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Editorials

Rising rates of HIV infection

BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7487.320 (Published 10 February 2005) Cite this as: BMJ 2005;330:320

Rapid Response:

ABC is a (social) vaccine against HIV with high effectiveness

The dramatic fall of HIV prevalence rates in Uganda, which have fallen by two-thirds over the past decade, is in stark contrast to the more than doubling in HIV prevalence in the UK over the same period. The main contributing factors in the reduction of HIV prevalence in Uganda were behavioural changes coupled with change in communication about the disease.

The most important factor in the Ugandan success of ABC is B – ‘be faithful’, i.e. partner reduction. (1) The 70% reduction in HIV prevalence in Uganda was preceded by a 60% reduction in casual sex. There has been condom promotion in Uganda, but only with an ever (lifetime) condom use of only about 20%. Therefore, condom use in itself could not have contributed to the fall in HIV prevalence in Uganda. Indeed, condom use in Uganda is somewhat lower than in neighbouring African countries, which, despite heavy condom promotion, have not experienced such dramatic HIV reductions. (2)

Robinson and Gazzard claim that ‘The lower rate of infections [in Uganda] now may be associated with the lower rate of transmissibility during the latent period of infection.’ However, if this assumption were correct, similar reductions of HIV prevalence should by now have bee observed in countries such as Kenya, Malawi and Zambia which showed – at least initially – a similar pattern of the HIV epidemic to Uganda. However, none of these three countries have seen such a dramatic fall in HIV prevalence as Uganda has. (2)

Robinson and Gazzard furthermore state that ‘The ideal prevention would be a universally available vaccine against HIV.’ In a recent review, Stoneburner and Low-Beer find that the behavioural and communication changes in Uganda are equivalent to a ‘social’ vaccine against HIV with 80% effectiveness. (2)

The same authors find that, wherever there has been a significant reduction in HIV prevalence, such as in Uganda or in Thailand, there has been both a significant change in communication about the disease and changes in behaviour, such as partner reduction. (3)

The number of sexual partners appears to be the most significant risk factor for acquiring a sexually transmitted infection. In the UK, there has been a significant increase in lifetime sexual partners, increase in concomitant partnerships and increasingly risky sexual behaviour UK. (4) These behavioural changes (in the wrong direction) continuing to drive the UK epidemic of STIs including HIV. I am convinced that UK policy could learn a thing or two from the Ugandan approach of behavioural change (in the right direction) focussing on partner reduction [B], abstinence [A] and, if this is not possible, consequent condom use [C]. This needs to be coupled with better communication, for example on the risks of STIs, which (especially for non-HIV STIs) are often not as effectively prevented by condom use than many might think. (5)

Yours sincerely Dr Hans-Christian Raabe MD MRCP MRCGP DRCOG Toronto, Ontario, Canada hcraabe@yahoo.com

Footnotes 1. United States Agency for International Development: The ‘ABCs’ of HIV prevention. ‘ABC’ Expert Technical Meeting September 17, 2002. 2. Stoneburner RL, Low-Beer D. Population level HIV declines and behavioural risk avoidance in Uganda. Science, 2004; 304: 714ff. 3. Low-Beer D., Stoneburner RL : Behaviour and communication change in reducing HIV: is Uganda unique? African Journal of AIDS Research 2003, 2(1): 9–21. 4. Johnson AM et al. Sexual behaviour in Britain: partnerships, practices, and HIV risk behaviours. National Survey of Sexual Attitudes and Lifestyles; Natsal 2000; Lancet 2001: 358; 1835-42. 5. The Medical Institute for Sexual Health: Sex, condoms and STI’s – what we now know. 2002

Competing interests: None declared

Competing interests: No competing interests

12 February 2005
Dr Hans-Christian Raabe
General Practitioner
Toronto, Ontario, Canada M5S 2W8