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."A Lethal Mix of Causes
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 largess 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.
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, speaking from suburban Boston. "There's no place in the world where you have very high HIV and you don't have those two factors."No Word for 'Fidelity'
From under the broad thatched roof of Francistown's Customary Court, which handles minor crimes and misconduct, Chief Judge Ludo Margaret Mosojane had long suspected that the city's torrent of AIDS deaths flowed from its sexual culture. Each year brought more cases resulting from elaborate, overlapping relationships, she said.
"It explains why Africa is hardest hit" by AIDS, Mosojane said. "The way we contract for sex is different from how others do it."
Polygamy once was common in the region, and in some parts still is; Swaziland's king has 13 wives. In generations past, even Batswana with just one spouse rarely expected monogamy. Husbands spent months herding cattle while their wives, staying elsewhere, tended crops, Mosojane said. On his return, a husband was not to be quizzed about his activities while he was away. He also was supposed to spend his first night back in an uncle's house, giving his wife time to send off boyfriends.
In Setswana, the national language, "the word 'fidelity' does not even exist," Mosojane said.
The few checks that traditional villages had on sexual behavior dwindled during the development frenzy after 1967, when diamonds were discovered. Batswana increasingly moved to cities for school or work. Plentiful television sets delivered a flood of Western images, including racy soap operas and music videos featuring lightly clad women vying for the attention of wealthy, bejeweled men.
Francistown, with nearby mines, military camps and border posts overflowing with desperate refugees, changed faster than most cities. Amid the bustling malls, there was soon an unsettling concentration of young adults because so many people ages 35 to 50 had already died of AIDS complications, residents say.
Faruk Maunge, 36, a high school counselor whose dreadlocks, goatee and rectangular glasses give him a cosmopolitan air, noticed the changes when he returned from stays abroad. "They are just a lost bunch," he said. "They are very, very reckless."
Maunge said that rent, clothing, even cellphone airtime became part of implicit sexual exchanges. Men and women maintained two, three, even four regular partners. The toll was clear from the snapshots he kept in a green plastic first-aid box.
"This one is gone," Maunge said, pointing to a faded picture of a woman in a red top who was nibbling her fingernails. Moving deeper into the pile, he continued: "This one is gone, Mooketsi. And this one is gone, Themba. This one is gone, too, this one on the far left. This one is positive."
With a hint of frustration, Maunge said of one man, "He's sleeping around again." Maunge also grew irritated at a picture showing a friend with AIDS who seemed to father a child -- he was awaiting his fourth -- with every girlfriend.
Maunge said he once was reckless, too, having sex with three women in a week, sometimes without condoms. But after watching the disease kill more than 20 of his friends, he settled down with a new girlfriend and stayed faithful, he said.
"Praise God, I've been lucky," Maunge said. "It's like you have 10 bullets going through you and none hits you."The Missing Message
On a hospital wall here, not far from the AIDS clinic that Khumalo visited with his friend, the painted image of a condom shimmers like a comic-book superhero. Giant, colorful block letters declare, "CONDOMISE AND STAY ALIVE!!"
In cramped black script below, it adds, "Abstain first."
Yet rarely seen among Botswana's AIDS prevention messages is one that has worked in other African countries: Multiple sex partners kill. Dubbed "Zero Grazing" by Ugandan President Yoweri Museveni, this approach dominated in East Africa, where several countries curbed HIV rates.
Fidelity campaigns never caught on in Botswana. Instead, the country focused on remedies favored by Western AIDS experts schooled in the epidemics of America's gay community or Thailand's brothels, where condom use became so routine it slowed the spread of HIV.
These experts brought not just ideas but money, and soon billboards in Botswana touted condoms. Schoolchildren sang about them. Cadres of young women demonstrated how to roll them on. The anti-AIDS partnership between the Bill & Melinda Gates Foundation and drugmaker Merck budgeted $13.5 million for condom promotion -- 25 times the amount dedicated to curbing dangerous sexual behavior.
But soaring rates of condom use have not brought down high HIV rates. Instead, they rose together, until both were among the highest in Africa.
The focus on condoms endured even after the arrival of internationally heralded "ABC" programs, named for their prescription of "Abstain, Be Faithful and Condomize." The middle concept -- fidelity -- often got lost.
The few posters advocating it in Francistown are old and torn; ads for condoms and abstinence are far more prominent. A 2004 government study measured the result: Three-quarters of Batswana surveyed knew that condoms could stop the spread of HIV. Half knew that abstinence would. Yet only one in five knew that fidelity to a single, uninfected partner prevented spreading the disease.