term partners – and that Africans were more likely than people in other parts of the world to have a number of long-term partners at the same time.

More than half of CADRE's respondents said it was okay to stop using a condom with a long-term sexual partner. But more than a third reported having more than one partner in the past year.

HIV, many experts now believe, is spreading through interlinked sexual networks. And what's needed is a concerted effort to educate people about the dangers of multiple partnerships.

"We found we had been successful on condom use, but it wasn't enough," says Richard Delate, country program director of the Johns Hopkins Health and Education in South Africa program (JHHESA). "Almost nothing was being done around concurrency and multiple partnerships."

Research has also shown that some AIDS prevention programs may also even have unintentionally sent the wrong message.

For example, the CADRE study found that many people thought "faithfulness" meant making sure your partner didn't find out about your other sexual partners.

Targeted messages

The new prevention messages are more complex and more targeted than those from a few years ago, and are backed by detailed research into the drivers of the epidemic.

South African organizations, which are pioneering the new approach, are also marshaling the kind of market research and focus grouping long used in the advertising industry.

A new animated commercial produced by JHHESA uses local slang to explain the sexual networks that link patrons of a taxi stand.

One man, the narrator explains, has "a big house" – his wife – and three "small houses," his mistresses. A woman has a "minister of housing, transport, and culture" – a reference to the different men she relies on to support different aspects of her lifestyle.

The cartoon shows how HIV, represented as a ninja, can work his way through those networks.

The television spot reflects research about the dangers of multiple partnerships and the social factors driving them, in this case the reliance of poor women on sexual relationships to survive, often called transactional sex. But it also puts to use better knowledge about how these issues are talked about and understood by ordinary people.

The new approach is boosting enthusiasm for HIV/AIDS prevention efforts.

"There was a feeling for a while that prevention was depressing, that it didn't work," says Mr. Delate. "But prevention is coming back on the public agenda again."