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Who infects whom? Migration and the HIV epidemic in South Africa
Mark Lurie
2004-09-01

High rates of population movement fuel the spread of HIV in Southern Africa. Urban migrants returning home to their rural communities can help drive the epidemic.

However, is this migration pattern the main cause of the spread of infection within rural communities? The South African Medical Research Council investigated this issue in Hlabisa, a rural district of KwaZulu/Natal.

The most common migration pattern is for men to move on their own to urban centres in search of work, leaving partners and families in rural areas. It is usually assumed that men become HIV-positive while away from home and infect their rural partners when they return. But is this true in the context of South Africa's mature epidemic?

The researchers looked at HIV rates among 98 migrant and 70 non-migrant couples in the district, where 62% of adult men spend most nights away. They found that

* One in five adults is HIV-positive - 24.4% of men and 15.5% of women.

* HIV infection is more common in younger couples, those with an earlier sexual debut and couples where one partner has had a sexually transmitted infection (STI) in the last four months.

* In 70% of couples, neither partner is infected, whereas both are HIV-positive in 9%. In one fifth of couples, only one partner is infected. The man is the infected partner in 71.4% of these 'discordant' couples.

* Migrant couples are more likely than non-migrant couples to have one or both partners infected and to be HIV discordant.

* The researchers used data to develop a mathematical model to estimate the relative risk of becoming infected from inside compared to outside a regular relationship and found that:

* Migrant men are 26 times more likely to be infected from outside their regular relationships than from within. The figure for non-migrant men is 10%.

* Women are also more likely to be infected from outside their relationship than they are by their husband, whether or not he is a migrant.

These results show that migration is a risk factor for the spread of HIV not just because men return home and infect their rural partners.

Women - whether partners of migrants or non-migrants - are actually more likely to become infected from outside their primary relationships. But women with absent husbands more commonly have additional sexual partners, which puts them at higher risk.

Migrant men are clearly at high risk of infection and need their own targeted interventions. But programmes are also needed in rural areas. There should be a specific focus on situations in which one partner is already infected in order to protect the uninfected partner. Strategies could include:

* couple counselling

* more aggressive STI treatment

* antiretroviral therapy for HIV-infected partners

* education messages aimed at couples

* development of more family-friendly housing near the mines

* rural development, including better economic opportunities, that would allow men not to have to migrate.

Contributor(s): Mark Lurie

Source(s):

Who infects whom? HIV-1 concordance and discordance among migrant and non-migrant couples in South Africa', AIDS 17: 2245-2252, by M. Lurie et al, 2003

Funded by: Wellcome Trust South African Medical Research Council National Institutes of Health (National Institute of Drug Abuse Fogarty International Center National Institute of Mental Health) (Source: http://www.id21.org/getweb/h5ml1g1.html)

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