In Botswana, unsafe sex couples with AIDS
By Craig Timberg: The Washington Post
March 18, 2007

  FRANCISTOWN, Botswana — The young and hip at ground zero of the AIDS epidemic meet, drink and pair off under the knowing gaze of bartender Brian Khumalo. Sometimes they first buy a three-pack of condoms from the box he keeps by the liquor, sometimes not.
  Night after night they return for the carefree, beery vibe, with the same partners or new ones, creating a web of sexual interaction. A growing number of studies single out such behavior — in which men and women maintain two or more ongoing relationships — as the most powerful force propelling a killer disease through a vulnerable continent.
  This new understanding of how the AIDS virus attacks individuals and their societies helps explain why the disease has devastated southern Africa while sparing other places. It also suggests how the region's AIDS programs, which have struggled to prevent new infections even as treatment for the disease has become more widely available, might save far more lives: by discouraging sexual networks.
  "The problem of multiple partners who do not practice safe sex is obviously the biggest driver of HIV in the world," said Ndwapi Ndwapi, a top government AIDS official in Botswana, speaking in Gaborone, the capital. "What I need to know from the scientific community is, What do you do? ... How do you change that for a society that happens to have higher rates of multiple sexual partners?"
Scared, but not enough
  Khumalo, 25, tall and lanky with a crooked-toothed smile, described the problem succinctly as he pointed to a spiky-haired woman in a corner booth of the bar. "She's new around here, so every guy is going to talk to her," he said. "She will be with me today. Tomorrow she will be with my best friend. And I will be with somebody else."
  Khumalo moved from Gaborone to Francistown a year ago, finding a city of 85,000 with a red-brick downtown, modest concrete homes and an accommodating sexual culture. The first night, he slept with a woman he had just met, he said. He did the same the second night, the third, the fourth.
  Though he used condoms each time, he said, an alarmed friend soon drove him to the white, low-slung buildings of Francistown's biggest AIDS clinic.
  "I saw thousands of beautiful women going to get pills," Khumalo recalled.
It scared him, but not enough. By the end of the year, Khumalo had slept with more than 100 women, he said.
  But the number of sexual partners is not the only factor that increases the risk of AIDS. The most potentially dangerous relationships, researchers say, involve men and women who maintain more than one regular partner for months or years. In these relationships — more intimate, trusting and long-lasting than casual sex — most couples eventually stop using condoms, studies show, allowing easy infection by HIV.
  Researchers increasingly agree that curbing such behavior is key to slowing the spread of AIDS in Africa. In a July report, southern African AIDS experts and officials listed "reducing multiple and concurrent partnerships" as their first priority for preventing the spread of HIV in a region where nearly 15 million people are estimated to carry the virus — 38 percent of the world's total.
  But for many Batswana, as citizens of this landlocked desert country of 1.6 million call themselves, it is a strategy that has rarely been taught.
  "There has never been equal emphasis on 'Don't have many partners,' " said Serara Selelo-Mogwe, a public-health expert and retired nursing professor at the University of Botswana, who says she steps past broken bottles and used condoms as she arrives on campus each Monday morning. "If you just say, 'Use the condom' ... we will never see the daylight of the virus leaving us."
HIV's resilience
  International experts long regarded Botswana as a case study in how to combat AIDS. It had few of the intractable social problems thought to predispose a country to the disease, such as conflict, abject poverty and poor medical care. And for the past decade, the country has rigorously followed strategies that Western experts said would slow AIDS.
  With its diamond wealth and the largesse of international donors, Botswana aggressively promoted condom use while building Africa's best network of HIV testing centers and its most extensive system for distributing the antiretroviral drugs that dramatically prolong and improve the lives of those with AIDS.
  But even though the relentless pace of funerals began to ease in recent years, the disease was far from under control. The national death rate fell from the highest in the world, but only to second-highest, behind AIDS-ravaged Swaziland. Men and women in Botswana continued to contract HIV faster than almost anywhere else on Earth.
  Twenty-five percent of Batswana adults carry the virus, according to a 2004 national study, and among women in their early 30s living in Francistown, the rate is 69 percent.
  Researchers increasingly attribute the resilience of HIV in Botswana — and in southern Africa generally — to the high incidence of multiple sexual relationships. Europeans and Americans often have more partners over their lives, studies show, but sub-Saharan Africans average more at the same time.
  Nearly one in three sexually active men in Botswana reported having multiple, concurrent sex partners, as did 14 percent of women, in a 2003 survey paid for by the U.S. government. Among men younger than 25, the rate was 44 percent.
  The distinction between having several partners in a year and several in a month is crucial because those newly infected with HIV experience an initial surge in viral loads that makes them far more contagious than they will be for years. During the three-week spike — which ends before standard tests can even detect HIV — the virus explodes through networks of unprotected sex.
  This insight explained what studies were documenting: Africans with multiple, concurrent sex partners were more likely to contract HIV, and countries where such partnerships were common had wider and more lethal epidemics.
  A model of multiple sexual relationships presented at a Princeton University conference in May showed that a small increase in the average number of concurrent sexual partners — from 1.68 to 1.86 — had profound effects, connecting sexual networks into a single, massive tangle that, when plotted out, resembles the transportation system of a major city.
Circumcision a factor
  A second key factor helping the virus spread through southern Africa is low rates of circumcision. Before European colonialists arrived, most tribes in the region removed the foreskins of teenage boys during manhood rituals. Those rites, which were discouraged by missionaries and other Westerners who regarded them as primitive, have gradually declined as the region rapidly modernized.
  Dozens of studies, including three experimental trials conducted in Africa in recent years, show that circumcised men are much less likely to contract HIV because the most easily infected cells have been removed.
  These factors, researchers say, explain how North Africa, where Muslim societies require circumcision and strongly discourage sex outside monogamous and polygamous marriages, has largely avoided AIDS. They also explain why the epidemic is far more severe south of the Sahara, where webs of multiple sex partners are more common, researchers say.
  West Africa has been partially protected by its high rates of circumcision, but in southern and eastern Africa — which have both low rates of circumcision and high rates of multiple sex partners — the AIDS epidemic became the most deadly in the world.
  "That's the lethal cocktail," said Harvard University epidemiologist Daniel Halperin, a former AIDS-prevention adviser in Africa for the U.S. government. "There's no place in the world where you have very high HIV and you don't have those two factors."
  Copyright © 2007 The Seattle Times Company