Date Published: March 8, 2016
Publisher: BioMed Central
Author(s): Zakir Gaffoor, Handan Wand, Renée A. Street, Nathlee Abbai, Gita Ramjee.
Women in sub-Saharan Africa continue to be at greater risk for HIV acquisition than men. Concurrency, viz. multiple sexual partnerships that overlap over time, has been studied as a possible risk factor for HIV transmission. The aim of this study was to identify predictors of perceived male partner concurrency among sexually active, HIV negative women.
Socio-demographic and behavioural data from women enrolled in a biomedical HIV prevention clinical trial were assessed in relation to perceived male partner concurrency using the Chi squared test. Univariate and multivariate logistic regression was performed to assess the independent predictors of perceived male partner concurrency. Kaplan–Meier survival estimates were obtained for HIV and STI incidence in relation to male partner concurrency. A Cox Proportional Hazards model was used to assess the association between perceived male partner concurrency and HIV and STI incidence.
The results revealed that 29 % of women reported their male partners to be in concurrent sexual relationships, 22 % reported partners that were not engaging in concurrency, whilst 49 % reported not knowing their partners concurrency status. Older women, having never married, experiencing economic abuse, and women reporting individual concurrency, were found to be significant predictors of perceived male partner concurrency in the studied population. Perceived male partner concurrency was not found to be a significantly associated with incident HIV and STI infections in this analysis.
The study provides insight into predictors of perceived male partner concurrency among women at high risk for STI and HIV acquisition. These results may inform the design of behavioural and biomedical interventions, to address the role of multiple sexual partnerships in HIV prevention.
In 2012, an estimated 35.3 million people were living with HIV/AIDS, with 2.3 million new infections reported globally . The latter figure represents a substantial 33 % decline, when compared to the HIV incidence reported in 2001. Sub-Saharan Africa continues to bear the brunt of the epidemic, accounting for 70 % of all new infections in 2012, with a majority of these occurring in women . A broad range of factors contribute to women in this region being at a greater risk for HIV acquisition when compared to men. These include established gender inequalities, gender-based violence, and lack of access to proven preventative and treatment options, in addition to behavioural and biological risk factors .
Table 1 describes various socio-demographic, biological and behavioural factors that were evaluated for association with steady partner concurrency status. Twenty-nine percent of women reported their steady partners as having at least one other sexual partner besides themselves, whilst 49 % of women reported not knowing if their steady partner had other partners. There were no statistically significant associations between perceived steady partner concurrency status and pregnancy, forced sex, reporting emotional and physical abuse, sex for cash, reporting >3 coital acts in the 2 weeks prior to screening, unprotected oral and anal sex;, and any contraceptive use at screening. Significant associations were noted between perceived male partner concurrency and women’s age, partner age, women’s individual concurrency status, marital status, economic abuse, partner circumcision status, women changing partners during the study, condom use, contraception use and being diagnosed with an STI at screening.
To our knowledge, this is one of the first studies from the Durban region to have investigated predictors of perceived male partner concurrency, among women at risk of HIV and STI acquisition. The effect of social desirability bias when responding to sensitive behavioural interviewer-administered questionnaires likely played a factor in this analysis, and must be taken into account when interpreting these findings. In response to the question about their partner having other sexual partners besides themselves, women may have felt social pressure when responding positively. Nearly 50 % of women did not know if their partner engaged in sexually concurrent partnerships. This finding may be relevant to understanding women’s risk perception for HIV acquisition, and may inform the design of HIV prevention strategies in this region. Further qualitative research is needed to understand the implications of this finding.
Our report had several limitations. Firstly, data were collected from women who presented themselves for screening in an HIV prevention trial. These women were actively recruited based on, among other inclusion criteria, their risk for HIV acquisition. The results may therefore not be generalizable to the local population as a whole. We were not able to measure concurrency per the guidelines recommended by UNAIDS, therefore the prevalence estimate of concurrency may not be strictly comparable to other reports in the field. Furthermore, varying definitions of what constitutes concurrency may also pose a challenge. The behavioural questionnaire used was interviewer-administered, and responses may have been subjected to social desirability bias. Furthermore, only data from the baseline visit with regard to measuring perceived male partner concurrency, were available for analysis. Thus, we were unable to ascertain any change over time, with regard to the outcome variable among women who reported on steady partner concurrency. Given the design of the clinical trial from which this secondary analysis was conducted, the HIV status of male partners were not accurately determined via standard diagnostic techniques at any time point during the study. As a result, it was not possible to determine whether HIV incidence was related to male partner concurrency, or to other risk factors not accounted for. Furthermore, we were unable to measure directly from male partners’, their experiences with concurrency.
A high prevalence of perceived male partner concurrency (29 %) was reported by women in this study. Furthermore, we observed a high percentage of women who didn’t know if their partner engaged in concurrent sexual partnerships (49 %). Older women, never being married, experiencing economic abuse and women reporting individual concurrent sexual partnerships, were found to be significant predictors of perceived male partner concurrency in the studied population. The association between incident HIV and STI infections and perceived male partner concurrency was not found to be statistically significant in this study. A strength of this report is the relatively large sample size, as well as the fact that the study was conducted among a population with some of the highest HIV prevalence rates in the world. Further research is needed that recruits dyad couples, and measures concurrency using data collection methods that may be less subject to social desirability bias. The findings presented here also lend support for further research into behavioural and biomedical interventions that can address the role of multiple partnerships in HIV prevention.