Partner reduction in the developed world

In the developed world, far from the number of partners being reduced amongst the general population, the trend in the 1990s was the opposite. Several factors have worked against reductions in the number of partners and ‘faithfulness’. The increasing sexualisation of popular culture has gone hand in hand with increasing opportunities to access non-marital sex, for example via the internet. Moreover, increasing numbers of men and women have had same-sex partnerships.

The early 1990s may also have been an exceptional period with historically low points of sexual risk behaviour (as the data on STIs suggest), in that they coincided with the peak of public concerns about what was then an untreatable AIDS epidemic.

For instance, in the UK, comparing the 1990 and 2000 National Surveys of Sexual Attitudes and Lifestyles (NATSALs),¹ the average number of lifetime sexual partners increased from 8.6 to 12.7 in men and from 3.7 to 6.5 in women, with a particularly sharp increase in the proportion of women reporting more than five lifetime partners, and an equally sharp decrease in the number reporting that they had only had one.

In the US, matters may be somewhat different, at least among young people. The percentage of high school students who reported having had four or more sexual partners declined in recent years from 19% in 1991 to 14% in 2005, male students from 23.5 to 17% and females from 15 to 12%.²

However, monogamy or partner reduction, in themselves (as opposed to abstinence till marriage), have not usually been targets of HIV prevention campaigns in the developed world.

What about vulnerable populations in the developed world? There is evidence from the early days of the epidemic that gay men rapidly adjusted their sexual behaviour as soon as the first reports of AIDS appeared. Rates of STIs and HIV incidence started falling almost immediately, particularly among the more socially cohesive white gay community.

A paper discussing these changes and comparing them with what happened in Uganda contains the chart below.³  This chart shows declines in STI diagnoses. At the time, the most frequently-diagnosed STI was gonorrhoea, which is a very good ‘surrogate marker’ of unsafe sex and almost certainly documents rapid and relevant behaviour change. However, that behaviour change could be condom adoption, having fewer partners, or abstinence from sex.

The authors comment that: “These responses preceded and exceeded HIV prevention.” Another way of looking at it, using a broader definition of prevention, is that they were the first examples of community-led HIV prevention. A chain of ‘grapevine knowledge’ spread by word of mouth through a closely-knit community.

Exactly the same thing, according to the authors of the paper, happened in Uganda slightly later, in the late 1980s, around the time of the ‘Zero Grazing’ campaign.

According to this paper, “Ugandans [were] relatively more likely to receive AIDS information through friendship and other personal networks than through mass media or other sources, and significantly more likely to know of a friend or relative with AIDS. Social communication elements, as suggested by these kinds of indicators, may be necessary to bridge the motivational gap between AIDS prevention activities and behavior change sufficient to affect HIV incidence.”

In other words, the researchers are arguing that the Ugandan experience is an example of social diffusion (see the social diffusion model in Behaviour change). This requires two conditions to be met for positive change to happen in the direction of reducing HIV risk and incidence:

• A wide personal acquaintance with HIV/AIDS in the population
• The encouragement and willingness to speak about it and pass knowledge on in informal social networks.

The first is the inevitable consequence of a developing untreated epidemic; the second, however, can be influenced by political leadership and widespread awareness-raising work. Such work was, supporters say, initiated by Museveni when he started his AIDS awareness campaign in 1986, which included the ‘Zero Grazing’ policy that urged monogamy on all Ugandans.