Writing in this week’s edition of The Lancet, to coincide with today, Saturday 1st December being World AIDS Day, a senior science advisor and global health specialist argues that although we are making considerable progress in the global race against the spread HIV/AIDS, the disease is still outpacing us, and there is a need to dispel some myths if we are to stand a chance of winning the race.
In developing countries, the rate of new infections hugely outnumbers the rate at which people infected with HIV start anti-retroviral therapy, wrote Dr James Shelton, senior medical scientist at the Bureau for Global Health, US Agency for International Development, Washington, DC, USA.
Although HIV incidence has dropped in Uganda, Kenya and Zimbabwe, the generalized epidemic continues to spread at a pace. According to Shelton, there are 10 misconceptions about HIV which he believes are getting in the way of successfully preventing the spread of the disease. He discussed them one by one in a Comment article in the journal.
- Myth: HIV Spreads Like Wildfire.
This is not true, because typically, it does not, wrote Shelton. While it is very infectious in the first weeks, because the levels of virus are high, for the many years after this, virus levels are low. This is borne out by the statistic that only 8 per cent of people whose main heterosexual partner has the virus become infected with HIV every year. This is part of the reason the virus has not spread like wildfire all over the world, wrote Shelton who suggested the reason the epidemic is spreading more rapidly in Africa seems to be down to people having more than one sexual partner at a time.
- Myth: Sex Workers are the Problem.
Sex workers are not likely to be the problem in Africa as formal sex work in uncommon in the regions affected. For instance, in Lesotho, only 2 per cent of men said they had paid for sex, whereas 29 per cent said they had had multiple partners, in the previous year. Shelton argued that targetting of sex work in HIV prevention campaigns is ineffective in areas where economic support helps people sustain multiple partners and pay for sex.
- Myth: Men Are the Problem.
This may be partly true, but a heterosexual epidemic also requires that some women have multiple partners too. A 2003 national survey of couples in Kenya showed that both partners had HIV in 3.7 per cent of couples, and in 4.7 per cent only the woman was HIV positive, and in 2.8 per cent, only the man was positive.
- Myth: Adolescents Are the Problem.
Shelton argued that targetting young people, to promote abstinence for example, might be important, but has limited use in stemming an epidemic, because generalized epidemics span all reproductive ages.
- Myth: Poverty and Discrimination Are the Problem.
While these factors can result in risky sex argued Shelton, it is wealth that enables concurrent partnerships, thus explaining why HIV is more common among wealthier than among poorer people. He referred to Zimbabwe where HIV has dropped in the absence of significant improvements in poverty and discrimination.
- Myth: Condoms Are the Answer.
While they can help to contain epidemics and protect some people, for example sex workers, condoms have limited effect in generalized epidemics, wrote Shelton. Many people don’t like them, especially in stable relationships, use is not regular, and they do not offer 100 per cent protection. He argued that promoting condoms seems to encourage people to become less inhibited, and thereby engage in riskier sex, either with condoms, or with the intention of using them.
- Myth: HIV Testing is the Answer.
While many people might assume that having an HIV test might cause them to change their behaviour, the evidence does not support this, especially for the large majority who find they do not have the virus. Newly infected people, who are highly infectious because the virus levels are at their highest in the early weeks, are likely to test negative. Changes in behaviour also have to last ten years to be effective, wrote Shelton.
- Myth: Treatment is the Answer.
In theory, while treatment reduces infectiousness, it should also encourage people to change behaviour. But, wrote Shelton, this is not supported by the evidence; once people realize they are not going to die, and when the antiretrovirals kick in and they feel better, they resume sexual activity.
- Myth: New technology is the Answer.
A lot of work is going on in developing vaccines, antiretrovirals and microbicides, but the day when these will start to have a substantial effect are years away, and they may only be targetted at high risk populations, suggested Shelton, and they could also encourage people to resume risky behaviour. Male circumcision, which has been proved to be effective, will also take years to reach a level where it has a substantial impact on a generalized epidemic.
- Myth: Sexual Behaviour Will Not Change.
Shelton disagrees: faced with a deadly illness, he wrote, many people do change. He cited the example of homosexual American men in the 1980s, and in Kenya, where there has been substantial progress in encouraging people to give up multiple, concurrent sex partners.
Shelton’s overriding argument is that reducing concurrent partnerships is the key to making substantial and rapid impact on generalized epidemics of HIV/AIDS. Many people do not appreciate this, he wrote, and it has only recently been appreciated from a technical standpoint.
There is a barrier among medical professionals, however, to promoting reduction in sexual partners, because as Shelton pointed out “it smacks of moralising”, and “mass behavioural change is alien to most medical professionals”.
State of the art techniques are available to effectively promote behaviour change, for instance using explicit messages, sensitive to local cultures, that can increase people’s perception of the risks they are taking with their current behaviour:
“Even modest reductions in concurrent partnerships could substantially dampen the epidemic dynamic,” wrote Shelton.
Other approaches have merit, but they are more effective when run together with partner-limitation strategies.
“Now, more than 20 years into HIV prevention, we have to get it right,” wrote Shelton.
“Ten myths and one truth about generalised HIV epidemics.”
James D Shelton.
The Lancet 2007; 370:1809-1811.
Written by: Catharine Paddock