10 myths and 1 truth about generalized HIV

A Comment in this week’s edition of the Lancet argues that, despite substantial progress against AIDS worldwide, we are still losing ground, with new infections dwarfing numbers starting anti-retroviral therapy in developing countries. And while HIV incidence has fallen in Uganda, Kenya, and Zimbabwe, the generalised epidemic rages on. The Comment, coinciding with World AIDS day on December 1, is written by Dr James Shelton, Bureau for Global Health, US Agency for International Development, Washington, DC, USA. In it he discusses ten misconceptions which he believes impede HIV prevention.

1. HIV spreads like wildfire – typically it does not. It is very infectious in the first few weeks when virus levels are high, 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, partly explaining why HIV has spared most of the world’s populations. However, the epidemics is Africa seem largely driven by concurrent partnerships, ie, multiple regular partners which allow rapid dissemination of new infections.

2. Sex work is the problem – Formal sex work is uncommon in African epidemics – but whereas only 2% of men in Lesotho reported paying for sex in the previous year, 29% reported multiple partners. Whilst economic support enables multiple partnerships and paid-for sex, targeting of sex work in prevention campaigns has limited use.

3. . Men are the problem – Whilst the behaviour of men contributes to HIV epidemics, a heterosexual epidemic requires some women to have multiple partners. A representative national survey of Kenyan couples in 2003 revealed 3.7% had both partners as HIV positive, while 4.6% had only the womanpositive and in 2.8% only the man was positive.

4. Adolescents are the problem – Generalised epidemics span all reproductive ages, thus interventions in young people, including abstinence, while important, have limited usefulness.

5. Poverty and discrimination are the problem – Whilst these factors can lead to risky sex, HIV is paradoxically more common in wealthier people than poorer people – perhaps because wealth facilitates concurrent sexual partnerships. Note the example of Zimbabwe, where HIV has declined without major improvements in poverty and discrimination, notwithstanding substantial economic and social distress.

6. Condoms are the answer – Condoms can help contain concentrated epidemics and protect some individuals, especially sex workers. However they have limited impact in generalised epidemics – many people dislike using them (especially in regular relationships), protection is imperfect and use is irregular. Condoms also seem to foster disinhibition, where people engage in risky sex either with condoms or with the intention of using condoms.

7. HIV testing is the answer – learning one’s HIV status should lead to behavioural change, but evidence for this is discouraging, especially for the large majority who test negative – and such behavioural changes need to last years to be effective. Also, very newly infected people, who are highly infectious, do not yet test HIV-positive.

8. Treatment is the answer – Whilst treatment could reduce infectiousness and theoretically promote behavioural change, no clear evidence of this has emerged. In fact, the positive effects could soon be outweighed by the negative – such as resumption of sexual activity once the patients feels better on antiretroviral treatment – including risky sex when people realise HIV may not be a death sentence.

9. New technology is the answer – much work is ongoing on vaccines, microbicides, and prophylactic antiretrovirals, but success seems far away and any successes may only be targeted at high risk populations, and could encourage risky behaviour. Even male circumcision, unmistakably effective, and a compelling priority, will take years to have an additional substantial effect.

10. Sexual behaviour will not change – Faced with deadly illness, many people will change, eg. homosexual men in the USA in the 1980s, and drops in multiple partners in Kenya.

Dr Shelton believes the focus must be on the key driver of generalised epidemics – concurrent partnerships – a risk that people do not fully appreciate, and the technical appreciation of which is only recent. However, he believes partner-limitation has been neglected as, among other things, it smacks of moralising and such mass behavioural change is alien to most medical professions.

He concludes: “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.”

Notes to editors: Please see contents list for other HIV-related content in this week’s issue.

The paper associated with this release can be found at http://multimedia.thelancet.com/pdf/press/HIV.pdf