Why do some South African ethnic groups have very high HIV rates and others not?

Abstract

The differences in HIV prevalence between South Africa's racial/ethnic groups (19.9%, 3.2%, and 0.5% among 15-49-year-old blacks, coloureds and whites, respectively) are as big as those between the countries with the highest and lowest levels of HIV prevalence worldwide. These large racial/ethnic differences are largely determined by different sexual network structures. In networks among black South Africans, sexual partnerships are more likely to be arranged concurrently - a configuration that leads to exponential increases in the spread of HIV. An examination of the historical origins of polygamy (where it is normative for partnerships to be arranged concurrently) and monogamy (serial or lifetime) reveals that it is the practice of universal monogamy in stratified societies which is the outlier. The ideology and practice of universal monogamy originated in Europe as the result of several factors, most prominently conflicts between the Christian Church and the nobility. After its imposition in Europe, the European colonial project would see this ideology disseminated around the world. Under the influence of liberalism it would mutate into a secular and unacknowledged value-programme of monogamy as a universal norm. This value-programme and practice of monogamy (mostly serial) is still the norm for white South Africans; thus, this sexual behaviour 'spandrel' (by-product of other historical processes) is a large contributor to the lower levels of HIV prevalence among whites. In pre-colonial African societies, polygyny was normative, and the Christian value-programme of monogamy never achieved the hegemonic status it did in Europe and other areas of conquest. Married black African men who converted to Christianity were no less likely to have additional sexual partners, but only more likely to conceal them. The ongoing secrecy about having concurrent partners has contributed to the connectedness of sexual networks among black Africans at large and in this manner has contributed to the rapid spread of HIV.

Could differences in implicit attitudes to sexual concurrency play a role in generalized HIV epidemics?

“…Historical and anthropological analyses suggest that the shift from polygamy to monogamy in Southern Africa over the last 150 years did not reduce the number of partners men had. Non-marital and non-main partnerships were however driven underground 4 , 6 , 8 , 30 . This created the norm which - although heavily contested - maintains that it is acceptable for men to have ‘kwapeni’s’ (secret lovers) as long as their main partner does not find out 5 – 7 .…”

Strong associations between national prevalence of various STIs suggests sexual network connectivity is a common underpinning risk factor

“…Markers of network connectivity, such as sexual partner concurrency, have been found to be positively correlated with the prevalences of HIV [ 6 ], HSV-2 [ 63 ], BV [ 64 ], syphilis [ 65 ] and trichomoniasis [ 61 ]. Furthermore, historical studies from South Africa suggest that differential network connectivity by ethnic group could explain the differences in syphilis prevalence since the 1930s [ 33 , 66 , 67 ].…”

Correlation between National Peak HIV Prevalence and Concurrency, STI Treatment Capability, Condom Use and Circumcision: An Ecological Study

“…(1989/90) is a useful sampling time as this precedes the peak HIV prevalence of all the affected countries [1]. In addition, various lines of evidence suggest that the prevalence of concurrency in this region have persisted at these high levels for some time [35] [36].…”