I recently visited Ethiopia to help conduct an HIV and AIDS prevention training program as part of a grant by the President’s Emergency Plan for AIDS Relief (PEPFAR). The participants were expecting yet another biological crash course in how to minimise the risk of infection. Instead, it centred around themes like true love versus false love, respect and communication. These are all aspects of mutual faithfulness as a strategy to avoiding HIV infection, the "B" of the Ugandan-inspired "ABC" strategy in which A=Abstinence, B=Be Faithful and C=Condoms.
For the men and women attending the training, the "Be Faithful" approach was a revelation and a relief. One woman, a wife and a mother, expressed a sentiment shared by many by saying she was pleased with this approach and the horizons it opened in people’s hearts and minds. But she was also puzzled as to why such basic human themes are not more routinely promoted in the context of HIV prevention, adding: "Why hasn’t anyone explained it like this before?" By the end of the week, another married couple decided to reunite instead of continuing to hold different jobs in different cities.
At the end of the day, then, it may in part be allegiance to ideology that is what ultimately keeps rather ineffectual HIV prevention interventions firmly entrenched, immune from erosion by the waves of reason, evidence and common sense.
In recent years, a growing body of evidence has steadily emerged that indicates faithfulness, or partner reduction, can be an effective, if oft-neglected, strategy in the fight against AIDS. In a large swath of southern Africa and parts of eastern Africa, the AIDS epidemic is being driven by the dynamics of multiple and often concurrent sexual partnerships. These behavioural patterns are inherently dangerous because "as soon as one person in a network of concurrent relationships contract HIV, everyone else in the network is placed at risk." (1)
Yet public knowledge of this prevention strategy is sorely lacking. In Lesotho, a national survey revealed that approximately 75 percent of respondents could identify condoms as a means of preventing HIV, but only approximately 5 percent of respondents identified abstinence or faithfulness as a means of avoiding HIV. More people in that survey were aware that "wearing gloves" (universal precaution against non-sexual transmission) was a means of avoiding HIV infection than they were that A and B were also means of avoiding HIV. (2) This data indicates a baffling lack of supply of life-saving messages, given that behaviour change has been present in all instances of HIV prevalence decline. (3)
In addition to multiple partnerships, a handful of researchers have also been tracking the relationship between the lack of male circumcision and high rates of HIV and AIDS. This research has been ongoing for some time, but has been in the news much more of late. In March, the Word Health Organization (WHO) cited three randomised controlled trials in South Africa, Kenya and Uganda, that found male circumcision provided a significant, though limited, form of protection against HIV transmission. (4) Overall, they indicated that the risk is approximately halved by male circumcision. (5) As a result, the WHO has added male circumcision to its arsenal of weapons for HIV prevention, alongside fixtures such as condoms, counselling and testing, and the treatment of other sexually transmitted infections (STIs).
Only two months later, however, the world's leading medical journal, The Lancet, issued a profoundly disturbing critique of WHO's judgement. (6) A Norwegian academic, after conducting extensive interviews with WHO staff, including its specialists in HIV and AIDS, concluded that when the agency draws up "evidence-based" guidelines, one key ingredient is often omitted: the evidence. "People are well-intended at WHO," the study’s author, Dr Andrew Oxman, told the Associated Press. "The problem is that good intentions and plausible theories aren't sufficient." And the editor of The Lancet, Richard Horton sounded a note of alarm about the world's leading health authority: "This study shows that there is a systemic problem within the organisation, that it refuses to put science first." (7)
What are we to make of this? How confident can we be that WHO's guidelines on HIV prevention are truly based on "compelling evidence" and are not simply expressions of personal bias or manifestations of underlying cultural presuppositions? One WHO director told Dr Oxman: "There is a tendency to get people around the table and get consensus—everything they do has a scientific part and a political part. This usually means you go to the lowest common denominator or the views of a 'strong' person at the table." (8) And as influential as "strong personalities" can be, ingrained ideologies can, quite simply, determine entire agendas as well. Has this been happening with WHO's HIV and AIDS prevention policies?
First, with respect to male circumcision, the scientific evidence is sound. The types of trials conducted offer the highest standard of evidence possible, and thus confer on male circumcision a protective effect an order of magnitude above that of the other pillars of HIV prevention policy that have been so routinely extolled. So far so good.
The problem arises when the WHO situates the new, biologically-based promise of male circumcision within its long-established, "comprehensive" package of technical or bio-medical interventions for which there is little evidence of impact on HIV incidence, to the exclusion of an adequate emphasis on the actual behaviour responsible for HIV transmission. This would suggest that perhaps Dr. Oxman was onto something -- that perhaps the WHO preferred strategy is deficient precisely because it is, though well intentioned, based on plausible theories generated through the prism of accepted ideological conviction – and not purely on scientific evidence.
Recipes for failure
Let's look at the strategies that have long constituted the WHO’s front line of defence in the fight against HIV and AIDS.
HIV testing and counselling services. Certainly counselling and testing are important for a host of reasons. Yet their impact on behaviour and on HIV incidence remains unimpressive. A recent randomised trial of voluntary control and testing (VCT) services in Zimbabwe concluded that, even "highly accessible VCT did not lead to declines in HIV incidence". (9) Another recent study from Uganda likewise found that VCT did not achieve either an HIV decline or behaviour change. This study also went on to suggest that HIV negative people who accept repeated sessions of VCT constitute a special risk group, due to their continued engagement in risky behaviour. (10) Another review of the impact of VCT on risk-taking behaviour and HIV incidence concluded that it would be difficult to assert that further scale-up of VCT would yield its hoped-for prevention benefits. (11)
Treatment for sexually transmitted infections (STI).The available evidence about the impact of treatment of STIs on HIV incidence is inconclusive. Only one of six randomised controlled trials designed to treat STIs in order to reduce HIV actually did so. (12) Treating STIs – a considerable source of morbidity in their own right – would be important even if there were no HIV epidemic. But it would be unwise to rely upon the treatment of other STIs to control HIV, especially in generalised epidemics.
Providing condoms and promoting their correct and consistent use. Of all recommendations, this is the most fervently defended. Yet, the WHO recommends prioritising male circumcision in countries with "generalised epidemics", such as South Africa, Zambia and Botswana. It is precisely in these regions, which are home to less than 3 percent of the world's population but account about half of all HIV cases, (13) where condoms have been most ineffectual. Even agencies with a vested interest in profiting from condoms and the United Nations have acknowledged this. An exhaustive review commissioned by its AIDS agency, UNAIDS, found that "prevention campaigns relying primarily on the use of condoms have not been responsible for turning around any generalised epidemic." (14)
After more than two decades of fighting the AIDS epidemic, it is clear we cannot expect much success from these secondary measures (condoms, VCT and STI treatment) that have been relied upon so heavily to date. It is puzzling that they continue to enjoy such privileged status.
What if the obesity epidemic were tackled in the same way, with subsidies for weight-loss drugs and blacklists of unhealthy food – but nothing said about eating less? What chance would there be of turning the tide? Rather, a change in behaviour is needed.
Indeed, actual changes in behaviour have led to the most significant reductions in HIV prevalence. The most important factor in HIV declines observed in Uganda, Kenya, Zimbabwe and Haiti has been an increase in "fidelity" or "partner reduction." (15) In contrast, South Africa has been a vigorous promoter of condoms, but its persistent rates of multiple partnerships have helped account for its sustained, alarmingly high incidence. (16) Given much well-documented evidence, it is entirely reasonable to conclude that greater attention needs to be placed on the actual behavioural dynamics of HIV transmission. Several in the scientific community have persuasively – and bravely – argued for this course of action.
At long last, some realism
A 2006 gathering of leading HIV prevention technical experts at the Southern African Development Community (SADC) challenged the conventional wisdom represented by WHO and appropriately shifted the emphases in its recommendations. The two key drivers of the epidemic in the region were identified as high levels of concurrent partnerships by men and women and low levels of male circumcision. This combination was described as a "lethal cocktail".
SADC pinpointed the main drivers of HIV transmission and crafted sensible responses. First it seeks to "reduce multiple, concurrent partnerships for both men and women." It backs "mass campaigns or social movements -- with strong political, religious and community leadership – discouraging multiple partnerships and accurately depicting them as a threat to individual and public health." Other key recommendations include "addressing gender issues especially from the perspective of male involvement and responsibility" and the preparation "for potential national roll-out of male circumcision." (17)
Identifying the underlying policy drivers
There is no sound reason why the WHO recommendations for containing HIV in generalised epidemics cannot budge as well, in response to the epidemiological track record. So, if scientific observation has found the principal HIV prevention pillars to be lacking, why has the WHO and other international aid agencies emphasised them so reflexively – even in the face of mounting doubts over their impact on transmission patterns?
It is reasonable to speculate that, just as multiple partners and the lack of male circumcision serve as the drivers of HIV transmission in generalised epidemics, there are ideological drivers of international HIV prevention policy, which could be described as a "lethal mix" of utilitarianism, relativism, and individualism (an exaggerated sense of human autonomy). These schools of thought dominate public health thinking, drive HIV prevention policy, and ultimately dictate priority recommendations. Quite intentionally, they eschew considerations of the moral dimensions of human actions, even as they replace them with their own claims and preferences. As such, they advance no internally consistent or coherent rationale for limiting sexual partnerships, and thus tend to yield interventions that could only be considered "secondary" measures of HIV prevention.
To the extent that these measures are enlisted to help achieve "the greatest good (read: pleasure) for the greatest number," they are quintessentially utilitarian. Even if many are unaware of it, this maxim influences our thinking and conclusions about many complex social issues. Though it may have a certain intuitive appeal, it masks considerable flaws.
For one thing, it rests on the assertion that the value or worth of an act is determined solely by its consequences. Contracting HIV would be an undesirable consequence, so all remedies short of an actual shift in behaviour – even if they can only hope to reduce the risk of infection – are urgently summoned to offset this possibility. In the process, however, these measures can serve to facilitate, as the name itself implies, the use or exploitation of one person by another. The wholesale reliance upon this utilitarian calculus as the basis for HIV prevention policy, though intended to reduce harm, has led not to a decreased burden of disease, or of other, very real, internal wounds. Instead it has helped to perpetuate what John Paul II described as "a civilisation of things and not of persons, a civilisation in which persons are used the same way things are used." (18)
Even secular commentators such as University of California at Berkeley sociology professor Robert Bellah, have lamented "the sombre utilitarianism" in which "the Other becomes an instrument to one’s self-fulfilment; if they obstruct it or lose attraction, or stop fulfilling the needs of the self, they are discarded".(19)
At the end of the day, then, it may in part be allegiance to ideology that is what ultimately keeps rather ineffectual HIV prevention interventions firmly entrenched, immune from erosion by the waves of reason, evidence and common sense. But a reasoned approach to the behavioural dynamics of HIV transmission will never feel threatened by evidence. Rather it should be welcomed as a means of achieving greater clarity and focus, and could go a long way towards forming more sensible recommendations in the true service of the human person. What is required is a reorientation towards bedrock principles of public health, such as "primary prevention" and "do no harm" within a sound, "person-centred" ethical framework.
Finally, the millions suffering from AIDS in Africa are not the only casualties of misguided policy emphases and omissions. The WHO itself suffers. Turning a blind eye to contradictory opinions and data, and clinging to feeble secondary measures at the expense of valid, primary measures, is decidedly irrational, and undermines its own scientific credibility. It should strive to meet its own noble scientific ideals rather than abdicating them for the more comfortable position of conformity with the Zeitgeist. Referring to the Lancet’s critique of its guidelines for a broad range of global health issues, the WHO's Director of Research Policy, Dr Tikki Pang acknowledged, "We know our credibility is at stake, and we are now going to get our act together." (20)
Revising its HIV prevention guidelines would be a good place to start.
Matt Hanley is co-author, along with Jokin de Irala and Christina Lopez, of "Propontelo, Proponselo: Evitar el Sida". An updated version of this book dealing with the global AIDS pandemic, entitled "Avoiding Risk, Affirming Life: Science, Love and, AIDS", will soon be available in English.
(1) Halperin, D. "Concurrent sexual partnerships help to explain Africa’s high HIV prevalence: implications for prevention" The Lancet, Vol 364 July 3, 2004
(2) Lesotho Ministry of Employment & Labour, Report on HIV/STI KAP of Basotho Miners and Farm Workers
(3) See Stammers, T. "As easy as ABC? Primary prevention of sexually transmitted infections." Postgraduate Medical Journal 2005;81:273-275
(4) WHO and UNAIDS announce recommendations from expert consultation on male circumcision for HIV prevention. March 28, 2007 (http://www.who.int/mediacentre/news/releases/2007/pr10/en/index.html)
(5) Auvert, B. et al., Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 trial, PLoS Medicine, 2005;2:1112-1122. Bailey et. al. "Male Circumcision for HIV prevention in young men in Kisumu, Kenya: A Randomized Controlled Trial" The Lancet 2007. 369:643-56. Gray et al., Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657.
(6) Oxman et al. "Use of evidence in WHO recommendations’ The Lancet, 9 May 2007 (Published online: www.thelancet.com) DOI:10.1016/S0141-6736(07)60675-8
(7) Cheng, Maria "WHO Criticized for Neglecting Evidence" Associated Press. May 7, 20007
(8) Oxman et al. "Use of evidence in WHO recommendations’ The Lancet, 9 May 2007 (Published online: www.thelancet.com) DOI:10.1016/S0141-6736(07)60675-8
(9) Corbett et. al. "HIV incidence during a cluster-randomized trial of two strategies providing voluntary counselling and testing at the workplace, Zimbabwe" (AIDS, 2007 21:483-489)
(10) Matovu et. al. Repeat Voluntary Counseling and Testing (VCT), Sexual risk Behavior, and HIV Incidence in rakai, Uganda. AIDS Behavior 2007. 11:71-78
(11) Glick, P. "Scaling up HIV Voluntary Counseling and testing in Africa: What can evaluation studies tell Us About Potential Prevention Impacts?" SAGA working paper, March 2005
(12) Halperin, D. "Evidence-Based Behavior Change; HIV Prevention Approaches for Sub-Saharan Africa" Harvard University Program on AIDS: Seminar Series. Jan. 17, 2007
(13) Epstein, Helen. "Africa's lethal web net of AIDS; The quiet acceptance of informal polygamy is spreading the risk" Los Angeles Times, April 15, 2007
(14) Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? Stud Fam Plann 2004; 35: 39-47
(15) SADC Expert Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern Africa. Lesotho, May 2006
(16) Shelton, J. "Confessions of a Condom lover." Lancet, Vol. 368, December 2, 2006.
(17) SADC Expert Think Tank Meeting on HIV Prevention in High-Prevalence Countries in Southern Africa. Lesotho, May 2006
(18) John Paul II, Letter to Families, 1994
(19) Fisher, Anthony, O.P. "Moral Theology from Vatican II to John Paul II" Lecture to Australian Confraternity of Catholic Clergy National Conference, Galong, 14 July, 1998
(20) Cheng, Maria "WHO Criticized for Neglecting Evidence" Associated Press. May 7, 20007
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