Concurrent sexual partnerships do not explain the HIV epidemics in Africa: a systematic review of the evidence

Abstract

The notion that concurrent sexual partnerships are especially common in sub-Saharan Africa and explain the region's high HIV prevalence is accepted by many as conventional wisdom. In this paper, we evaluate the quantitative and qualitative evidence offered by the principal proponents of the concurrency hypothesis and analyze the mathematical model they use to establish the plausibility of the hypothesis.We find that research seeking to establish a statistical correlation between concurrency and HIV prevalence either finds no correlation or has important limitations. Furthermore, in order to simulate rapid spread of HIV, mathematical models require unrealistic assumptions about frequency of sexual contact, gender symmetry, levels of concurrency, and per-act transmission rates. Moreover, quantitative evidence cited by proponents of the concurrency hypothesis is unconvincing since they exclude Demographic and Health Surveys and other data showing that concurrency in Africa is low, make broad statements about non-African concurrency based on very few surveys, report data incorrectly, report data from studies that have no information about concurrency as though they supported the hypothesis, report incomparable data and cite unpublished or unavailable studies. Qualitative evidence offered by proponents of the hypothesis is irrelevant since, among other reasons, there is no comparison of Africa with other regions.Promoters of the concurrency hypothesis have failed to establish that concurrency is unusually prevalent in Africa or that the kinds of concurrent partnerships found in Africa produce more rapid spread of HIV than other forms of sexual behaviour. Policy makers should turn attention to drivers of African HIV epidemics that are policy sensitive and for which there is substantial epidemiological evidence.

Prevalence and Correlates of Sexual Partner Concurrency Among Australian Gay Men Aged 18–39 Years

“…At least in the United States, heterosexual populations tend to report concurrency at prevalence rates of around 10% or less [26,28]. There has also been some debate over the extent to which concurrency drives HIV infections in these populations, particularly in sub-Saharan Africa where HIV is more prevalent among heterosexual men and women [4,[29][30][31][32].…”

Economic Inequality and HIV in Malawi

“…Sawers and Stillwaggon (2010b) and Lurie and Rosenthal (2010) argue that the empirical support is weak or non-existent, and Mapingure et al (2010) fail to find that the number of sexual partners matters when comparing samples from Tanzania and Zimbabwe. Instead, undernourishment, infectious diseases, and bad health in general, are claimed to be more important intermediating factors, since they increase the per-contact transmission rate (Stillwaggon, 2006(Stillwaggon, , 2009Sawers and Stillwaggon, 2010a).…”

Mono-Causal and Multi-Causal Theories of Disease: How to Think Virally and Socially about the Aetiology of AIDS

“…Most implausibly, they assume that each individual involved in the concurrency network has sexual contact with all of his/her partners every day and that concurrency is gender symmetric (that is, that both men and women have multiple partners). The evidence supports neither of these assumptions, and once they have been adjusted to more closely align with data from the areas being analysed, the models fail to generate any difference in HIV prevalence between populations that practice concurrency and those that practice serial monogamy (Sawers and Stillwaggon 2010).…”

“…Indeed, a combination of the plausible mechanism and the mathematical modelling has made the concurrency theory the mainstream explanation for the disproportionate prevalence of HIV in southern Africa (Allais and Venter 2012;Sawers and Stillwaggon 2010).…”