Sunday, March 1, 2009

Multiple Concurrent Madness?

Helen Epstein's teriffic "The Invisible Cure" ( has helped push the conversation toward the essential role played by multiple concurrent partnerships in spreading HIV, especially in Africa. I don't sense a lot of serious debate about Helen's essential point. It's clear that men and women who keep more than one sex partner in a single week or month are more likely to get HIV, and to transmit it to others, including their monogamous husbands or wives. It's a point also at the core of the ideas put forth by my friend Daniel Halperin (who is the co-author on our forthcoming book "Dr. Livingstone's Children: Why We Are Losing the War on AIDS, and How To Win").
What has proven more nettlesome is translating that insight into action. The Ugandans famously did it in the late 1980s and early 1990s, but then forgot how to do it as the big AIDS money rolled in, and perhaps also as that society normalized into a more-settled postwar era ( The Zimbabweans also did it, with the help of massive economic collapse and outmigration that made keeping multiple sex partners a luxury few could afford ( But the dilemma has been, and continues to be, how do create these sorts of changes in societies not coming out of a civil war, or not going through a historic economic and social collapse?

These issues dominated a revealing conference I attended in Gaborone, Botswana in late January, and sponsored by the Harvard AIDS Prevention Research Project, UNAIDS and the World Bank. The group struggled to find a single, dominant coherent message that could be rolled out across southern Africa, a region that (aside from Zimbabwe) has been notoriously poor at talking directly about the sexual behaviors that spread HIV particularly fast there.
I've been keeping tabs on the conversations that flowed out of that conference, and the effort to draft a solid, concise document that can be distributed around the region. My old friend Francois Venter, president of the Southern African HIV Clinicians Society, blasted the original effort in a blistering blast email. His point, in short, was: Everybody is sick of being told what to do (condoms/HIV testing/etc). If you are going to come forward now with another idea, it better be rooted in rock-solid, demonstrable science, with clear guidance on how to turn it into effective programs.
On this, I mostly agree. The science has to careful, the arguments rigorous and well-explained. But I'd like to think that, thanks to Helen and others, that even Francois would agree that the most urgent questions in AIDS prevention today has to be: How can we help change the sexual behaviors that are most dangerous? As a first step, don't we have a moral responsibility to make clear what these are?
I've spent dozens upon dozens of hours in bars/shebeens all over southern Africa talking about this stuff. And inevitably I end up flipping my notebook over and drawing a simple diagram of a sexual network, with my interviewee in the center in an expanding spiderweb of interactions. Not once has somebody failed to express surprise. A quarter century into the world's response to the epidemic in African, shouldn't everybody in these hardest-hit nations be familiar with this stuff. If they aren't, whose fault is it?


  1. Yes, I agree re the question. I am very worried about 'behaviour change' being complacent - the constant 'we HAVE to make it work' refrain does not remove the importance of measuring effectiveness of interventions. Behaviour change messaging is not cheap, requires resources, is not without its dangers, and it can be very annoyingly intrusive (and often is used by groups with moral agendas, undermining the overall message).

  2. Couldn't the same be said of treatment: "not cheap, requires resources, is not without its dangers, and can be intrusive." And yet who today questions that we have a moral obligation to provide smart, well-resourced, effective treatment programs?

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