Daniel T. Halperin

Concurrent sexual partnerships help to explain Africa's high HIV prevalence: implications for prevention

As Kiat Ruxrungtham and colleagues describe in today’s Lancet HIV transmission in most Asian countries remains strongly associated with particularly high-risk activities—ie injection-drug use male-male sex prostitution and in China paid donation of plasma. Although there is understandable concern that the virus could soon spread widely through the general population. HIV has been present in Asia for nearly two decades and such extensive spread has yet to occur. For example analysis of trends in India suggests that HIV prevalence both in high-risk groups and in the generally low-risk antenatal clinic population has probably stabilised in recent years. It is possible that large-scale heterosexual epidemics will never emerge in most of Asia except perhaps on the island of Papua. Furthermore in some of the world’s most populated countries—Pakistan Bangladesh Indonesia and the Philippines home to some one billion people-nearly all men are circumcised further restricting the potential for extensive heterosexual spread. In chilling contrast as Emil Asamoah-Odei and colleagues report also in today’s Lancet HIV rates remain very high in much of east and especially southern Africa. The overwhelming burden of HIV/AIDS is still concentrated in this region which accounts for only 3% of the global population yet some 50% of global HIV cases. For example infection rates in adults in South Africa Botswana Zimbabwe and western Kenya range from 20 to 40% roughly an order of magnitude higher than anywhere else in the world. (excerpt)

Concurrent Sexual Partnerships and the HIV Epidemics in Africa: Evidence to Move Forward

The role of concurrent sexual partnerships is increasingly recognized as important for the transmission of sexually transmitted infections, particularly of heterosexual HIV transmission in Africa. Modeling and empirical evidence suggest that concurrent partnerships—compared to serial partnerships—can increase the size of an HIV epidemic, the speed at which it infects a population, and its persistence within a population. This selective review of the published and unpublished literature on concurrent partnerships examines various definitions and strategies for measuring concurrency, the prevalence of concurrency from both empirical and modeling studies, the biological plausibility of concurrency, and the social and cultural underpinnings of concurrency in southern Africa.

Risk compensation: the Achilles' heel of innovations in HIV prevention?

The benefits of new methods of prevention of HIV could be jeopardised if they are not accompanied by efforts to change risky behaviour

Uganda's HIV Prevention Success: The Role of Sexual Behavior Change and the National Response

There has been considerable interest in understanding what may have led to Ugandas dramatic decline in HIV prevalence, one of the worlds earliest and most compelling AIDS prevention successes. Survey and other data suggest that a decline in multi-partner sexual behavior is the behavioral change most likely associated with HIV decline. It appears that behavior change programs, particularly involving extensive promotion of “zero grazing” (faithfulness and partner reduction), largely developed by the Ugandan government and local NGOs including faith-based, women’s, people-living-with-AIDS and other community-based groups, contributed to the early declines in casual/multiple sexual partnerships and HIV incidence and, along with other factors including condom use, to the subsequent sharp decline in HIV prevalence. Yet the debate over “what happened in Uganda” continues, often involving divisive abstinence-versus-condoms rhetoric, which appears more related to the culture wars in the USA than to African social reality.

Partner reduction is crucial for balanced “ABC” approach to HIV prevention

Behaviour change programmes to prevent HIV have mainly promoted condom use or abstinence, while partner reduction remains the neglected component of ABC The key to preventing the spread of HIV, especially in epidemics driven mainly by heterosexual transmission, is through changing sexual behaviour. Interest has been growing in an “ABC” approach in which A stands for abstinence or delay of sexual activity, B for be faithful, and C for condom use (box).1 Although “be faithful” literally implies monogamy, it also includes reductions in casual sex and multiple sexual partnerships (and related issues of partner selection) that would reduce higher risk sex. While most of the often polarised discussion surrounding AIDS prevention has focused on promoting abstinence or use of condoms,w1 w2 partner reduction has been the neglected middle child of the ABC approach. It seems obvious, but there would be no global AIDS pandemic were it not for multiple sexual partnerships. The rate of change of sexual partners—especially concurrent partners—is a crucial determinant in the spread of sexually transmitted infections,w3 including HIV.2 Moreover, HIV viral load and therefore infectiousness is dramatically higher during the early (acute) stage of HIV infection,3 so transmission would be particularly heightened by partner change among newly infected people. Transmission of HIV is also facilitated by the presence of other sexually transmitted infections, especially ulcerative ones.w4 Hence, increased risk of other sexually transmitted infections from multiple partnerships further magnifies the spread of HIV. ### ABC of sexual behaviour change A = abstinence or delay of sexual activity B = be faithful (including partner reduction and avoiding high risk partners) C = condom use, particularly for high risk sex Partner reduction seems to have been pivotal to success in two countries heralded for reversing their HIV epidemics, Thailand and Uganda. Thailands “100% condom” approach in brothels is …

Male circumcision for HIV prevention: from evidence to action?

An estimated 2.5 million people were newly infected with HIV in 2007 of whom two-thirds live in sub-Saharan Africa. In the context of the urgent need for intensified and expanded HIV prevention efforts the conclusive results of three randomized controlled trials (RCT) showing that male circumcision reduces the risk of HIV-acquisition by approximately 60% are both promising and challenging. Translation of these research findings into public health policy is complex and will be context specific. To guide this translation we estimate the global prevalence and distribution of male circumcision summarize the evidence of an impact on HIV incidence and highlight the major public health opportunities and challenges raised by these findings. (excerpt)

Male circumcision and HIV infection: 10 years and counting

A decade has passed since publication of Cameron and colleagues’ prospective study that showed a greater than eight-fold increased risk of HIV-1 infection for uncircumcised men. Today many observers of the AIDS pandemic are puzzled by the glaring discrepancies in HIV seroprevalence between different countries and regions despite the presence of what seem to be similar risk factors. For example the November 1998 UNAIDS/ WHO Report on the AIDS Epidemic concludes “It is not fully understood why HIV infection rates take off in some countries while remaining stable in neighbouring countries over many years.” We argue that since Cameron and colleagues’ landmark study the epidemiological and biological evidence that links lack of circumcision with HIV transmission has become compelling and that lack of male circumcision is one of the main causes of many regional discrepancies in rates of HIV infection. Furthermore as increasing numbers of men in some traditionally non-circumcising communities seek safe affordable circumcisions to avoid AIDS and other sexually transmitted diseases (STDs) it is time for the international health community to add male-circumcision services to the current limited armamentarium of AIDS prevention measures in countries with a high prevalence of heterosexually transmitted HIV and STDs. (excerpt)

Reassessing HIV prevention

The largest investments in AIDS prevention targeted to the general population are being made in interventions where the evidence for large-scale impact is uncertain.

Complications of circumcision in male neonates, infants and children: a systematic review

BackgroundApproximately one in three men are circumcised globally, but there are relatively few data on the safety of the procedure. The aim of this paper is to summarize the literature on frequency of adverse events following pediatric circumcision, with a focus on developing countries.MethodsPubMed and other databasess were searched with keywords and MeSH terms including infant/newborn/pediatric/child, circumcision, complications and adverse events. Searches included all available years and were conducted on November 6th 2007 and updated on February 14th 2009. Additional searches of the Arabic literature included searches of relevant databases and University libraries for research theses on male circumcision.Studies were included if they contained data to estimate frequency of adverse events following neonatal, infant and child circumcision. There was no language restriction. A total of 1349 published papers were identified, of which 52 studies from 21 countries met the inclusion criteria. The Arabic literature searches identified 46 potentially relevant papers, of which six were included.ResultsSixteen prospective studies evaluated complications following neonatal and infant circumcision. Most studies reported no severe adverse events (SAE), but two studies reported SAE frequency of 2%. The median frequency of any complication was 1.5% (range 0-16%). Child circumcision by medical providers tended to be associated with more complications (median frequency 6%; range 2-14%) than for neonates and infants. Traditional circumcision as a rite of passage is associated with substantially greater risks, more severe complications than medical circumcision or traditional circumcision among neonates.ConclusionsStudies report few severe complications following circumcision. However, mild or moderate complications are seen, especially when circumcision is undertaken at older ages, by inexperienced providers or in non-sterile conditions. Pediatric circumcision will continue to be practiced for cultural, medical and as a long-term HIV/STI prevention strategy. Risk-reduction strategies including improved training of providers, and provision of appropriate sterile equipment, are urgently needed.

Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries.

BackgroundBoth religious practices and male circumcision (MC) have been associated with HIV and other sexually-transmitted infectious diseases. Most studies have been limited in size and have not adequately controlled for religion, so these relationships remain unclear.MethodsWe evaluated relationships between MC prevalence, Muslim and Christian religion, and 7 infectious diseases using country-specific data among 118 developing countries. We used multivariate linear regression to describe associations between MC and cervical cancer incidence, and between MC and HIV prevalence among countries with primarily sexual HIV transmission.ResultsFifty-three, 14, and 51 developing countries had a high (>80%), intermediate (20–80%), and low (<20%) MC prevalence, respectively. In univariate analyses, MC was associated with lower HIV prevalence and lower cervical cancer incidence, but not with HSV-2, syphilis, nor, as expected, with Hepatitis C, tuberculosis, or malaria. In multivariate analysis after stratifying the countries by religious groups, each categorical increase of MC prevalence was associated with a 3.65/100,000 women (95% CI 0.54-6.76, p = 0.02) decrease in annual cervical cancer incidence, and a 1.84-fold (95% CI 1.36-2.48, p < 0.001) decrease in the adult HIV prevalence among sub-Saharan African countries. In separate multivariate analyses among non-sub-Saharan African countries controlling for religion, higher MC prevalence was associated with a 8.94-fold (95% CI 4.30-18.60) decrease in the adult HIV prevalence among countries with primarily heterosexual HIV transmission, but not, as expected, among countries with primarily homosexual or injection drug use HIV transmission (p = 0.35).ConclusionMale circumcision was significantly associated with lower cervical cancer incidence and lower HIV prevalence in sub-Saharan Africa, independent of Muslim and Christian religion. As predicted, male circumcision was also strongly associated with lower HIV prevalence among countries with primarily heterosexual HIV transmission, but not among countries with primarily homosexual or injection drug use HIV transmission. These findings strengthen the reported biological link between MC and some sexually transmitted infectious diseases, including HIV and cervical cancer.