Effort 'Badly Targeted'. 09/05/08

Mark Henderson, Science Editor

May 9, 2008

The fight against the Aids epidemic in Africa is founded on ineffective strategies and should focus on male circumcision and reducing promiscuity, according to leading scientists in the field.

HIV containment is generally based on the "three pillars" - promotion and provision of condoms, HIV status testing and treatment of other sexually transmitted infections (STIs) that can increase the risk of becoming infected. There is little evidence, however, that any of these methods works well in sub-Saharan Africa, where two thirds of the 33.2 million people who carry the virus live, a review for the journal Science has found. It was published in a special issue to mark the 25th anniversary of the discovery of the HIV virus that causes Aids. 

Its authors said that only two approaches - male circumcision and campaigns to persuade people to take fewer sexual partners - have been shown to reduce HIV transmission significantly in the world's worst affected region. 

International resources need to focus on these unfashionable policies, which receive minimal funding, to make them the cornerstones of HIV prevention, the scientists from Harvard School of Public Health and the University of California, Berkeley, said. 

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"Despite relatively large investments in Aids prevention efforts for some years, including sizeable spending in some of the most heavily affected countries (such as South Africa and Botswana), it's clear that we need to do a better job of reducing the rate of new HIV infections," said Daniel Halperin, of Harvard, who led the research team. 

"We need a fairly dramatic shift in priorities, not just a minor tweaking. The vast majority of donor investments in HIV prevention in the generalised epidemics of Africa continue to go to approaches for which the evidence of actual impact is increasingly unclear. 

"Many of these approaches, such as HIV testing and treating other sexually transmitted infections, 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 scientists found that the "three pillars" have been effective at reducing transmission of HIV in countries such as Thailand, where the epidemic is spread mainly by gay men, intravenous drug users and sex workers. 

In sub-Saharan Africa, however, the virus is commonly passed on through heterosexual relationships, particularly when people have multiple partners. This makes each of the usual approaches less effective. Regular condom use, for instance, is hard to promote for long-term relationships. 

Studies in Africa have also shown that neither HIV testing nor treating other STIs has a lasting impact. Male circumcision, by contrast, has been shown to be highly effective, reducing the risk of infection by at least 60 per cent in three recent randomised controlled trials run in Africa. Yet it receives only about 1 per cent funding distributed by the UN Aids Programme.

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