IJE International Epidemiological Association 2004; all rights reserved.

International Journal of Epidemiology 2004;33:12

DOI: 10.1093/ije/dyh167
Commentary: Still dying of ignorance? Human
immunodeficiency virus (HIV) prevention
strategies revisited
Margaret May
In 1987 there was an advertising campaign in the UK which
started with a volcano erupting and moved on to show a man
chiselling on a tombstone the letters AIDS. This campaign
which gave advice on how to prevent transmission of human
immunodeficiency virus (HIV) had as its strap line Dont die of
ignorance. The implication of this message is that AIDS is
a preventable disease provided we are in possession of certain
knowledge which we use to inform our behaviour. Seventeen
years later has the promise of that campaign been fulfilled? The
volcano has certainly erupted: figures released by the Joint
United Nations Programme on HIV/AIDS (UNAIDS) show that
globally in 2003, an estimated 5 million people were infected
with HIV and 3 million died of AIDS, with both figures having
increased from 2002.
1
This increase is not confined to developing
nations: in the US there has been a 5% increase in HIV infections
over the past 3 years according to figures released by the
Centers for Disease Control and Prevention (CDC).
1
UNAIDS
estimates that worldwide there are now 40 million people living
with HIV/AIDS. More than half of these live in sub-Saharan
Africa where prevalence rates are as high as 40% in countries
such as Botswana and Swaziland. HIV is truly a biological weapon
of mass destruction (WMD).
In 2004 there is no doubt that the pandemic is becoming worse,
causing devastation in Africa and threatening to engulf India and
other parts of Asia. So the general picture is very gloomy, but
there are some success stories, one of which is the marked
decline in incidence of HIV infection in Uganda. This decline has
been well documented and is often held up as an example of what
can be achieved.
2
The paper by Stoneburner and Low-Beer in
this issue of the International Journal of Epidemiology
3
analyses
the factors leading to the decline and argues that it is crucial to
understand this Ugandan success in disrupting the spread of HIV
if similar policies are to be implemented elsewhere in Africa.
Uganda implemented a traditional public health approach to
the problem of prevention of HIV infection. The government
ran campaigns to warn people of the risk and provided risk
reduction information and education as early as 1987, the same
year as the tombstone advertisement in the UK. The thrust of the
message was AIDS is to be feared, casual sex has consequences,
love carefully and zero graze (practise monogamy), and care for
people with AIDS rather than stigmatize them. Stoneburner
and De Beer
3
analysed HIV prevalence among pregnant women
in Uganda, Kenya, Zambia, and Malawi using data collected from
antenatal clinics between 1991 and 1998. In Uganda the overall
HIV prevalence rate fell by 54% from 21% in 1991 to less than
10% in 1998. There was an even greater decline in prevalence of
75% in the1519 year age group whose rate fell from 21% to 5%.
The reduction in HIV prevalence in Uganda has been attributed
to increased condom use, sexual abstinence, delaying first sexual
experience, reduction of multiple partners, provision of clinics
to treat sexually transmitted diseases (STD), and voluntary coun-
selling and testing programmes.
4
It is likely that all these measures
contributed to the decline, but, according to this paper, the key
behavioural change was a 60% reduction in multiple sexual
partners.
3
Their evidence is based on comparisons with Kenya,
Zambia, and Malawi, countries which did not show a decline in
HIV prevalence over the same period. The authors examined data
from Demographic and Health Surveys in these countries over the
same time period which revealed that all countries had similar
levels of primary sexual abstinence and increased condom use,
but that reduction in number of partners occurred only in
Uganda; the rates of multiple sexual partnerships in the other
countries remained similar to that in Uganda in 1989. Their
conclusions are that reducing the number of sexual partners
was critical to interrupting the transmission of HIV in Uganda,
particularly amongst young adults, and that current rates of
condom usage in other African countries are insufficient to affect
the spread of the virus.
3
It would appear that estimates of the level to which universal
condom promotion would reduce HIV infection rates in Africa
were over-optimistic and nave. Countries such as Zimbabwe
achieved the same condom use as Uganda, but their HIV pre-
valence continues to rise. Attributing Ugandas success to condom
use is still occurring, for example, in a commentary in the Lancet
on HIV in children.
5
Stoneburner and Low-Beer maintain that
this focus on condom use is deflecting attention from the real
explanation for HIV declines in Uganda. They claim that a
successful campaign to reduce multiple sexual partnerships is
a social vaccine for AIDS with 80% efficacy. Furthermore, it is
a solution developed by communities in Africa that could avert
millions of deaths and prove more effective than any potential
bio-medical approach.
3
Are there other lessons to be learnt from Uganda? The
Ugandan communities were urged not to blame those infected
with HIV, but to care for them. What happens in communities
where the opposite happens? Stigmatization of those with HIV
positive status leads to concealment which results in further
infections. Women who live in strongly patriarchal societies who
become HIV infected often suffer discrimination and stigma-
tization. They may be shunned or cast out of normal society and
1 of 2
(All websites accessed 30 January 2004.)
University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
E-mail: [email protected]
Int. J. Epidemiol. Advance Access published May 6, 2004
not receive care. This situation may result in women who become
HIV positive being driven to prostitution as the only way of
surviving and hence becoming instruments in spreading the
disease further.
1
Forty per cent of governments worldwide have
yet to adopt anti-discrimination laws to protect people who
are infected with HIV.
Vertical transmission of HIV from mother to child resulted
in 800 000 children being infected in 2002.
6
In Uganda, the
prevention of transmission of HIV amongst young adults will
have been a powerful factor in preventing babies being born
HIV positive. However, the growth of the paediatric pandemic,
particularly in Africa, requires more urgent action. In particular,
when women know they are HIV positive, they may wish to avoid
becoming pregnant, but their contraceptive needs are not
currently being met due to inadequate health services provision
resulting in unwanted pregnancies.
7
Furthermore, antiretroviral
drugs administered to pregnant women who are HIV positive
can reduce peripartum transmission rates to around 5% in breast-
feeding populations.
8
Unfortunately, the estimated coverage for
the uptake of this intervention is currently only around 5% of
all African HIV-infected pregnant women.
6
A powerful part of the Ugandan public health campaign, and
also of that in the UK in 1987, was to instil a fear of HIV infection
which altered high-risk sexual behaviours in individuals.
Unfortunately, in 2004 there is evidence of complacency, parti-
cularly in developed countries where HIV infection is no longer
seen as a death sentence as effective antiretroviral drugs are
available. There has been an increase in other STD which may
presage a new increase in HIV incidence. France, Ireland, The
Netherlands, and the UK have reported outbreaks of syphilis in
men who have sex with men and in England and Wales diagnoses
of gonorrhoea at sexually transmitted infection clinics rose by
102% in 19952002.
1
People are not dying of ignorance, but of lack of implementa-
tion of scientific knowledge. The theme for the AIDS 2004
conference in Bangkok, Thailand, is Access for All reflecting
the need for us to make the multitude of scientific knowledge
and experience accessible to all, at every level of the fight against
HIV/AIDS.
9
It is to be hoped that the AIDS 2004 conference will
act as further impetus in mobilizing the political will of all nations
to tackle the problem of HIV infection which is the real WMD
threatening global security and peace.
References
1
UNAIDS. AIDS epidemic update December 2003. http://www.unaids.
org/wad/2003/Epiupdate2003_en
2
UNAIDS. A measure of success in Uganda. UNAIDS, 1998.
3
Stoneburner RL, Low-Beer D. Sexual partner reductions explain HIV
declines in Uganda: comparative analyses of HIV and behavioural data
in Uganda, Kenya, Malawi and Zambia. Int J Epidemiol 2004;DOI:
10.1093/ije/dyh094.
4
Asiimwe-Okiror G, Opio AA, Musinguzi J, Madraa E, Tembo G,
Caral M. Changes in sexual behaviour and decline in HIV infection
among young pregnant women in urban Uganda. AIDS 1997;11:
175763.
5
Dabis F. Children and HIV in Africa: what is next? Lancet 2003;362:
159798.
6
UNAIDS. HIV/AIDS epidemiological surveillance update for the WHO
African region 2002. http://www.unaids.org/Unaids/EN/Resources/
Epidemiology/epi_recent_publications/
7
Dabis F, Ekpini ER. HIV-1/AIDS and maternal and child health in
Africa. Lancet 2002;362:85968.
8
Dabis F, Ekouevi DK, Rouet F et al. Effectiveness of a short course
of zidovudine lamivudine and peripartum nerivapine to prevent
HIV-1 mother-to-child transmission: the ANRS DITRAME-PLUS trial,
Abidjan, Cote dIvoire. Antivir Ther 2003;8(Suppl.1):s23637.
9
Access for all: XV International AIDS Conference, Bangkok, Thailand
2004. http://www.aids2004.org
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Source: COI footage file, Film-Images.