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Rapid Responses: Rapid Responses published:
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UNAIDS supports combination HIV prevention approaches which address the epidemic’s complexity
- Dr Paul De Lay (28 November 2008)
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There you go again....
- Helen Epstein (29 November 2008)
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By the way....
- Helen Epstein (30 November 2008)
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Leading by example: Jacob Zuma's post coital shower.
- Richard G Fiddian-Green (11 December 2008)
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AIDS and the irrational: after concurrency, do not forget male genital hygiene
- Nigel O'Farrell (11 December 2008)
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Known for half a century
- Luc Bonneux (11 December 2008)
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Dr Paul De Lay, Director, Evidence, Monitoring, and Policy, UNAIDS Geneva, Switzerland
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UNAIDS has consistently supported the most effective responses to HIV which deal with the dynamics of the epidemic and address both HIV risk behaviors and changing the underlying social and economic conditions that make people vulnerable. UNAIDS does not agree with Helen Epstein’s characterization of the UNAIDS’ position as “needlessly complicated”. Indeed, she concedes that addressing concurrent partnerships in southern Africa does not “imply a simple solution.” UNAIDS has not downplayed multiple partnerships or the issue of concurrency. In each Report on the global AIDS epidemic produced by UNAIDS every other year, attention has been drawn to the need to reduce multiple sexual partners. As early as 1998 UNAIDS drew attention in its Report on the global AIDS epidemic to the role of overlapping partnerships in increasing HIV spread in countries of southern and eastern Africa. UNAIDS has commissioned and published research which showed the role of partner reduction in contributing to Uganda’s successes in reducing HIV rates. The findings of those studies showed that partner reduction, condom uptake and delayed age at first sex all contributed to reducing HIV rates in Uganda. Epstein claims that the UNAIDS’ 2008 Report on the global AIDS epidemic shows increases in multiple partnerships in countries where prevalence declined. In fact in the UNAIDS 2008, Report on the global AIDS epidemic (p 34), the data on changes in young people’s behaviour, shows that for every decline in prevalence there was a significant decline in multiple partnerships or the measurable change was not significant. UNAIDS strongly supports national and regional HIV prevention efforts in southern Africa, and the special focus they have given to multiple concurrent partnerships. Addressing HIV risks within sexual relationships has always been one of the most difficult of programmatic challenges. For that reason UNAIDS has been a consistent supporter of the multi-faceted community-grounded responses. Understanding sexual networks is crucial to understanding the HIV epidemic. Considerable work is still needed to refine methods for measuring and comparing sexual norms, behaviours and networks in diverse cultural contexts and risk settings worldwide. More effective interventions are needed to overcome the denial and misunderstandings of HIV risk in concurrent and age-disparate relationships that are weakening prevention efforts in the region. Competing interests: None declared |
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Helen Epstein, Consultant/writer 424 West 144th Street, New York NY 10031, USA
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Paul Delay and I agree that addressing sexual transmission of HIV isn't easy, but UNAIDS's tomfoolery only makes it harder. Delay tacitly admits every charge I make in the piece. The agency did indeed publish a report on partner reduction in Uganda, but it did so in 2004, nine years after behavioral data on the Uganda decline, and the correct analysis of it, first became available in 1995. Page 36 of UNAIDS 2008 Global AIDS report states: "The proportion of young men and women (15-24) who had more than one partner in the previous 12 months decreased in 10 countries and remained unchanged in two but increased in young women in two countries and among young men in one." Now, in this letter, Mr Delay tells us that the Table on page 34, to which this sentence refers, shows these increases did not occur. So which does the agency maintain is true? Finally, UNAIDS mentioned concurrency in a long list of other risk factors in its 1998 Global AIDS report, but this hardly constitutes taking the issue seriously. Sincerely, Helen Epstein Competing interests: I am the author of the original article. |
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Helen Epstein, Writer 424 West 144th Street, New York NY 10031
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...if UNAIDS did recognize the dangers of concurrent long term partnerships--as distinct from typical "promiscuity"--in 1998, why didn't the agency help develop programs to warn vulnerable populations about this? Or even attempt to measure the frequency of these relationships until now--10 years later? Sincerely, Helen Epstein Competing interests: I am the author this article |
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Richard G Fiddian-Green, FRCS, FACS None
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Helen Epstein, independent consultant on public health in developing countries, claims that "AIDS prevalence is orders of magnitude greater in Southern Africa than in either Asia or the West (1). I am not familiar with the latest data but older data (2) does not support her claim. Neither did my personal observations a few years later(3). These included rounding on all patients in the Charles Johnson Memorial Hospital in Zululand, the epicenter of the AIDS epidemic in South Africa, visiting rural villages and looking at graveyards. Every operation has risks. Circumcision is not exempt even in Canada (4). Ritual circumcision in the Xhosa in South Africa can be primitive in the extreme and horrendous complications, some of which I have seen, and even death are not uncommon (5). Even when performed in a small cohort in a very recent study conducted by specially trained surgeons and nurses registered with the health department complications, albeit minor, were not uncommon (6). If uncontrolled in a rural rural environment complications and deaths in their hands are likely to be far more common and serious. "Aids experts have called for a mass circumcision programme in South Africa" (7). That would be disasterous for it would greatly increase the numbers at risk of complications and death. More importantly a mass circumcision program would reverse the healthy trend towards the abolition of circumcision. In the Zulus "the practice for ritual's sake has largely been modified/abandoned". Jacob Zuma showed a different way of addressing the risks of HIV infection: having a post coital shower. Those calling for mass circumcision need first to show that outcomes following prophylactic circumcision are better than those in uncircumcised controls taking post coital showers. How does Helen Epstein suppose a rural Xhosa or Zulu keeps clean if couples have to use very public local streams to carry out post coital ablutions, especially in the winter. South Africa has more pressing problems than worrying about HIV transmission. What its rural communities need is universal access to clean water, showers and sewerage systems. The costs are prohibitive unless Africans abandon their open styles of traditional rural housing and begin to live in cluster housing. 1. Epstein H. AIDS and the irrational. BMJ. 2008 Nov 25;337 2. AIDS in the World: a Global Report. Edited by Jonathan Mann, Daniel Tarantola and Thomas Netter. Harvard University Press 1992. 3. HIV/AIDS: the biggest error? Richard G Fiddian-Green bmj.com/cgi/eletters/320/7237/0#7270, 4 Apr 2000 4. Circumcision: A minor procedure? Paediatric Death Review Committee: Office of the Chief Coroner of Ontario. Paediatr Child Health. 2007 Apr;12(4):311-2. 5. Male Circumcision in South Africa. www.isixhosa.co.za/culture/circumcision.htm 6. Peltzer K, Nqeketo A, Petros G, Kanta X. Traditional circumcision during manhood initiation rituals in the Eastern Cape, South Africa: a pre-post intervention evaluation. BMC Public Health. 2008 Feb 19;8:64. 7. SA needs mass circumcision. www.news24.com/News24/South_Africa/Aids_Focus/0,,2-7-659_2126049,00.html 8. S Africa's Zuma denies Aids risk. news.bbc.co.uk/2/hi/africa/4875930.stm Competing interests: None declared |
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Nigel O'Farrell, Consultant Physician Ealing Hospital, Uxbridge Rd, London UB1 3HW
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Few would disagree about the importance both of concurrent sexual partnerships in the spread of STIs and HIV in Africa and the need for combination HIV prevention including male circumcision as discussed by Epstein (1). However there are other factors that might be contributing to the apparent paradox of Africa’s high HIV infection rates. Neither concurrent partnerships nor lack of male circumcision are unique to high prevalence HIV areas in Africa. In the UK, concurrent partnerships are not uncommon amongst the 16-34 age group (2) and in the general UK population, the prevalence of circumcision is relatively low as in high prevalence HIV areas in Africa (3). One biological risk factor associated with HIV not mentioned by Epstein that differs in prevalence between at least one high HIV prevalence area in Africa and the UK is penile wetness, a clinical finding that reflects poor genital hygiene and is uncommon in the UK (4, 5). Combination HIV prevention is clearly the way forward in Africa but should include messages about penile hygiene for those who decline to be circumcised or who have to wait for a procedure that is still both not without risk or acceptable in some African cultures. 1. Epstein H. AIDS and the irrational. BMJ 2008;337: 1265-1267 (29 Nov 2008) 2. Johnson AM, Mercer CH, Erens B, Copas AJ, McManus S, Wellings K et al. Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours. Lancet. 2001;358:1835-42. 3. Dave SS, Johnson AM, Fenton KA, Mercer CH, Erens B, Wellings K. Male circumcision in Britain: findings from a national probability sample survey. Sex Trans Inf 2003 499-500 4. O'Farrell N, Morison L, Moodley P, Pillay K, Vanmali T, Quigley M et al. Association between HIV and subpreputial penile wetness in uncircumcised men in South Africa. J Acquir Immune Defic Syndr. 2006;43:69 -77. 5. O'Farrell N, Morison L, Chung CK. Low prevalence of penile wetness among male sexually transmitted infection clinic attendees in London. Sex Transm Dis 2007;34:408-9. Competing interests: None declared |
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Luc Bonneux, Sr Researcher 2511 The Hague
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As an MSc student in Epidemiology, in the London School of Hygiene and Tropical Medicine 1987-1988, I wrote a paper on the transmission of HIV, part of which was published in 1989 (Bonneux L, Houweling H. Is an epidemic of heterosexually transmitted HIV infection possible in Europe? Ned Tijdschr Geneeskd 1989;133(39):1922-6.) The main point was that a selfsustaining heterosexual epidemic in Europe was not likely and would spread slowly. We could wait and monitor, before jumping to campaigns directed to the general population In simple transmission models, all showed the relative low importance of individual risk reduction, such as condom use, for generalised epidemics but the great importance of partner acquisition. You acquire a STD and you transmit a STD: that squares parameters of partner change and overwhelms all other effects. Unwanted pregnancies were actually increasing, condom use replacing more reliable contraception, a result of dreadfully wrong AIDS campaigns. Condoms are not safe contraceptives in inexperienced couples, they have never been. Condoms are efficacious in laboratory conditions but far less effective when used by sexually excited people, let alone if they drank alcohol or used other drugs during sex parties. What is still called "safe sex", condom use, is seriously unsafe in these conditions. As a then young epidemiologist, I was quite proud of these findings. I only got comments from independent epidemiologists. I was described as "not loyal" by the AIDS research community. Frightening the public was lucrative research business. Even after twenty years, I can be proud of my paper. All of it came true. Competing interests: None declared |
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