KIGALI, 20 June 2007 (IRIN) - It's not cheap motels or the back seats of cars but the marriage bed where the new high-risk sex takes place in Uganda, delegates attending a conference on scaling up AIDS services, held in Kigali, Rwanda, heard this week.

Dr David Apuuli, director-general of the Uganda AIDS Commission, warned that marital sex accounted for 42 percent of new infections as the country's prevalence rate begins to climb after years of stagnation.

AIDS policymakers are now turning their attention to the phenomenon of HIV discordant couples - where one partner is HIV-positive and the other negative. Preventing HIV transmission among these couples, when most are unaware of their status, has become a critical new area of focus.

So, is it the same old story of men bringing home the virus and infecting their partners? Perhaps not, according to provocative new research presented at the conference, organised by the US President's Emergency Plan for AIDS Relief.

Vinod Mishra, director of research at Macro International, a US-based research group, noted that in a considerable proportion of discordant couples it was the female partners who were infected, and a likely source of transmission to their male spouses.

"We found that in a lot of countries, such as Kenya, Cote d'Ivoire and others, more than 60 percent of female partners [in discordant couples] are HIV-positive, which is totally not recognised in the AIDS prevention community," Mishra told IRIN/PlusNews.

Existing prevention campaigns usually targeted men, identifying them as the link between high-risk behaviour and high-risk groups, but neglected the vulnerability of male HIV-negative partners in discordant relationships, he added.

The study used demographic and health surveys from 12 countries in sub-Saharan Africa, including Burkina Faso, Ghana, Malawi, Uganda and Zimbabwe, to examine patterns of serodiscordant couples, and also tried to look for possible explanations to this "apparent anomaly".

"From what we see in this data there is clear evidence that a substantial proportion of these women are getting infected within marriage, from a source other than their spouse," Mishra said.

A "major plausible" reason, he noted, was that married women were having more extramarital sex than was generally acknowledged or reported.

This did not go down well with most of the conference participants attending the session, who erupted in uncomfortable laughter. Nor is it likely to be well received anywhere else; the idea of infidelity among married females is inconsistent with prevailing models of epidemic progression and with women's sexual behaviour as reported in surveys.

Playing the blame game?

Mishra warned that by ignoring the risk of female partners transmitting the HI virus to their spouses there was a danger of not addressing a "very substantial proportion of the HIV epidemic".

"It's not about laying the blame, it's about saving lives; it's about preventing future infections within marriage, and marriage is ... the primary route of the epidemic, and the primary source of new infections in many of these countries now," he said.

Women are biologically more prone to infection than men, and a higher prevalence of other sexually transmitted infections can make women more vulnerable to HIV infection.

In addition, some men and women are already infected before entering the marriage, either from a premarital casual partner or a previous spouse.

Lynde Francis, director of The Centre, an NGO for HIV-positive Zimbabweans, stressed that with large numbers of younger women forced into intergenerational relationships, taking a sugar-daddy for economic survival, this could be the primary route of infections, rather than extramarital sex.

Mishra acknowledged that while there were women who were already HIV-positive before marriage, this did not account for such a substantial proportion of female infections in discordant couples.

Could it be non-sexual transmission? "Is it that women are more likely using unsafe medical injections? Could it be that? Is it because women are exposed to unsafe health practices during delivery or childbirth? We do not find any correlations to support this hypothesis," he stated.

Rebecca Bunnell, of the US Center for Disease Control and Prevention (CDC) in Kenya, called for more research before any conclusions were reached, and suggested that the rates of infection in young women, which were three to 10 times higher than those of men, still needed to be fully accounted for.

"We really need to look at the data objectively, without making it a gender issue, without making it a blame game," Mishra said. "[Let's] see the data and see how best to design the programmes."

kn/oa/he

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