Speeding HIV's Deadly Spread

Faruk Maunge, 36, a high school counselor in Francistown, Botswana, points out one of several friends who died of complications from AIDS.
Faruk Maunge, 36, a high school counselor in Francistown, Botswana, points out one of several friends who died of complications from AIDS. (By Craig Timberg -- The Washington Post)
By Craig Timberg
Washington Post Foreign Service
Friday, March 2, 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?"

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 last March, 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 infiltration 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 recalled stepping past broken bottles and used condoms as she arrived on campus each Monday morning. "If you just say, 'Use the condom' . . . we will never see the daylight of the virus leaving us."

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