Multiple sexual partnerships more common in Uganda than usually thought

In poor urban neighbourhoods of Kampala, 29% of men and 7% of women report having had more than one sexual partner in the past six months, Phoebe Kajubi reports in an article published online ahead of print in the Journal of Acquired Immune Deficiency Syndromes. The figure for women is considerably higher than the estimate usually given.

As a consequence, HIV prevention strategies which assume that the majority of infections occur in stable heterosexual relationships may be misguided. The data may support calls for prevention programmes which aim to reduce multiple partnerships (concurrency).

It is thought that a substantial decrease in the numbers of Ugandan people engaging in multiple sexual partnerships was an important factor in reductions in HIV rates during the 1990s. In a large household survey conducted across Uganda in 2006 (the Demographic and Health Survey), 29% of men and 2% of women reported having had more than one sexual partner in the past twelve months.

Those figures informed the assumption in the country’s National Strategic Plan that transmission within stable heterosexual couples is the largest contributor to new HIV infections. Emphasis has been placed on HIV testing to identify serodiscordant couples and condom promotion for those couples.

Phoebe Kajubi and colleagues wished to find out if the household surveys figures were underestimates - as some researchers suspected. They conducted a random sample, door-to-door household survey in two poor communities on the fringes of Kampala, Uganda’s capital city. Only adults aged 20 to 39 were interviewed; most had low levels of education and worked in unskilled jobs.

While this may be a group of people at high risk of HIV infection, the sample does not have the same demographic profile as that of the Demographic and Health Survey, which was conducted in both rural and urban settings, and with a wider range of ages.

However Kajubi believes that her study may have some methodological advantages, and as a consequence socially stigmatised behaviours are less likely to be under-reported than in the national survey. The study was conducted after the researchers had built trust in the communities, the interviewers were more experienced, they paid particular attention to privacy, and the questionnaire was kept short.

A total of 405 people took part. The number reporting multiple sexual partnerships varied according to the question asked:

• Those having more than one sexual partner in the past six months: 29% of men and 7% of women.
• Those who had at least two sexual partners at the time of the interview: 23% of men and 4% of women.
• Those who had had another partner during their current relationship: 30% of men and 8% of women.
• Those who believed that their partner had had other partners during their current relationship: 22% of men and 32% of women.

The researchers also asked participants whether they agreed with a series of statements concerning the severity of HIV and AIDS. Examples of statements included “People with HIV/AIDS lead a normal life,” “Treatment for HIV/AIDS is available to everyone,” and “AIDS is not as bad as it used to be.”

They found that people who rated HIV as being more severe than others were more likely to stick to one sexual partner. However they were not more likely to have had no sex at all in the past six months or to use condoms.

The authors conclude: “These results suggest that many urban Ugandans may be included in one way or another in networks of multiple and concurrent sexual partnerships.”

Confirmation from Rakai

Meanwhile, researchers working in the rural Rakai district of Uganda have released data which suggests that only a limited number of new HIV infections occur in monogamous, sero-discordant couples.

Looking at new HIV infections in 2005-2006, 43% occurred in people who were not married or in a stable relationship and 26% occurred in people whose stable partner was HIV negative (and was also taking part in the study), suggesting infection acquired from another person. For 18% of the newly infected, the HIV status of their spouse or stable partner was unknown. Only 14% of people with a new HIV infection were married to (or in stable relationship with) an HIV-positive person.

The researchers comment: “Our data indicate that only a minority of total HIV infections occur to a person in an identifiable stable HIV discordant couple relationship in this generalized HIV epidemic setting… Universal VCT targeted on HIV-discordant couples is unlikely to have a major impact on the epidemic.”