New research shows that the most common HIV prevention strategies-condom promotion, HIV testing, treatment of other sexually transmitted infections (STIs), vaccine and microbicide research, and abstinence-have not been very successful in reducing the predominance of heterosexual epidemics in Africa.
The same research also suggests that male circumcision and a reduction in multiple sexual partnerships may have a greater impact on the AIDS pandemic, but the two interventions have been getting very less attention.
The research reported in the journal Science is based on a new policy analysis led by experts at the Harvard School of Public Health (HSPH) and the University of California, Berkeley.
"Despite relatively large investments in AIDS prevention efforts for some years now, including sizeable spending in some of the most heavily affected countries (such as South Africa and Botswana), it's clear that we need to do a better job of reducing the rate of new HIV infections. We need a fairly dramatic shift in priorities, not just a minor tweaking," said Daniel Halperin, lecturer on international health in the HSPH Department of Population and International Health and one of the paper's lead authors.
The study report points out that condom use is effective in countries like Thailand where the epidemic is spread primarily through sex work, but studies have found no evidence that this intervention has played a primary role in reducing HIV infections primarily in heterosexual populations, such as those in southern Africa.
The researchers believe that this is mainly because most HIV transmission there occurs in more regular sexual relationships, in which achieving consistent condom use has proved extremely difficult.
According to them, the evidence is similarly lacking for other popular prevention approaches as well.
However, several studies conducted in the last two decades have shown that male circumcision significantly reduces the risk of heterosexual HIV infection, they add.
The researchers corroborate their observation with the fact that the prevalence of HIV is relatively low in west Africa, where male circumcision is widespread.
"It is tragic that we did not act on male circumcision in 2000, when the evidence was already very compelling. Large numbers of people will die as a result of this error," said Malcolm Potts, Bixby Professor of Population and Family Planning at UC Berkeley School of Public Health.
Similarly, according to the study report, partner reduction has also found to play a significant role in reducing HIV rates in Uganda, Kenya, Zimbabwe, Cote d'Ivoire, and in urban Malawi and Ethiopia.
The researchers blame the political fight between the supporters of condoms and supporters of abstinence for obscuring which is the most powerful of the 'ABC strategy'-Abstinence, Be Faithful and Condoms.
They argue that HIV prevention priorities need to shift significantly to reflect the best available scientific evidence.
The researchers note that only one per cent of total prevention funding requested by the United Nations AIDS Program is earmarked for male circumcision, and that reducing multiple sexual partnerships would probably garner only a small fraction of "community mobilization and mass media," "workplace" or other HIV prevention investments.
"The vast majority of donor investments in HIV prevention in the generalized epidemics of Africa continue to go to approaches for which the evidence of actual impact is increasingly unclear," said Halperin.
"Many of these approaches, such as HIV testing and treating other STIs, do have important public health benefits, and should be continued, but not because we believe they will definitely have a major impact on reducing HIV infections. Meanwhile, there is still some foot dragging on more fully implementing those approaches for which the evidence is much stronger, namely to scale up safe, voluntary male circumcision services, and to more assertively promote partner reduction," the researcher added.