Experts call for major shift in HIV prevention priorities
May 9th, 2008 - 1:46 pm ICT by admin -Washington, May 9 (ANI): New research shows that the most common HIV prevention strategiescondom promotion, HIV testing, treatment of other sexually transmitted infections (STIs), vaccine and microbicide research, and abstinencehave not been very successful in reducing the predominance of heterosexual epidemics in Africa.
The same research also suggests that male circumcision and a reduction in multiple sexual partnerships may have a greater impact on the AIDS pandemic, but the two interventions have been getting very less attention.
The research reported in the journal Science is based on a new policy analysis led by experts at the Harvard School of Public Health (HSPH) and the University of California, Berkeley.
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 papers lead authors.
The study report points out that condom use is effective in countries like Thailand where the epidemic is spread primarily through sex work, but studies have found no evidence that this intervention has played a primary role in reducing HIV infections primarily in heterosexual populations, such as those in southern Africa.
The researchers believe that this is mainly because most HIV transmission there occurs in more regular sexual relationships, in which achieving consistent condom use has proved extremely difficult.
According to them, the evidence is similarly lacking for other popular prevention approaches as well.
However, several studies conducted in the last two decades have shown that male circumcision significantly reduces the risk of heterosexual HIV infection, they add.
The researchers corroborate their observation with the fact that the prevalence of HIV is relatively low in west Africa, where male circumcision is widespread.
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, Bixby Professor of Population and Family Planning at UC Berkeley School of Public Health.
Similarly, according to the study report, partner reduction has also found to play a significant role in reducing HIV rates in Uganda, Kenya, Zimbabwe, Cote dIvoire, and in urban Malawi and Ethiopia.
The researchers blame the political fight between the supporters of condoms and supporters of abstinence for obscuring which is the most powerful of the ABC strategyAbstinence, Be Faithful and Condoms.
They argue that HIV prevention priorities need to shift significantly to reflect the best available scientific evidence.
The researchers note that only one per cent 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. Meanwhile, there is still some foot dragging on more fully implementing those approaches for which the evidence is much stronger, namely to scale up safe, voluntary male circumcision services, and to more assertively promote partner reduction, the researcher added. (ANI)
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May 9th, 2008 at 8:37 pm
Halprin is pushing 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 May issue of Future HIV Therapy.
Lead author Dr. Lawrence Green says, “Having served on both the US Preventive Services Task Force and the Community Preventive Services Task Force, which do systematic reviews of research to arrive at government-supported evidence-based guidelines for practice, I believe the African studies on the basis of which some are promoting circumcision as HIV prevention would be classified at best as ‘insufficient evidence%u2019 by both panels.”
“Promoting circumcision will drain millions, possibly billions, of dollars away from more effective prevention strategies,” cautions co-author John Travis, MD, “and cause tens of thousands of infections and other surgical complications, further straining an already overwhelmed healthcare system and undermining the current ABC (abstinence, be faithful, and use condoms) campaigns by creating a false sense of immunity and increasing risk-taking behaviors. African males are already lining up to be circumcised, believing that they will no longer need to wear condoms, and this is a serious concern.”
Travis says, “The African studies were conducted in atypically sanitary clinics with highly skilled operators and cannot be extrapolated to the general population. The studies have been criticized for their poor science including: the men were paid to be circumcised, received free condoms and extensive education, and the studies were halted after only 21 to 24 month periods.”
During the course of these studies, 77 fewer circumcised than uncircumcised males contracted HIV, however, the circumcised group needed to refrain from sex to recoup from surgery, and they were receiving extensive monitoring and counseling about sexual behavior. Also, hundreds of study participants were lost to follow-up. “There is not enough evidence to conclude circumcision would offer any real long-term benefit in the HIV battle. Even if circumcision did reduce the risk of HIV infections, condoms and safe-sex practices are still far more effective. If an individual is engaging in high-risk behavior, he and his partner are at risk, regardless of whether he is circumcised or not.”
The paper also cautions against neonatal circumcision for HIV prevention, stating it is unethical to circumcise an infant for a possible benefit 15%u201320 years later, if at all, to reduce the risk of contracting an adult-acquired disease for which there are far more effective prevention strategies available.
Circumcision proponents, hailing from English-speaking countries, have been intensely lobbying world health agencies to adopt male circumcision as an additional HIV-prevention tool based on the release of three African randomized clinical trials reporting reduced HIV infections during their study periods.
Many sources of data contradict the claim that circumcision protects against HIV. The United States has one of the highest rates of circumcision and HIV infection in the developed world. European nations, which rarely practice circumcision, have very low rates of HIV. Numerous regions in Africa show higher rates of HIV in circumcised populations compared to uncircumcised populations. For example, 2004 data from Lesotho show HIV infection of 15 percent for uncircumcised males and 23 percent for circumcised males. A 2007 study showed that, once commercial sex worker patterns were taken into consideration, circumcision status was irrelevant in HIV infection rates.