Circumcision, fidelity touted in AIDS fight

Some say Africa needs more than condoms, abstinence

By Laurie Goering
Tribune foreign correspondent

April 23, 2006

JOHANNESBURG -- The most promising way to stem Africa's worst AIDS epidemics appears to be encouraging male circumcision and faithfulness to a single partner at a time, not promoting condom use or abstinence, a new look at AIDS studies across the continent suggests.

Condoms are rarely used by regular sex partners, who are involved in much of the spread of the disease in southern Africa, the region of the continent worst hit by AIDS, studies show. And abstinence campaigns appear to simply delay the infection of young people by a year or two, Daniel Halperin, a leading U.S. AIDS prevention expert, said in a provocative speech last week in Johannesburg.

But persuading people to have just one sex partner at a time and men to be circumcised could help end what Halperin called a "perfect storm" of the disease in southern Africa. Circumcision appears to cut HIV transmission by 60 percent to 75 percent.

He and other researchers, who are analyzing 20 years of AIDS studies from throughout the continent for potential answers to the continuing spread of HIV, have tried to "put aside intuitions, emotions, ideologies and look at the evidence in as coldhearted a way as we can," he told an overflow crowd of doctors, medical researchers and AIDS activists at a meeting of the Southern African HIV Clinicians Society.

The result has been some decidedly counterintuitive conclusions about AIDS in Africa.

Condoms not only solution

Condom use, for instance, appears to have dramatically helped prevent the spread of the disease only in countries such as Ghana and Senegal, where sex workers and their partners are the major victims. In such countries as South Africa and Botswana, where the epidemic has reached the general population, condoms show relatively little protective effect, mainly because they are rarely used consistently by regular sex partners.

"There are no definitive examples yet of generalized [African] epidemics that have been turned back by prevention programs based primarily on condom promotion," UNAIDS, the United Nations leading agency on the disease, said in a report in 2003.

Similarly, wealth has not proved to be much protection. Though political leaders in nations such as South Africa call HIV a disease of poverty, the reality is that "contrary to popular wisdom, as income levels go up in both men and women, we see higher rates of HIV," said Halperin, an adviser on AIDS prevention and behavior change for the U.S. Agency for International Development. The reason, he said, appears to be that people with higher incomes tend to attract more sexual partners and have more money to spend on dating.

Also, encouraging people to know their HIV status appears to have little effect in stemming the spread of AIDS, studies show, and treating secondary sexually transmitted diseases like syphilis--once thought be a key contributor to transmission of HIV--also has shown little protective effect, he said.

What has worked, particularly in Uganda and Kenya, Halperin said, is faithfulness to a single partner at a time. A recent UNAIDS study shows that in Kenya, where HIV infection appears to be falling, there has been a 50 percent decline recently in people reporting more than one sex partner in the last year.

Uganda famously cut its infection rate largely through a prominent national campaign urging "zero grazing" beyond one sexual partner. And Ethiopia appears to be following suit with a "we're sticking one to one" campaign, Halperin said.

Pattern of several partners

While studies show southern Africans do not have more sex partners than people in other parts of the world, they appear to be at particular risk for contracting HIV because of a pattern of having several regular sexual partners at a time, rather than one partner after another, Halperin said.

Studies suggest that people newly infected with HIV quickly develop a very high level of the virus in their blood, making them more likely to pass the disease on in their first three weeks of carrying it than at any time for years afterward, he said.

If that highly infectious person has just one partner during those crucial weeks, that partner will likely be infected but not pass the disease on to anyone else.

But if the highly infectious person has several partners, and those people in turn have several partners, "the virus spreads like wildfire," Halperin said.