Major shift in HIV prevention priorities needed

For example, condom use is widely promoted as an HIV prevention measure and is effective in countries such as Thailand, where the epidemic is spread primarily through sex work. However, studies have found no evidence that condom use has played a primary role in HIV decline in generalized, primarily heterosexual epidemics, such as those in southern Africa, the authors note. This is mainly because most HIV transmission there occurs in more regular sexual relationships, in which achieving consistent condom use has proved extremely difficult.

The evidence is similarly lacking for other popular prevention approaches as well, according to the authors. Studies have shown no consistent reduction in risk for those testing HIV-negative and testing programs have produced no evidence of HIV reduction in populations. The treatment of other STIs has had discouraging results; vaccine development trials and microbicide testing have been disappointing; and abstinence is not likely to have a major impact since most HIV infections occur among people in their 20s or older, when most are already sexually active.

In contrast, many studies in the last two decades have shown that male circumcision significantly reduces the risk of heterosexual HIV infection. In west Africa, where male circumcision is widespread, the prevalence of HIV remains relatively low. When initial findings from three recent randomized controlled trials of male circumcision in Africa showed at least a 60% reduction in HIV risk, the trials were stopped early because it was not ethical to withhold the clearly proven benefits of this simple surgical procedure. “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 Potts.

Similarly, partner reduction appears to have played a primary role in reducing HIV rates in Uganda, Kenya, Zimbabwe, Cote d’Ivoire, and in urban Malawi and Ethiopia. Uganda’s “Zero Grazing” campaign, initiated in 1987, indicated that reducing partners can be achieved on a large scale as later surveys revealed that the number of people reporting multiple and casual partners declined by over half.

The political fight in the United States between supporters of condoms and supporters of abstinence has obscured the importance of what is arguably the most powerful of what are known as the three “ABC” strategies (Abstinence, Be Faithful, Condoms), which is the “B,” or partner reduction and fidelity aspect, according to the paper’s authors.

The authors argue that HIV prevention priorities need to shift significantly to reflect the best available scientific evidence. They note that only 1% 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.