Back to basics in HIV prevention: focus on exposureBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7403.1384 (Published 19 June 2003) Cite this as: BMJ 2003;326:1384
All rapid responses
Pisani et al. (2003) advocate using evidence on the source of
incident HIV infections to prioritise resources . The paper focuses on
HIV surveillance, and rightly argues that country-by-country monitoring of
behaviour and patterns of incident infection would better inform the
prioritisation of resources. However, it falls short when discussing the
broader implications of the distributions of new HIV infections presented,
as it does not acknowledge the limitations of current options to respond.
For example, in Cambodia, in part because of the successes of condom
promotion among sex workers, in 2002 over 60% of incident infection were
due to ‘heterosexual sex with a partner at higher risk of infection’, and
the authors call for prevention strategies to reduce transmission between
spouses who may previously have been exposed to HIV through buying and
selling sex. Likewise, substantial proportions of incident infection in
Honduras, Kenya and Russia were identified as being from heterosexual sex
with a partner at risk. However, although high levels of condom use can be
achieved in commercial and some casual sexual relationships, the desire to
conceive and the common association of condoms with a lack of intimacy
make their consistent use in long-term partnerships difficult to achieve.
In representative household surveys of women in 14 African countries, less
than 7% reported condom use in the last sex act with their main partner.
Surveys of sex-workers in 4 states of India and of street sex-workers in 5
cities of Vietnam generally found that less than 40% reported condom use
in their last non-commercial sex act (an exception is in Maharashtra
brothels, where 70% reported condom use). Similarly, only 17% of
injecting drug users in Togliatti, Russia reported condom use with their
regular partner .
This highlights the urgent need for additional prevention methods for
use in spousal and other long-term partnerships. Options include
microbicides - gels, creams, and suppositories - that when used vaginally
could reduce transmission of HIV (and potentially other sexually
transmitted infections). Over 60 products are at different stages of
development, including 17 in clinical trials. With sufficient funding one
could enter Phase III effectiveness trials later this year, and an
additional four could enter Phase II expanded safety trials in late
2003/2004 . As microbicides could be promoted as a hygiene product for
use in spousal partnerships and could potentially allow conception, they
would be an important addition. Their development should be prioritised.
Charlotte Watts, Anna Foss
Health Policy Unit,
Department of Public Health and Policy,
London School of Hygiene and Tropical Medicine
1. Pisani E, Garnett GP, Brown T, Stover J, Grassley NC, Hankins C.
et al. Back to basics in HIV prevention: focus on experience. BMJ
2. Foss A, Watts C, Vickerman P, Kumaranayake, L. Are people using
condoms? Current evidence from Sub-Saharan Africa and Asia and the
implications for microbicides. Mimeo Report, HIVTools Research Group,
London School of Hygiene and Tropical Medicine June 2003.
3. Rhodes T, Lowndes CM, Judd A, Mikhailova L, Sarang A, Rylkov A.
et al. Explosive spread and high prevalence of HIV infection among
injecting drug users in Togliatti City, Russia. AIDS 2002;16: F25-F31.
4. Stone A. Microbicides: a new approach to preventing HIV and other
sexually transmitted infections. Nature Rev Drug Discov 2002;1(12): 977-
5. Harrison P. Personal communication to Foss A. March 2003.
CW and AF receive partial salary support from research grants from the EU, the Programme for Appropriate Technologies in Health, and the UK MRC that support mathematical modelling of microbicide impact and its determinants
Competing interests: No competing interests
Editor – The paper by Pisani et al reports that a commonsense
approach based on simple country by country analyses could improve the
efforts to prevent HIV infection.1
Therefore as public health doctors, we find that this approach is always
too limited and we venture to say "we have never been modern". The
partition of knowledges and expertises compels us, contempories, to
redesign our modernity in front of constraints imposed to changes and
innovations by man and society. New knowledges are emerging to fill the
gap between theory and process to knowledge, between knowledge and psycho-
social reality of individuals and societies.2
With AIDS, the question is to put our questioning in centre of the
thinking. The AIDS problem puts forward the ambivalence of a systemic
approach and different nets with individual training identities,
specialisations, expertises, institutions. It is indeed a public health
questioning : how far are we prepared to understand our systems and nets
though such a complicated problem, AIDS.
And now we have this opportunity. Before analysing the situation or
proposing strategies of action, we must first understand. Understand the
individual, drug addict person, prostitute person, young person, person in
the street, married person, the person him(her)self. The understanding of
the personal and temporal vulnerability multiplies endlessly specific
situations.3 To understand this individual within his group, a closed or
open system reflection of his society and his own context. To understand
the intricate net of micro, meso and macro systems of organisation in
which behaviours and attitudes leading to the development of the disease
get into place.
There appears to be a disproportion in competences capacities in the
health system against a much wider problem. First step is to ascertain it.
Then one must question oneself on the part the health system must play in
this intricate net. How far is the health system capable of adapting
itself to the needs of this disease and these patients. But above all how
far can the health system improve the well-being of the persons, their
family and friends confronted with the risk of sero-positivity and the
Part of a wider net, the health system can now consider his own concepts
of "integration" and "globality". Confronted to the individual or to the
system in its whole, these concepts have to be reconsidered when
approaching AIDS in health. How far will a program approach of a health
problem like AIDS lead to the development of a net of competences and
capacities able to respond to the demand of a multidisciplinary vision in
order to install necessary "global" strategies?
How far is the decentralised health system more capable to adopt social
and environmental dimensions needed for this approach? What are the
different mechanisms that the health system can install in order to better
understand the answer given to AIDS within the associative, social and
family net. How can we add the technical answer to the sociological,
psychological and economical answer?
Surely the health system can give a coherent technical, integrated and
global answer. In public health, some "verticalist" have adopted a
systematic tendency integrating more the health system, others have gone
further in imposing a systemic approach to all their actions in public
health, be it AIDS related problems. With AIDS, an additional dimension
is put forward, which includes the idea of net, superior to the system and
favourable to the emergence of a dual way of thinking, cross-roads to
sociological, epidemiological, medical, psychological, anthropological,
political, philosophical sciences.
1. Pisani E, ,Garnett GP, Grassly NC, Brown T, Stover J, Hankins C, Walker
N, Ghys PD. Back to basics in HIV prevention: focus on exposure. BMJ
2. Delor F, Hubert M. Revisiting the concept of 'vulnerability'. Social
Science & Medicine 2000;50 (11):1557-70.
3. Groupe Thématique ONUSIDA Maroc. L'approche culturelle dans la lutte
contre le VIH/SIDA. Regional Conference, Fès (Maroco), 2001.
Competing interests: No competing interests