An inevitable truth about HIV is that it is a sexually transmitted disease. Even if there are biological factors that may increase a person’€™s risk of HIV infection the fact is that the risk of being infected with any sexually transmitted infection increases in relation to the number of sexual partners that a person may have.

But it is not only the number of partners that you have now. It is also in relation to the number of partners you may have over your lifetime. When we start to have sex we become part of each other’€™s sexual network or the sexual history much along the same lines as the six degrees of separation as the refrain from the television series, Intersexions said: ‘€œIn sex there are no strangers ‘€“ for we are all intimately connected’€.

It is correct that the risk of HIV transmission per sexual act is low, a fact that has been well documented in science.   But this masks the fact that the risk of transmission from one sex partner to another is also dependent on the burden of disease ‘€“ which in South Africa is very high with some districts having HIV prevalence rates that exceed 40% amongst pregnant women.

The risk of infection is also the highest in the acute infection period (also known as the window period). This is the period immediately after one is infected with HIV during which the viral load is high as the immune system has not identified and responded to the invasion of HIV. The issue that has not been resolved is what is the duration of this acute infectious period. Until recently, it was accepted that this period was within the first 3 months following initial infection. A new study suggests that it may be longer than what we initially thought, perhaps up to 400 days.

This means that in the 400 days after initial infection a person may have HIV but it will not show up in their HIV tests because the body has not produced antibodies. Also, until the immune system starts to respond to the attack, the levels of virus ‘€“ viral load ‘€“ is so high that the risk of transmission is increased.  

The real crux of recent debates concerns the issue relating to multiple partners and HIV. So let’€™s take one high prevalence district to see if we can unpack what is happening.

The Gert Sibande District in Mpumalanga spans the area from Swaziland in the east to about Standerton in the West. The HIV prevalence amongst pregnant women   is 38% (ANC, 2009). In  this district 44% of males  and 10.7% of females reported having more than one sexual partner in the past year. This is more than double the provincial average for Mpumalanga of 19% for males and 0.7% for females. Between 12 ‘€“ 18% of men report having more than one sexual partner in the past month ‘€“ which is significant if one takes the acute infection period into account.

Having more than one sexual partner at the same time gives rise to sexual networks as each person is connected to another person sexually who is connected to   someone else both in the present but also has their sexual network from the past.

In his book The Tipping Point , Malcolm Gladwell talks about connectors. These are people who are highly connected to others in social networks. The same principles would apply in a sexual epidemic where there are people who are more likely to have more sexual partners than others as the data suggests ‘€“ the men and women who do have more than one sexual partner in a year or a month. The extent to which these are concurrent remains an issue that we are exploring.

We know from anthropology and sociology that people are pretty well aware of these connectors and talk about people with ‘€œundercover lovers’€. A study by the research institute CADRE found, for example, that people considered themselves faithful to their partners as long as the other partner did not find out about the others.

Community dialogues currently ongoing in KwaZulu-Natal find young people talking openly about older men who cheat on their wives and their partners. If we then bring in the factor of the acute infectious period then this provides fertile grounds for the spread of the epidemic.

Reducing partners does reduce the risk of infection ‘€“ but it too has its constraints in particular in the context of low levels of steady relationships. In Gert Sibande, 3% of men between the ages of 20 ‘€“ 24; 13% of those between the ages of 25 ‘€“ 29 and only 19% of those between the ages of 30 ‘€“ 35 reported being married or living with their sexual partners.

Reducing the number of partners is possibly one of the hardest things that people can do, especially when people are single. Sex is natural and sex is pleasurable. In the context of low levels of steady relationships, people will naturally engage in sex with several partners in search of the one partner that they wish to settle with. This is all part of the natural way in which we behave.

However, for those who have multiple partners, condoms are an alternative and are between 80 ‘€“ 90% effective in reducing the risk of HIV. In Gert Sibande, condom usage at last sex is high particularly amongst the 15 ‘€“ 19 year old males (87%) which is good. But in the age category reporting the highest level of multiple partners (25 ‘€“ 29 years of age), condom usage at last sex is only 66%.

But for a man or a women in Mpumalanga that wants to use condoms there are real limitations. People generally think that condoms are widely available ‘€“ well ,that is if you live in middle class suburbia where condoms are available at a petrol station near you, at a cost of course.

In Gert Sibande, only between 10 ‘€“ 15 free government male condoms are distributed per annum per sexually active male. These condoms are more likely obtainable through government clinics which may be far from where the person is staying and may also inhibit older men from accessing condoms if they have to walk into the waiting room to get their handful of condoms. In the context of high unemployment, low wages and long distances how many men or women can really go to the nearest petrol station to buy a condom?

Condom usage may further be compromised by alcohol consumption which is known to inhibit decision making. In Gert Sibande, 19% of men reported drinking more than 5 alcoholic beverages 3 ‘€“ 5 days in a week. Sixty six percent of people reported that they met their sexual partners at shebeens and 24% of people who reported having more than one alcoholic beverage reported having a one night stand while under the influence of alcohol.

Condom usage continues to lag behind for young women. This may be owing to the power dynamics within their relationships that may prohibit their right to insist on condom usage. More recent studies are showing that young women are becoming more empowered in relation to insisting on condom usage.

The point is that what we are seeing in the data is the perfect conditions for the propagation of HIV. A high burden of disease, combined with high levels of multiple partners and what would most likely be inconsistent condom usage which is linked to issues of supply, accessibility and societal norms and values.

The purpose of prevention efforts, in particular the use of social and behavioural communication, at its very simplistic definition, is to make sure that people know of the factors that place them at risk of HIV infection so that they can take action to mitigate these risks and to address the social, community and societal issues that may inhibit their uptake of the behaviour.

We know that behaviours, social norms and values do and have changed. Condoms have been the focus of much of our prevention efforts since the onset of the epidemic. In the late 1990s condom usage was as low as 20% and in the space of the last ten years through modest prevention efforts this has changed to where we are today.

Programme evaluations have shown that either the person concerned will recognise the risk and look to reintroduce condoms, or they will test for HIV so as to determine their HIV status or they will reduce their number of partners. Either outcome is desirable in the context of HIV.

At the present moment, these are the only tools that are available to reducing new HIV infections and promoting one at the expense of the other is not an option ‘€“ and NO South African intervention has ever promoted one at the exclusion of the other.

Yes, we have made advances, but more must and should be done if we are looking to turn around this epidemic. An inevitable truth about HIV is that we cannot only focus on one dimension but need to have a combined response that enables people to make the decisions that works best for them in the context of their lives. This means scaling up prevention and scaling up treatment so that we can turn this epidemic around.  

* Richard Delate is the country director for Johns Hopkins Health and Education South Africa.