James D Shelton a
The Lancet 2007; 370:1809-1811. DOI:10.1016/S0140-6736(07)61755-3
Despite substantial progress against AIDS worldwide, we are still
losing ground. The number of new infections continues to dwarf the
numbers who start antiretroviral therapy in developing countries.1,2
Most infections occur in widespread or generalised epidemics in
heterosexuals in just a few countries in southern and eastern Africa.
Although HIV incidence has fallen in Uganda, Kenya, and Zimbabwe, the
generalised epidemic rages on. Something is not working. Ten
misconceptions impede prevention.
HIV spreads like wildfire—Typically it does not. HIV is very
infectious in the first weeks when virus levels are high,3 but not in
the subsequent many-year quiescent phase. Only about 8% of people
whose primary heterosexual partners have the virus become infected
each year.4 Thus Kenya has more couples in which only one person is
infected than couples in which both are (figure).5 This low
infectiousness in heterosexual relationships partly explains why HIV
has spared most of the world's populations. However, the exceptional
generalised epidemics in Africa seem largely driven by concurrent
partnerships, in which some people have more than one regular
partner. This pattern allows rapid dissemination when a new infection
is introduced6 and probably involves more frequent risky sex than in
sporadic or exclusive relationships.
Sex work is the problem—Formal sex work is uncommon in these
generalised epidemics. In Lesotho, fewer than 2% of men reported
paying for sex in the previous year, although 29% reported multiple
partners.7 Nuanced economic support is an important enabler of
regular concurrent partnerships and transactional sex, but the
targeting of sex work in prevention campaigns has limited usefulness.
Men are the problem—The behaviour of men, including cross-
generational and coercive sex, contributes substantially to the
establishment of generalised epidemics. But a heterosexual epidemic
requires some women to have multiple partners.3 The importance of
women in generalised epidemics is evidenced by the high proportion
(sometimes the majority) of discordant couples in which the woman,
not the man, is HIV positive (figure).5
Adolescents are the problem—Generalised epidemics span all
reproductive ages. Although adolescent women are affected through sex
with older men, HIV incidence increases in women in their 20s and
later in life.8 Men are infected at even older ages. Thus
interventions in young people, including abstinence, although
important, have limited usefulness.
Poverty and discrimination are the problem—These factors can surely
engender risky sex. But HIV is paradoxically more common in wealthier
people than in poorer people, perhaps because wealth and mobility
support concurrent sexual partnerships.9 Moreover, HIV has declined
without major improvements in poverty and discrimination, notably in
Zimbabwe (notwithstanding substantial economic and social distress).
Condoms are the answer—Condom use, especially by sex workers, is
crucial to the containment of concentrated epidemics, and condoms
help to protect some individuals. But condoms alone have limited
impact in generalised epidemics. Many people dislike using them
(especially in regular relationships), protection is imperfect, use
is often irregular, and condoms seem to foster disinhibition, in
which people engage in risky sex either with condoms or with the
intention of using condoms.8
HIV testing is the answer—That learning one's HIV status (hopefully
with counselling) should lead to behavioural change and reduced risk
seems intuitive. However, real-world evidence of such change is
discouraging, especially for the large majority who test negative.3
Moreover any changes must be sustained for years. And very newly
infected people, who are highly infectious, do not yet test HIV-
positive.
Treatment is the answer—Theoretically, treatment and counselling
might aid prevention by lowering viral levels (and infectiousness) in
those treated, reducing denial about HIV, and promoting behavioural
change. However, no clear effect has emerged. Indeed these salutary
effects might be outweighed by negative effects, such as resumption
of sexual activity once those on antiretrovirals feel well, and
disinhibition when people realise that HIV might no longer be a death
sentence.
New technology is the answer—Many resources are devoted to vaccines,
microbicides, and prophylactic antiretrovirals. Unfortunately any
success appears to be far off. Moreover, such innovations might be
mainly targeted only at very high-risk populations, rely on
behavioural compliance, and engender disinhibition.10 Similarly,
treatment of sexually transmitted infections to prevent HIV has been
disappointing.11 Even male circumcision, an already available,
unmistakably effective, and compelling priority will take years to
have additional substantial effect.
Sexual behaviour will not change—Actually, facing the prospect of
deadly illness, many people will change. Homosexual men in the USA
radically changed behaviour in the 1980s. And the reductions in HIV
incidence in Kenya and eastern Zimbabwe were accompanied by large
drops in multiple partners,8,12 probably largely as a spontaneous
reaction to fear.
Truthfully, our priority must be on the key driver of generalised
epidemics—concurrent partnerships. Although many people sense that
multiple partners are risky, they do not realise the particular risk
of concurrent partnerships. Indeed, technical appreciation of their
role is recent.6 But partner limitation has also been neglected
because of the culture wars between advocates of condoms and
advocates of abstinence, because it smacks of moralising, because
mass behavioural change is alien to most medical professionals, and
because of the competing priorities of HIV programmes.
Fortunately we can enhance partner-limitation behaviour, akin to the
behaviour change that many people have adopted spontaneously. State-
of-the-art behaviour-change techniques, including explicit messages,
that are sensitive to local cultures, can raise perception of
personalised risk. Even modest reductions in concurrent partnerships
could substantially dampen the epidemic dynamic. Other prevention
approaches also have merit, but they can be much more effective in
conjunction with partner-limitation. Now, more than 20 years into HIV
prevention, we have to get it right.
I thank Daniel Halperin and Willard Cates for helpful ideas on this
Comment. My views here are not necessarily those of USAID. I declare
that I have no conflict of interest.
References
1. UNAIDS, WHO. AIDS epidemic update. December, 2007:
http://data.unaids.org/pub/EPISlides/2007/2007_epiupdat...
(accessed Nov 21, 2007)..
2. World Health Organization, UNAIDS, UNICEF. Towards universal
access: scaling up priority HIV/AIDS interventions in the health
sector. Progress report, April 2007. April 17, 2007:
http://www.who.int/hiv/mediacentre/univeral_access_prog...
(accessed Nov 21, 2007)..
3. Cassell MM, Surdo A. Testing the limits of case finding for HIV
prevention. Lancet Infect Dis 2007; 7: 491-495.
4. Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1
transmission per coital act by stage of HIV-1 infection, in Rakai,
Uganda. J Infect Dis 2005; 191: 1403-1409.
5. Central Bureau of Statistics, Ministry of Health Kenya, Kenya
Medical Research Institute, Centers for Disease Control and
Prevention Kenya, ORC Macro. Kenya demographic and health survey
2003. 2004:
http://www.measuredhs.com/pubs/pub_details.cfm?ID=462&c...
(accessed Nov 21, 2007)..
6. Halperin D, Epstein H. Concurrent sexual partnerships help to
explain Africa's high level of HIV prevalence: implications for
Pevention. Lancet 2004; 364: 4-6.
7. Ministry of Health and Social Welfare Lesotho, Bureau of
Statistics Lesotho, ORC Macro. Lesotho demographic and health survey
2004. 2005:
http://www.measuredhs.com/aboutsurveys/search/metadata....
(accessed Nov 21, 2007).
8. Shelton JD. Confessions of a condom lover. Lancet 2006; 368: 1947-
1949.
9. Shelton JD, Cassell MM, Adetunji J. Is poverty or wealth at the
root of HIV?. Lancet 2005; 366: 1057-1058.
10. Imrie J, Elford J, Kippax S, Hart G. Biomedical HIV prevention—
and social science. Lancet 2007; 370: 10-11.
11. Gray RH, Wawer MJ. Randomized trials of HIV prevention. Lancet
2007; 370: 200-201.
12. Gregson S, Garnett GP, Nyamukapa CA, et al. HIV decline
associated with behavior change in eastern Zimbabwe. Science 2006;
311: 664-666.
Affiliations
a. Bureau for Global Health, US Agency for International Development,
Washington, DC 20523, USA
Saturday 29 December 2007
Saturday 8 December 2007
Post-exposure HIV drugs won't boost risky behavior
Fri Nov 23, 2007 12:11pm EST
By Anne Harding
NEW YORK (Reuters Health) - Giving antiretroviral drugs to people after they may have been exposed to HIV is an effective way to prevent them from contracting the virus, a new study shows.
What's more, people who know this option is available to them don't appear to be more likely to engage in risky behavior, Dr. Steve Shoptaw of the UCLA Department of Family Medicine in Los Angeles, who was involved in the research, told Reuters Health. "This is a viable way of helping people stay (HIV)-negative, " he said.
So-called post-exposure prophylaxis, or PEP, has long been available to people who risk HIV infection on the job, for example a health care worker accidentally jabbed by a contaminated syringe. In 2005, the Centers for Disease Control and Prevention expanded its PEP guidelines to cover people exposed to HIV outside the workplace, for example through risky sex, condom breakage or drug use. But PEP still isn't widely used in such cases, Shoptaw and his team note, because it isn't covered by health insurance and is only very rarely offered as part of community health programs.
To investigate the feasibility of a community organized and funded non-occupational PEP program, the researchers conducted a demonstration project in which people were offered a 28-day course of anti-HIV drugs within 72 hours of potential exposure to HIV.
One hundred people, 95 of them men, participated. They received the drug treatment, HIV testing, and counseling for up to 26 weeks after enrolling in the study. Fifty-eight participants reported having unprotected anal sex, while 18 percent reported condom breakage.
Among the 84 people given the full course of medication, 75 percent actually took all the drugs. No one became HIV-positive during the course of the study.
Some health authorities have been reluctant to offer PEP after risky sex or drug use for fear that people wouldn't change their behavior if they knew "there's a parachute somewhere they can take to stay negative," Shoptaw noted. However, he and his colleagues found people reduced their risk behavior after using PEP, rather than increasing it.
He and his colleagues call for making non-occupational PEP programs more widely available to people at high risk of becoming infected with HIV. For now, Shoptaw noted, PEP is available only to people who can access it and pay for it out of pocket -- drugs and counseling together cost about $2,200.
Right now, "this is more of a social justice issue," Shoptaw said. "People who have means have access to this, people who don't, don't."
SOURCE: AIDS Care, published online October 24, 2007.
© Reuters 2006. All rights reserved.
By Anne Harding
NEW YORK (Reuters Health) - Giving antiretroviral drugs to people after they may have been exposed to HIV is an effective way to prevent them from contracting the virus, a new study shows.
What's more, people who know this option is available to them don't appear to be more likely to engage in risky behavior, Dr. Steve Shoptaw of the UCLA Department of Family Medicine in Los Angeles, who was involved in the research, told Reuters Health. "This is a viable way of helping people stay (HIV)-negative, " he said.
So-called post-exposure prophylaxis, or PEP, has long been available to people who risk HIV infection on the job, for example a health care worker accidentally jabbed by a contaminated syringe. In 2005, the Centers for Disease Control and Prevention expanded its PEP guidelines to cover people exposed to HIV outside the workplace, for example through risky sex, condom breakage or drug use. But PEP still isn't widely used in such cases, Shoptaw and his team note, because it isn't covered by health insurance and is only very rarely offered as part of community health programs.
To investigate the feasibility of a community organized and funded non-occupational PEP program, the researchers conducted a demonstration project in which people were offered a 28-day course of anti-HIV drugs within 72 hours of potential exposure to HIV.
One hundred people, 95 of them men, participated. They received the drug treatment, HIV testing, and counseling for up to 26 weeks after enrolling in the study. Fifty-eight participants reported having unprotected anal sex, while 18 percent reported condom breakage.
Among the 84 people given the full course of medication, 75 percent actually took all the drugs. No one became HIV-positive during the course of the study.
Some health authorities have been reluctant to offer PEP after risky sex or drug use for fear that people wouldn't change their behavior if they knew "there's a parachute somewhere they can take to stay negative," Shoptaw noted. However, he and his colleagues found people reduced their risk behavior after using PEP, rather than increasing it.
He and his colleagues call for making non-occupational PEP programs more widely available to people at high risk of becoming infected with HIV. For now, Shoptaw noted, PEP is available only to people who can access it and pay for it out of pocket -- drugs and counseling together cost about $2,200.
Right now, "this is more of a social justice issue," Shoptaw said. "People who have means have access to this, people who don't, don't."
SOURCE: AIDS Care, published online October 24, 2007.
© Reuters 2006. All rights reserved.
Deputy governor unwavering on plan to legalize prostitution
Friday, November 23, 2007
Prodita Sabarini, The Jakarta Post, Denpasar
Bali Deputy Governor Alit Kesuma Kelakan has said he will push ahead
with plans to recognize and provide support to prostitutes in an attempt
to halt the spread of HIV/AIDS on the island, despite objections from
Governor Dewa Made Beratha.
Kelakan's plan involves declaring known prostitution zones safe from
persecution in order to encourage the women to access health services.
"Approved or not, I will go ahead with the program," Kelakan said.
Kelakan, who is chairman of the Bali chapter of the National AIDS
Commission (KPAD Bali), said he believed such policy a would enable
health-related agencies to better identify and reach HIV/AIDS high-risk
groups to curb the spread of the virus through sexual contact.
KPAD Bali data show that more than half of the island's HIV/AIDS
patients were infected with the virus through sexual contact.
According to the Kerti Praja Foundation, an organization working on
HIV/AIDS prevention in the island, Bali has around 8,800 sex workers
with a customer base of around 85,000.
Research by the foundation in 2006 also found that 14 percent of sex
workers in Bali are infected with the virus.
In a plenary meeting with the Bali Regional Legislative Council earlier
this month, Beratha firmly rejected Kelakan's proposal. He said that the
policy of acknowledging and accepting the prostitution areas would
suggest that the practice of prostitution has been legalized.
He said this was clearly in opposition to Bali's religious teachings,
customs and culture.
The Indonesian Criminal Code states that prostitution is illegal.
However, commercial sex workers are common in tourist areas of Bali such
as Sanur and Kuta.
Kelakan has said that law enforcement has been ineffective in stopping
the practice, which stems from more complex issues of poverty, poor
education and unemployment.
He policy suggestion has also met with resistance from legislators and
the Indonesian Hindu Council. The Council of Customary Villages
initially objected to the plan but later accepted it.
Kelakan said that KPAD Bali will carry out strict supervision programs
at known prostitution areas in a number of regencies, including the
regular monitoring of sex workers' health.
"KPAD and other non-governmental organizations have already carried out
campaign programs for sex workers, so without the government
implementing the program in its budget, KPAD's and the NGOs' programs
would still go on. However, it would only be partial (in its coverage
and impact). It would not be a systemized program and would certainly
not be a sustainable one. What we need is a sustainable program
supported by the government," he said.
Kelakan said that positive developments had been seen in Badung regency,
where the government and local council there were deliberating a bill on
HIV/AIDS prevention that would make it mandatory for owners of
entertainment places to educate their employees on HIV/AIDS and to
routinely check their employees' health status in relation to sexually
transmitted disease.
KPAD has estimated that the number of people living with HIV/AIDS on the
island exceed 4,000 as of August this year.
Head of Kerti Praja Nyoman Wirawan gave the "very conservative"
estimation that 840 men in Bali will contract the virus this year
through sexual contact with HIV-positive sex workers, with the
assumption that there are only 3,000 sex workers in Bali, with one
customer per day, working 250 days per year.
The estimate doesn't account for other potential infected people, such
as the sexual partners of customers and the babies of pregnant
HIV-positive- mothers.
"Imagine Bali in 10 to 20 years. If we don't do anything there will be a
lost generation of Balinese due to HIV/AIDS. The government is nothing
but a hypocrite if it does not try to do anything about this," he said.
Prodita Sabarini, The Jakarta Post, Denpasar
Bali Deputy Governor Alit Kesuma Kelakan has said he will push ahead
with plans to recognize and provide support to prostitutes in an attempt
to halt the spread of HIV/AIDS on the island, despite objections from
Governor Dewa Made Beratha.
Kelakan's plan involves declaring known prostitution zones safe from
persecution in order to encourage the women to access health services.
"Approved or not, I will go ahead with the program," Kelakan said.
Kelakan, who is chairman of the Bali chapter of the National AIDS
Commission (KPAD Bali), said he believed such policy a would enable
health-related agencies to better identify and reach HIV/AIDS high-risk
groups to curb the spread of the virus through sexual contact.
KPAD Bali data show that more than half of the island's HIV/AIDS
patients were infected with the virus through sexual contact.
According to the Kerti Praja Foundation, an organization working on
HIV/AIDS prevention in the island, Bali has around 8,800 sex workers
with a customer base of around 85,000.
Research by the foundation in 2006 also found that 14 percent of sex
workers in Bali are infected with the virus.
In a plenary meeting with the Bali Regional Legislative Council earlier
this month, Beratha firmly rejected Kelakan's proposal. He said that the
policy of acknowledging and accepting the prostitution areas would
suggest that the practice of prostitution has been legalized.
He said this was clearly in opposition to Bali's religious teachings,
customs and culture.
The Indonesian Criminal Code states that prostitution is illegal.
However, commercial sex workers are common in tourist areas of Bali such
as Sanur and Kuta.
Kelakan has said that law enforcement has been ineffective in stopping
the practice, which stems from more complex issues of poverty, poor
education and unemployment.
He policy suggestion has also met with resistance from legislators and
the Indonesian Hindu Council. The Council of Customary Villages
initially objected to the plan but later accepted it.
Kelakan said that KPAD Bali will carry out strict supervision programs
at known prostitution areas in a number of regencies, including the
regular monitoring of sex workers' health.
"KPAD and other non-governmental organizations have already carried out
campaign programs for sex workers, so without the government
implementing the program in its budget, KPAD's and the NGOs' programs
would still go on. However, it would only be partial (in its coverage
and impact). It would not be a systemized program and would certainly
not be a sustainable one. What we need is a sustainable program
supported by the government," he said.
Kelakan said that positive developments had been seen in Badung regency,
where the government and local council there were deliberating a bill on
HIV/AIDS prevention that would make it mandatory for owners of
entertainment places to educate their employees on HIV/AIDS and to
routinely check their employees' health status in relation to sexually
transmitted disease.
KPAD has estimated that the number of people living with HIV/AIDS on the
island exceed 4,000 as of August this year.
Head of Kerti Praja Nyoman Wirawan gave the "very conservative"
estimation that 840 men in Bali will contract the virus this year
through sexual contact with HIV-positive sex workers, with the
assumption that there are only 3,000 sex workers in Bali, with one
customer per day, working 250 days per year.
The estimate doesn't account for other potential infected people, such
as the sexual partners of customers and the babies of pregnant
HIV-positive- mothers.
"Imagine Bali in 10 to 20 years. If we don't do anything there will be a
lost generation of Balinese due to HIV/AIDS. The government is nothing
but a hypocrite if it does not try to do anything about this," he said.
Stephen Lewis damns UNAIDS over statistics revision; diverts from the
Rob Dawson, Thursday, November 29, 2007
In a passionate speech at the World Health Editors Network in London,
a former United Nations Special Envoy for AIDS in Africa and
Co-Director of AIDS-Free World, Stephen Lewis, warned that a recent
UNAIDS document reporting decreased HIV infections has "undermined
public confidence in the reliability of the figures, introducing
completely unnecessary levels of doubt, contention and confusion".
Describing the UN as "stubborn and sloppy", he expressed concern that
the report does nothing to convince the world that we are "billions
and billions of dollars behind, when it comes to funding all the
components of the pandemic, from orphans to second line drugs."
In its latest report, UNAIDS cut the number of infections worldwide to
about 32.7 million, down from its estimated 39.5 million in 2006.
Rather than a reduction based on decreased rates of infection, the new
figure was mainly due to fixing flawed statistics from previous reports.
The former data collection methods relied heavily on "sentinel-site
surveillance" which extrapolates data gathered at prenatal clinics.
An assumption was made that the rate of HIV in the general population
would be similar to the rate among pregnant women in urban clinics.
This year the UN attributed more of their calculations to national surveys
and blood-testing.
While it's good news that fewer people are infected than previously
thought, there was concern that the dramatic re-representation of the
figures would result in diverted resources from an epidemic still in
desperate need of funds.
"For years, knowledgeable epidemiologists have been telling the UN
that the figures were too high. They didn't whisper their criticisms:
they wrote books and articles," Lewis said. "But the UN chose a course
of delay and dithering. It can never admit that it's wrong. So finally,
and predictably, came the moment of truth: the result is an overall
prevalence rate that is lower by almost seven million than last year's
estimate."
Lewis also expressed anger that the report did not address the human
tragedy and focused too much on statistics.
"The new estimates confirm a continuing apocalypse for sub-Saharan
Africa: 22.5 million infections, 61% of them women, 68% of world-wide
infections, 76% of all deaths, 11.4 million orphans. This is where the
focus must be, this is where it should always have been; not a report
cluttered by mathematical adjustments so that virtually every story
that's written begins with the news of a statistical volte-face. If the
recording of data had been more scrupulous all along, we could have
welcomed this report," he said. "Instead, all of us have to run to the
trenches to remind the world that more money is still desperately needed."
Lewis also highlighted several flaws in the data which could lead to
yet another recalculation. For example, the narrative evidence of the
report states repeatedly that Mozambique has shown no decrease in
infection rates yet later asserts that Mozambique is one of the six
countries in the world that has most significantly contributed to the
reduced numbers seen in the report. No data on Mozambique is set out
conclusively in the report.
In conclusion, Lewis stressed that more should be done no matter what
statistical calculation is applied to the figures.
"Whether it's 40 million or 33 million, this plague continues to
ravage humankind. I simply do not believe that the United Nations has
done everything it can possibly do to turn the tide," he said.
In a passionate speech at the World Health Editors Network in London,
a former United Nations Special Envoy for AIDS in Africa and
Co-Director of AIDS-Free World, Stephen Lewis, warned that a recent
UNAIDS document reporting decreased HIV infections has "undermined
public confidence in the reliability of the figures, introducing
completely unnecessary levels of doubt, contention and confusion".
Describing the UN as "stubborn and sloppy", he expressed concern that
the report does nothing to convince the world that we are "billions
and billions of dollars behind, when it comes to funding all the
components of the pandemic, from orphans to second line drugs."
In its latest report, UNAIDS cut the number of infections worldwide to
about 32.7 million, down from its estimated 39.5 million in 2006.
Rather than a reduction based on decreased rates of infection, the new
figure was mainly due to fixing flawed statistics from previous reports.
The former data collection methods relied heavily on "sentinel-site
surveillance" which extrapolates data gathered at prenatal clinics.
An assumption was made that the rate of HIV in the general population
would be similar to the rate among pregnant women in urban clinics.
This year the UN attributed more of their calculations to national surveys
and blood-testing.
While it's good news that fewer people are infected than previously
thought, there was concern that the dramatic re-representation of the
figures would result in diverted resources from an epidemic still in
desperate need of funds.
"For years, knowledgeable epidemiologists have been telling the UN
that the figures were too high. They didn't whisper their criticisms:
they wrote books and articles," Lewis said. "But the UN chose a course
of delay and dithering. It can never admit that it's wrong. So finally,
and predictably, came the moment of truth: the result is an overall
prevalence rate that is lower by almost seven million than last year's
estimate."
Lewis also expressed anger that the report did not address the human
tragedy and focused too much on statistics.
"The new estimates confirm a continuing apocalypse for sub-Saharan
Africa: 22.5 million infections, 61% of them women, 68% of world-wide
infections, 76% of all deaths, 11.4 million orphans. This is where the
focus must be, this is where it should always have been; not a report
cluttered by mathematical adjustments so that virtually every story
that's written begins with the news of a statistical volte-face. If the
recording of data had been more scrupulous all along, we could have
welcomed this report," he said. "Instead, all of us have to run to the
trenches to remind the world that more money is still desperately needed."
Lewis also highlighted several flaws in the data which could lead to
yet another recalculation. For example, the narrative evidence of the
report states repeatedly that Mozambique has shown no decrease in
infection rates yet later asserts that Mozambique is one of the six
countries in the world that has most significantly contributed to the
reduced numbers seen in the report. No data on Mozambique is set out
conclusively in the report.
In conclusion, Lewis stressed that more should be done no matter what
statistical calculation is applied to the figures.
"Whether it's 40 million or 33 million, this plague continues to
ravage humankind. I simply do not believe that the United Nations has
done everything it can possibly do to turn the tide," he said.
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