Health-e (Cape Town)
9 May 2008
Top researchers have called for male circumcision and the reduction of multiple sexual partnerships to become the cornerstone of HIV prevention in Africa if a significant impact is to be made on the HIV epidemic.
Policy analysis led by researchers at the Harvard School of Public Health (HSPH) and the University of California, Berkeley, found that the most common HIV prevention strategies - condom promotion, HIV testing, treatment of other sexually transmitted infections (STIs), vaccine and microbicide research, and abstinence are having a limited impact on the predominantly heterosexual epidemics found in Africa.
The researchers also said some of the assumptions underlying such strategies such as poverty or war being major causes of AIDS in Africa are unsupported by rigorous scientific evidence.
"Two interventions currently getting less attention and resources- male circumcision and reducing multiple sexual partnerships - would have a greater impact on the AIDS pandemic and should become the cornerstone of HIV prevention efforts in the high-HIV-prevalence parts of Africa," the researchers argued.
The research paper appears in the journal Science this week.
"Despite relatively large investments in AIDS prevention efforts for some years now, including sizeable spending in some of the most heavily affected countries (such as South Africa and Botswana), its clear that we need to do a better job of reducing the rate of new HIV infections. We need a fairly dramatic shift in priorities, not just a minor tweaking," said Daniel Halperin, lecturer on international health in the HSPH Department of Population and International Health and one of the paper's lead authors.
The AIDS pandemic continues to devastate some populations worldwide.
In most countries, HIV transmission remains concentrated among sex workers, men who have sex with men and/or injecting drug users and their sexual partners.
In many parts of Africa, especially sub-Saharan Africa, HIV has jumped outside these high-risk groups, creating generalised epidemics spread mainly among people who are having multiple and typically concurrent (overlapping, longer-term) sexual relationships.
In nine countries in southern Africa, more than 12% of adults are infected with HIV.
The authors said that the current widely used prevention strategies, while having value in some instances, are not as effective at preventing HIV transmission as male circumcision and reducing multiple sexual partners and thus should not continue to receive the bulk of donor investments for prevention, especially in Africa.
They cited the example of Thailand where condom use is widely promoted as an HIV prevention measure and is effective as the epidemic is spread primarily through sex work.
"However, studies have found no evidence that condom use has played a primary role in HIV decline in generalized, primarily heterosexual epidemics, such as those in southern Africa," the authors said.
They said this was mainly because most HIV transmission there occurs in more regular sexual relationships, in which achieving consistent condom use has proved extremely difficult.
"The evidence is similarly lacking for other popular prevention approaches as well," Halperin and his nine co-authors said.
Studies have shown no consistent reduction in risk for those testing HIV-negative and testing programs have produced no evidence of HIV reduction in populations, they said.
"The treatment of other STIs has had discouraging results; vaccine development trials and microbicide testing have been disappointing; and abstinence is not likely to have a major impact since most HIV infections occur among people in their 20s or older, when most are already sexually active," they said.
The authors pointed out that in contrast, many studies in the last two decades have shown that male circumcision significantly reduced the risk of heterosexual HIV infection.
In west Africa, where male circumcision is widespread, the prevalence of HIV remains relatively low.
When initial findings from three recent randomized controlled trials of male circumcision in Africa showed at least a 60% reduction in HIV risk, the trials were stopped early because it was not ethical to withhold the clearly proven benefits of this simple surgical procedure.
"It is tragic that we did not act on male circumcision in 2000, when the evidence was already very compelling. Large numbers of people will die as a result of this error," said Malcolm Potts, co-lead author and Bixby Professor of Population and Family Planning at UC Berkeley School of Public Health.
Similarly, partner reduction appears to have played a primary role in reducing HIV rates in Uganda, Kenya, Zimbabwe, Cote dIvoire, and in urban Malawi and Ethiopia.
Ugandas Zero Grazing campaign, initiated in 1987, indicated that reducing partners can be achieved on a large scale as later surveys revealed that the number of people reporting multiple and casual partners declined by over half.
"The political fight in the United States between supporters of condoms and supporters of abstinence has obscured the importance of what is arguably the most powerful of what are known as the three ABC strategies (Abstinence, Be Faithful, Condoms), which is the B, or partner reduction and fidelity aspect," according to the papers authors.
The authors also argued that HIV prevention priorities needed to shift significantly to reflect the best available scientific evidence. They noted that only 1% of total prevention funding requested by the United Nations AIDS Program is earmarked for male circumcision, and that reducing multiple sexual partnerships would probably garner only a small fraction of community mobilization and mass media, workplace or other HIV prevention investments.
The vast majority of donor investments in HIV prevention in the generalized epidemics of Africa continue to go to approaches for which the evidence of actual impact is increasingly unclear, said Halperin.
"Many of these approaches, such as HIV testing and treating other STIs, do have important public health benefits, and should be continued, but not because we believe they will definitely have a major impact on reducing HIV infections," he said. - Health-e News Service
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Circumcision can only possibly help men who have unsafe sex with HIV+ partners, so why this bizarre obsession with genital surgery when we know that ABC works better than circumcision ever could? (ABC=Abstinence, Being Faithful, Condoms). The two continents with the highest rates of AIDS are the same two continents with the highest rates of male circumcision. Rwanda has almost double the rate of HIV in circed men than in intact men, yet they've just started a nationwide circumcision campaign. Other countries where circumcised men are *more* likely to be HIV+ are Cameroon, Ghana, Lesotho,… [Read Full Text]
It is the same few "top researchers" - Daniel Halperin among them - who did the human experiments in order to claim that circumcision protects against HIV, who multiplied the small numbers of men involved by hundreds of thousands to claim that millions would be protected, and who now push for funding to be diverted from condoms - which work - toward circumcision.
In the Kenyan experiment, a greater proportion of the circumcised men got HIV than the non-circumcised men in Uganda, where there was a "Zero grazing" campaign.
These experiments were not (and maybe could not have been) double-blinded… [Read Full Text]
What these authors are suggesting here is insane. There is a very real risk that many people will miss the part that CONDOMS are STILL required. There are already stories leaking out about people overestimating the protective effects.
In this recent article in the trinidad express[1], we have this gem: "Aah," one subject said during trials, "I have a natural condom." Or from Rwanda, in a recent article[2] by David Gusongoirye, Nothing can fight HIV/AIDS better than discipline, speaking of the new campaign a man was quoted as saying: "Mister, these Aids people have spoken for long about fighting the… [Read Full Text]
I think "top researchers" is big spin. At least Mr. Halprin is a big pusher of circumcison. The people that did the African studies were pushing it too. They don't talk much about the companion study where circumcised men passed HIV at a higher rate than intact men. How can it be more effective to cut off a genital part and dull sexual pleasure instead of pusing condoms?
I agree with the report that gets little notice:
Promoting male circumcision in Africa is risky and dangerous and could lead to more HIV infections, warns a new paper published in the… [Read Full Text]