Circumcision and partner reduction should be priorities for HIV prevention, say US researchers

Investigators in the US are calling for male circumcision and partner reduction to become the focus of prevention efforts in countries with generalised HIV epidemics. In a paper published in the May 9^th edition of Science, they argue that although condom use, testing, and treatment of sexually transmitted infections are of value, resource constraints mean that attention should be shifted to the promotion of initiatives known to work: male circumcision and partner reduction.

A separate article in the British Medical Journal argues that a gay "rights agenda" set the scene for HIV exceptionalism, maintaining that only 10% of the current annual budget is needed for HIV programmes and that UNAIDS should be abolished.

In many parts of the world HIV infections are mainly located in high risk groups such as gay men and injecting drug users. However, in parts of southern Africa, where two-thirds of the world’s HIV infections are located, generalised epidemics have developed. In nine southern African countries, over 12% of the adult population is infected with HIV.

The authors, from the University of California, Harvard University and the San Francisco health department, dismiss traditional explanations, such as poverty, gender inequality and war for the high HIV prevalence in these countries, pointing to evidence that suggests that HIV infections are often located in the richer sections of some African societies, that HIV is not, “as is commonly assumed” brought into the relationship by the man. They add that Rwanda, Congo and Angola, countries that have suffered war, genocide and rape, have a lower HIV prevalence than their stable and peaceful neighbours Swaziland and Botswana.

But in settings where it is uncommon to have multiple, particularly concurrent sexual partners, and where male circumcision is common, HIV prevalence is lower, an example being Niger where HIV prevalence is below 1%.

The authors go on to outline what they see as the weaknesses of the prevention approaches currently favoured in African settings.

Promotion of condom use can have success in high-risk populations, such as gay men and sex workers, but they believe that condom use has not lead to a significant reduction in new HIV infections in countries with generalised epidemics. They note that consistent condom use is difficult to maintain, and that use has not reached a sufficient level to affect the epidemiology of HIV, despite decades of aggressive promotion.

Voluntary testing and counselling does not produce a sustained reduction in HIV risk behaviour amongst people testing negative, they argue. Although the authors acknowledge that this is essential for the diagnosis of HIV and the provision of life-saving antiretroviral therapy, they think it unlikely that it will have a substantial impact on the epidemiology of the infection.

Recent discouraging studies indicating that treatment for other sexually transmitted infections does not reduce HIV risk are also mentioned by the investigators. They believe that these indicate that, although treatment of sexually transmitted infections is essential for overall health, “the population-level evidence for impact on HIV transmission, especially for generalized epidemics, appears minimal.”

“Sadly disappointing” vaccine research is highlighted, and the investigators are pessimistic about the potential impact of a microbicide on the spread of HIV, suggesting that they are “unlikely to be used consistently enough, especially in longer-term partnerships, to slow a generalized epidemic.”

Although the investigators support delaying sexual debut in young people, they note that most new HIV infections occur in individuals who are in their 20s or older, “when most are sexually active and, thus, abstinence is unlikely to have a major epidemiological impact.”

But the authors are much more optimistic about the efficacy of male circumcision. They write, “over 45 observational, biological and other studies from the last 20 years have shown that male circumcision significantly reduces the risk of heterosexual HIV infection.” A significant advantage of male circumcision suggested by the investigators is that it is “a one-time procedure that confers lifelong protection.” They point to evidence suggesting that circumcision is highly acceptable and call on donor agencies to proactively support the procedure, and for African civil society and governments to “take the lead” and promote male circumcision.

Although there is little evidence that male circumcision protects women from infection with HIV, the authors say this “surgical vaccine” would “probably protect more women, albeit indirectly, than nearly any other achievable HIV prevention strategy.”

The authors also suggest that partner reduction has already had a “meaningful impact” on the epidemiology of HIV, but has the potential to have an even greater impact if it is assertively promoted.

They conclude, “currently the largest donor investments are being made in interventions for which evidence for large-scale impact is increasingly weak, whereas much lower priority is given to interventions for which the evidence for potential impact is greatest…this balance needs to be reassessed.”

HIV only “needs 10% of current funding", says article in BMJ

In a separate article, published in the British Medical Journal, Roger England of the Health Systems Workshop in Grenada, calls for the scrapping of UNAIDS, claiming that it is damaging health systems and distorting global health funding. He claims that HIV was been treated as exceptional ever since a “rights” agenda was pushed by gay men at the start of the HIV epidemic. The author then argues that too much is being spent on HIV relative to other health needs and that the money would be better spent treating and preventing pneumonia and diabetes which are bigger killers than HIV.

He adds that HIV is not the catastrophe it was predicted to be and that only 10% of current funding is needed to provide the current level of antiretroviral access around the world. However, it should be noted that current funding of HIV treatment and care is billions short of what is needed, and that less than a quarter of people in need of antiretroviral therapy actually receive it.