Unlocking the puzzle: HIV in East Africa

Let me ask you this: Do you believe patterns of sexual behavior are the primary determinant of rates of HIV infection in the world?  If a country has more HIV, does that mean more people are having more unprotected sex with more partners?

Personally, I don't believe the above statement, at least without major qualifications, but there are plenty of people (and plenty of people in the HIV/AIDS advocacy community) who do.  What I would say, is that countries with higher infection rates probably provide the virus with more opportunities for transmission--perhaps in the form of unprotected sex, but also in the form of overall poor health, additional untreated infections, possibly lower rates of circumcision, and other so-called "open windows" (to borrow a phrase from Elizabeth Pisani) into our normally protected bodies.

On the other hand, I am also troubled by how HIV rates could be so high in relatively well-off East African countries (such as Botswana) and so low in equally poor Latin American countries.  What's the missing variable?  One theory that I've heard advanced is that East African societies tend to favor concurrent sexual relationships, rather than serially monogamous ones, which is more conducive to HIV transmission.  The idea is that HIV is most infectious after you've been recently infected, so if you have sex with someone for several months, become infected, and then start a new relationship a few months later, you're less likely to transmit the disease than if you have an ongoing sexual relationship that involves multiple instances of unprotected sex with two people during the same time period.  But is it the case that East Africans have more concurrent sexual relationships than people in other countries?  Honestly, I don't know.  Feasibly, it seems like something you could find out by examining DHS surveys, but I don't know of anyone who's done this.  So in the absence of facts, let's at least talk about why that impression exists.

Here in Zambia, it is true that cheating seems to be not just a major problem, but also one that people have become resigned to.  A friend of mine taught me the nyanja word "Chipakisha," meaning to endure, and said that when women are married here, they're told they're now part of the "Chipakisha club."  Their job is to endure their husband's faults and infidelities, they're told.  While I can imagine someone telling a woman that in the fifties in the states, it certainly seems less than ideal today.  Another friend, who was cheated on multiple times, also told me that she no longer wanted to date a Zambian man because of how large a problem cheating posed, and that she was sure men in America cheated much less.  It's not that people don't form committed, long-term relationships--far from it.  It's just that many do seem to have relationships on the side.  Often, these side relationships are themselves committed, which poses a double problem: 1) It meets the criteria for concurrency, given that non-monogamous sex is not just a one-time occurrence, but often an ongoing relationship and 2) This element of commitment means that many people won't consider using condoms because their partners are long-term.  Bingo, HIV transmission. 

On the other hand, I wonder where exactly all these serially monogamous Americans that seem to be the comparison point are.  Many of my friends are in long-term committed relationships, and most wouldn't consider cheating, but those that haven't found "the one" yet tend to sleep with many different ones, on many different nights.  Perhaps if we're using our parents' generation as a point of comparison, we'd believe East African sexual mores result in more total high-risk unprotected sex, but certainly with the emergency of hookup culture, I believe that today, Americans on average probably start having sex younger and may have more partners over their lifetimes than East Africans.

So is it really that random instances of unprotected sex are less risky than concurrent partnerships?  Can that explain the divide?  And if sexual mores do play a role in higher rates of HIV transmission what do you do about it?  Helen Epstein's book "The Invisible Cure" advances the hypothesis (note, I have only read about it--not actually read it) that a "monogamy campaign" was largely responsible for the late nineties drop in HIV rates in Uganda.  In fact, she seems to hypothesize that stressing monogamy is more important than even condom usage.  But, that's not something I'm necessarily comfortable with.  It seems to me that changing who people have sex with, and how often, is more difficult and intrusive than changing what kind of protection they use.  Nonetheless, Pascaline Dupas' work on relative risks showed that informing Kenyan schoolgirls that older lovers were more likely to be HIV positive than boys their own age resulted in a decline in risky sex.  Could concurrency be a similar story?

Personally, I'd rather focus on condoms and female empowerment, and let cultures shape themselves.  Nonetheless, given the devastation of HIV in East Africa, it's something we may not be able to afford to ignore.

ETA: I generally get pretty defensive when people bring sexual mores up as a possible explanation of HIV rates, because often their suggestions are tinged with racism.   Before this last trip to Zambia, I probably wouldn't have been willing to engage in a discussion about it, or write this post.  But after being told by multiple Zambians that the sex lives of committed Zambians seem different to them than in other places, I thought it was worth at least bringing up the discussion.  I should also add that it's not that cheating isn't looked down upon or thought to be a sin, it's just that some people also seem to accept it as an inevitability.  Thoughts?