Helene D Gayle

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 …

The time has come for common ground on preventing sexual transmission of HIV.

The HIV/AIDS pandemic is an urgent health and growing humanitarian crisis especially in the high-prevalence regions of sub-Saharan Africa where most new infections continue to occur. On World AIDS Day (Dec 1) two decades after the discovery of the virus that causes AIDS and after many millions of deaths we believe it is critical to reach consensus on a sound public-health approach to the prevention of sexually transmitted HIV. Although transmission from injecting drug use is a serious and increasing problem in some regions here we focus on sexual transmission which continues to account for most infections globally. Sexual behaviour is influenced by many factors not always under an individual’s control including gender norms and social and economic conditions. However the public-health community has an obligation to offer people the most accurate information available on how to avoid HIV and to encourage changes in societal norms to reduce the spread of the virus. Although prevention should encompass multiple integrated elements including links to expanded treatment access changing or maintaining of behaviours aimed at risk avoidance and risk reduction must remain the cornerstone of HIV prevention. We call for an end to polarising debate and urge the international community to unite around an inclusive evidence-based approach to slow the spread of sexually transmitted HIV on the basis of the following key principles. (excerpt)

Seizing the opportunity to capitalise on the growing access to hiv treatment to expand HIV prevention

Access to antiretroviral therapy is expanding in resource-poor settings. This long-awaited action has the potential to improve the health of millions of HIV-infected people and stabilise societies in regions hardest hit by HIV/AIDS. Little discussed however is the fact that expanded access to treatment also offers critical new opportunities to simultaneously strengthen HIV-prevention efforts. More widespread access to treatment has the potential to attract millions of people into health-care settings in which HIV-prevention messages can be delivered and reinforced. The availability of HIV treatment will provide new incentives for HIV testing which in turn will increase opportunities for counselling on HIV prevention. And increased knowledge of serostatus will enable prevention programmes to develop interventions that are specifically tailored to the different needs of HIV-positive HIV-negative and untested individuals. To achieve a sustainable response to HIV/AIDS prevention and treatment services must be brought to scale simultaneously. Unless annual HIV incidence falls sharply from its current level of 5 million treatment programmes will be unable to keep pace with the number of people in need and will become financially unsustainable. (excerpt)

PREVALENCE OF AND MORTALITY FROM HIV TYPE 2 IN GUINEA BISSAU, WEST AFRICA

This letter to the editor challenges the conclusion by Dr. Poulsen and his colleagues (Apr. 15 p. 827) from their study of Guinea-Bissau that perinatal transmission of human immunodeficiency virus type II (HIV-2) is rare or absent. A 20-month-old boy admitted for malnutrition and diarrhea with abnormally straight and fragile hair and generalized lymphadenopathy tested positive for HIV-2 and negative for human immunodeficiency virus type I (HIV-1) antibodies. His mother 31 who had never travelled outside the Ivory Coast had amenorrhea weight loss and generalized lymphadenopathy; she also tested positive for HIV-2 and negative for HIV-1 antibodies. A sister 7 also with generalized lymphadenopathy showed HIV-2 infection. 2 healthy siblings 13 and 10 were HIV-negative. The husband who was tested but not examined showed antibodies to both HIV-1 and HIV-2 but the tests do not prove dual infection. This family cluster supports reports that HIV-2 may be transmitted from mother to child and suggests the HIV-2 infection has existed in the Ivory Coast for at least 7 years. Another report described antibodies to HIV-2 found in samples collected in the Ivory Coast in 1966. Hence conclusions about perinatal transmission should be drawn with caution pending results of prospective studies.

AIDS anniversaries in 2006 mark the time to deliver

The XVI International AIDS Conference (AIDS 2006) to be held on Aug 13--18 in Toronto Canada will mark two important moments in the history of the epidemic. 25 years ago the first reports of a disturbing new illness that defied medical classification began circulating in the Center for Disease Controls Morbidity and Mortality Weekly Report. Little could have prepared the medical community--or the world--for the human catastrophe that followed. Yet AIDS 2006 will mark another important anniversary: the stunning breakthroughs in clinical re search that led to highly active antiretroviral therapy (HAART) which were first reported 10 years ago at the XI International AIDS Conference in Vancouver the last time the conference was held in Canada. HAART revolutionised HIV treatment and amidst the unbridled optimism coming out of that conference held the tantalising promise not only of effective treatment but also of hopes for a cure. (excerpt)

eJIAS: The Journal of HIV/AIDS Science and Medicine in the Developing World.

On behalf of the International AIDS Society (IAS), Medscape, and our editors, we are pleased to introduce eJIAS: eJournal of the International AIDS Society , a new peer-reviewed journal dedicated to the science and practice of HIV/AIDS medicine in the developing world. And, on the occasion of the largest international gathering of HIV/AIDS scientists and healthcare and public health workers in 2 years, we are privileged to present the official online abstracts of the XV International AIDS Conference (Bangkok, Thailand; July 11–16, 2004) in this inaugural issue of eJIAS . (Published: 15 July 2004) doi:10.1186/1758-2652-6-3-56 Full text: BioMed Central: http://www.biomedcentral.com/1758-2652/content/6/3/56 PubMed Central: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2738662/