Reduction in number of sexual partners key to halting spread of HIV, says BMJ article

HIV prevention work is neglecting to inform individuals about the role partner reduction can play in stemming the spread of HIV, according to an article in the April 10^th edition of the British Medical Journal. The authors, who represent international development agencies, the US government, and US universities, argue that the importance of partner reduction to slowing the spread of HIV is not being recognised amidst ideologically driven discussions which focus on either abstinence or condom use as the best way to prevent HIV. The authors’ position is supported by an editorial in the same edition of the BMJ, and is applauded for highlighting the “simple truth” that partner reduction is of key importance to HIV prevention.

In recent years, interest in the “ABC” approach to HIV prevention has grown. This prevention model has three key components: sexual abstinence; being sexually faithful (which also implies a reduction in the number of sexual partners); and condom use. The use of this prevention approach is credited with helping to stem the spread of HIV in Uganda. However, in recent debates on HIV prevention, particularly in the US, the importance of either abstinence or condoms has been stressed, with monogamy, or a reduction in the number of sexual partners, left out as “the neglected middle child”.

This is despite the fact that “there would be no global AIDS pandemic were it not for multiple sexual partnerships”. Partner change by recently infected individuals who are likely to be particularly infectious due to a high viral load, and the spread of sexually transmitted infections due to multiple partnerships are highlighted as particular concerns.

The authors argue that partner reduction has been key to controlling the HIV epidemics in Uganda and Thailand. In Uganda, HIV prevalence has fallen from 15% to 5% in the space of a decade and “each component of the ABC approach probably had an important role”. However, the authors stress that “the least recognised element, partner reduction, was probably key.” Although surveys in Uganda conducted in the late 1980s and mid-1990s showed that young people initiated sexual activity at a slightly older age, and that condom use increased amongst both men and women, these changes were not in themselves sufficient to result in the reduction in HIV prevalence seen in the country over the same period. However, further surveys showed that the proportion of men and women reporting multiple casual sexual partners fell substantially, and modelling suggests that partner reduction was sufficient to have a marked impact on HIV incidence.

Evidence from the HIV epidemics amongst gay men in California, factory workers in Ethiopia, and from men visiting sex workers in the Dominican Republic all show, the authors argue, that partner reduction can play a key role in HIV prevention.

The authors add that it is feasible to promote monogamy or partner reduction at the same time as either abstinence or condom use. They comment, “people seem generally able to grasp that the root problem with HIV transmission is risky sex and adopt the behaviour that best fits their circumstances.” Although abstinence has a role in HIV prevention for young people, the authors suggest that “it may be an unrealistic expectation” for others. Similarly, although condoms are highly effective at preventing HIV transmission, “in real life they are often used incorrectly or inconsistently.”

Community leadership and support for all three elements of ABC are, however, needed to alter behavioural norms, note the authors. Again they cite evidence from Thailand and Uganda, where presidential announcements, the commitment of faith-based organisations, health service involvement, and community mobilisation achieved a “tipping point” where “avoiding risky sex became the community norm”.

ABC is not the last word in HIV prevention, stress the authors, noting that information should be provided on the need to avoid “the particularly risky practice of unprotected anal sex”, and that efforts must continue to prevent HIV transmission amongst injecting drug users.

An editorial by an official from the Global HIV Program at the World Bank in the same edition of the BMJ enthusiastically supports the authors' suggestions, commenting that it is a “simple truth” that the HIV epidemic would not have occurred without multiple sexual partnerships. A unified ABC approach to HIV prevention is praised as “good common sense - and good epidemiology.” The editorial also highlights the key elements to successful HIV prevention campaigns around the world. These initiatives, which have been targeted at diverse audiences including western gay men, the population of rural Uganda and the clients of sex workers in Thailand “share unnerving similarities” and were “rapid, endogenous, inexpensive, and simple”.

The editorial author also states that HIV prevention workers may often be recommending behaviour which they personally find unacceptable, stating: “As AIDS educators, we often publicly promote approaches that we would not countenance in our own personal lives, such as the notion that it is acceptable for our spouses or children to have multiple partners, provided condoms are used.”

Further information on this website

Editorial attacks shift away from condoms in HIV prevention - news story

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