Reducing heterosexual transmission of HIV in poor countries
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7331.207 (Published 26 January 2002) Cite this as: BMJ 2002;324:207
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EDITOR – According to Peter Lamptey1 "In Africa slightly more than 80% of infections are acquired heterosexually". The high levels of
heterosexual infection in Africa have been "generated by actuarial models and antenatal data"2. These high levels are not supported by data
originating from prospective epidemiological studies.
In 1997 Padian published a paper entitled "Heterosexual Transmission of Human Immunodeficiency Virus (HIV) in Northern California: Results
from a Ten-Year Study" 3. The data were divided in two parts, cross-sectional and prospective. From the cross-sectional study they estimated
that: "infectivity for male-to-female transmission is low, approximately 0.0009 per contact" and "approximately eight-times more efficient than
female-to-male transmission". Using their estimate of male-to-female transmission, it would take 770 or 3333 sexual contacts respectively to
reach a 50% or 95% probability of becoming infected. If sexual contact were to take place repeatedly every three days this would require a
period of 6.3 and 27.4 years respectively. Based on Padian’s estimate of female-to-male transmission it would require 6200 and 27000
contacts and a period of 51 and 222 years respectively (see Table).
In 2001, a community based study4 was reported from Uganda, where "174 monogamous couples, in which one partner was HIV-1 positive,
were retrospectively identified from a population cohort" involving 15,127 individuals. The probability of transmission per sexual contact was
0.0009 for male-to-female and 0.0013 for female-to-male respectively (see Table). The authors concluded that "The probability of HIV
transmission per sex act in Uganda is comparable to that in other populations, suggesting that infectivity of HIV subtypes cannot explain the
explosive epidemic in Africa"5. In other words, there is no more heterosexual transmission of HIV in Africa than anywhere else, including Britain,
USA, Australia and Europe.
Table. Number of years to attain 50% and 95% probabilities transmission of HIV assuming sexual contact once every three days
Table. Number of years to attain
50% and 95% probabilities transmission of HIV assuming sexual contact once every
three days
|
STUDY |
DIRECTION OF TRANSMISSION |
per contact PROBABILTY |
Years for 50% PROBABILTY |
Years for 95% PROBABILTY |
|
USA |
M to F |
0.0009 |
6.3 |
27.4 |
|
F to M |
0.0001125 |
51 |
222 |
|
|
Uganda |
M to F |
0.0009 |
6.3 |
27.4 |
|
F to M |
0.0013 |
4.4 |
19.5 |
Eleni Papadopulos-Eleopulos Biophysicist, Department of Medical Physics, Royal Perth Hospital, Perth, Western Australia
Valendar F. Turner Consultant Emergency Physician, Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia
John M Papadimitriou Professor of Pathology, University of Western Australia, Perth, Western Australia
Helman Alfonso Department of Research, Universidad Metropolitana Barranquilla, Colombia
Barry A. P. Page Physicist, Department of Medical Physics, Royal Perth Hospital, Perth, Western Australia
David Causer Physicist, Department of Medical Physics, Royal Perth Hospital, Perth, Western Australia
Sam Mhlongo Head & Chief Family Practitioner, Family Medicine & Primary Health Care, Medical University of South Africa, Johannesberg, South Africa
Todd Miller Assistant Scientist, Department of Molecular and Cellular Pharmacology, University of Miami School of Medicine, Florida, United States of America
Christian Fiala Gynaecologist, Department of Obstetrics and Gynaecology, General Public Hospital, Korneuburg, Austria
References
1. Peter R Lamptey Regular review: Reducing heterosexual transmission of HIV in poor countries. BMJ 2002; 324: 207-211.
2. Stuart W Dwyer President Mbeki might have a case on rethinking AIDS. BMJ 2002; 324: 237
3. Padian NS, Shiboski SC, Glass SO, Vittinghoff E. Heterosexual transmission of human immunodeficiency virus (HIV) in northern California: results from a
ten-year study. American Journal of Epidemiology 1997;146:350-357.
4. Gray RH, Wawer MJ, Brookmeyer R, et al. (2001). Probability of HIV-1 transmission per coital act in monogamous heterosexual, HIV-1 discordant couples in
Rakai, Uganda. Lancet 357:1149-1153.
5. Gray RH, Brookmeyer R, Wawer MJ, et al. The Probability of HIV-1 Transmission Per Coital Act in Monogamous HIV-Discordant Couples, Rakai, Uganda.
8th Conference on Retroviruses and Opportunistic Infections 2001, Chicago.
Competing interests: No competing interests
"Circumcision prevents HIV infection" is a medical myth.
EDITOR--Lamptey has produced a useful and valuable review of the AIDS epidemic.1 Unfortunately, he advocates male circumcision to reduce HIV infection. In reality, the view that male circumcision can reduce or eliminate HIV infection is not supported by recent evidence.
This idea originated in the 1980s when the late Aaron J. Fink, M.D., proposed that circumcision could prevent HIV infection.2 Dr. Fink was a noted proponent of male circumcision.2 There seems to have been little science and a lot of promotion of male circumcision behind his claim.
Several early studies seemed to indicate that male circumcision had a protective effect against HIV infection.3 Later, the Rakai project identified viral load and genital ulcers as the primary determining factors in HIV infection.4 In addition to other previously identified methodological flaws, the early studies did not control for viral load,3 they cannot be considered to be scientifically valid.
Circumcision proponents have published several opinion pieces that argue that male circumcision prevents HIV infection.5,6 The authors, however, have been unsuccessful in convincing medical authorities of the value of circumcision in reducing HIV transmission/reception. The Council on Scientific Affairs of American Medical Association calls male circumcision a "non-therapeutic procedure" and said that "circumcision cannot be responsibly viewed as 'protecting' against such infections."7 UNAIDS says that relying on male circumcision is "like playing Russian roulette with two bullets in the gun instead of three."8
The origin of the hypothesis that circumcision prevents HIV infection9,10 suggests that the true motivation of circumcision advocates may be the preservation of the outmoded practice of non-therapeutic male neonatal circumcision in North America, not the prevention of HIV infection in Africa and elsewhere.
Recent evidence shows male circumcision to be of no value in preventing HIV transmission reception in both heterosexual and homosexual contacts.4,11 The medical evidence now indicates that the statement, "male circumcision prevents HIV infection" should be regarded as a medical myth.
George Hill, Executive secretary.
Doctors Opposing Circumcision, 2442 NW Market Street, Seattle, Washington 98107, USA.
- Lamptey PR. Reducing heterosexual transmission of HIV in poor countries. BMJ 2002;324:207-211.
- Position Statement on the Use of Male Circumcision to Limit HIV Infection. San Anselmo, California: NOCIRC, 2001.
de Vincenzi I, Mertens T. Male circumcision: a role in HIV prevention?AIDS 1994;8(2): 153-160.
- Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet 2001; 357: 1149-53.
- Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet 1999;354:1813-1.
- Szabo R, Short RV. How does male circumcision protect against HIV infection?BMJ 2000;320:1592-1594.
- Council on Scientific Affairs, American Medical Association. Report 10: Neonatal Circumcision. Chicago: American Medical Association, 1999.
- UNAIDS. Report on the global HIV/AIDS epidemic. Geneva: UNAIDS, June 2000: p.71.
- Fink AJ. A possible explanation for heterosexual male infection with AIDS. N Engl J Med 1986;315:1167.
- Fink AJ. Newborn circumcision: a long-term strategy for AIDS prevention. J R Soc Med. 1989;82(11):695.
- Grulich, AE, Hendry O, Clark E, et al. Circumcision and male-to-male sexual transmission of HIV. AIDS 2001; 15(9):1188-1189.
Competing interests: No competing interests
Dr. Lamptey, Thanks for your excellent article in the BMJ. The
HIV/AIDS pandemic must be kept in the news until the epidemic is ended. My
wife and I have offered a very simple basic plan to end the epidemic. It
can be found at www.justsixthings.com. We hope that everyone in sub-
Saharan Africa and Asia and eastern Europe can learn these six things in
the next few months. Each child and adult needs the tools to know how to
stay healthy. Thanks, Dr Wicklund
Competing interests: No competing interests
Decreasing the risk of HIV infection: The importance of prevalence
In a recently published paper, Lamptey (1) made a very informative
review, highlighting the significance of heterosexual transmission in the
HIV/AIDS pandemic in resource-poor settings, specifically in Africa.
The author described two universal types of interventions to change
behaviors: those targeting the general population and those for high-risk
groups. He described high-risk groups (of acquiring HIV infection) as
typically including sex workers and their clients, people who are highly
mobile, such as truck drivers, and the military and police. To the
author’s list, I would also include people living in countries/areas with
a very high HIV prevalence. HIV prevalence is a significant factor in the
heterosexual transmission of the HIV infection in Africa, and it should be
taken into account in prevention programs. Efforts and messages to
decrease or control the risk of HIV infection should be different in a
countries a low HIV prevalence like Equatorial Guinea vs. high prevalence
countries like Botswana.
According to the Bernoulli model of HIV transmission (2), the probability
of HIV infection (p) is determined by the total number of sexual acts (n),
the prevalence of HIV infection (p) in the population, the presumed
infectivity of HIV per sexual act (a), and the number of partners (m).
In areas/countries with a low HIV prevalence, the probability of HIV
infection from a mutually monogamous relationship is very small even
without condom use. On the other hand, countries/areas with a very HIV
prevalence rate, the probability of eventual infection may be quite
significant for the same behavior. Efforts promoting monogamy to prevent
HIV transmission specifically in very high prevalence areas in Africa
should also add or emphasize knowing the HIV serostatus of the partner
prior to engaging in unprotected sex, even in marital or mutually
monogamous relationships.
1. Lamptey PR. Reducing Heterosexual Transmission of HIV in Poor
Countries. BMJ 2002; 324: 207-11.
2. Pinkerton DP and Abramson PR. Evaluating the Risk: A Bernoulli
Process Model of HIV Infection and Risk Reduction. Evaluation Review 1993;
17(5): 504-28.
Competing interests: No competing interests