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EDITORIALS: Angela J Robinson and Brian G Gazzard Rising rates of HIV infection BMJ 2005; 330: 320-321 [Full text]

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HIV does not Scare people anymore

Sethuraman K Raman   (11 February 2005)

Beyond ABC?

Frances T. Owusu-Daaku   (11 February 2005)

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

Dr Hans-Christian Raabe   (12 February 2005)

An Alternative to existing ABC of HIV prevention

Udaya S Mishra   (14 February 2005)

HIV - much more than sexual health

Jeffrey V. Lazarus, Martin C. Donoghoe   (14 February 2005)

Global Management of HIV/AIDS: Disparities in Prevalence and Treatment Access

Memoona Hasnain   (18 February 2005)

HIV does not Scare people anymore 11 February 2005
Sethuraman K Raman, Director-Professor of Medicine JIPMER, Pondicherry 605006, India. Send response to journal: Re: HIV does not Scare people anymore	Sir, In promoting the welfare of people living with HIV-AIDS, the activists have managed to create an image that it is 'hip' to be HIV positive. A recent AIDS campaign in India says "Be Positive." The intent and outcome of the advertisement are quite opposite. These are harmful subliminal messages that need to be curbed. The other push for complacency comes from promotion of Anti Retroviral Therapy (ART and HAART) as a solution to the scourge of HIV-AIDS. A bit of worry and fear about the HIV virus are needed in the public mind until we find an effective cure or a vaccine. Competing interests: None declared
Beyond ABC? 11 February 2005
Frances T. Owusu-Daaku, Senior Lecturer, Department of Clinical and Social Pharmacy Kwame Nkrumah University of Science and Technology, UPO, Kumasi, Ghana Send response to journal: Re: Beyond ABC?	HIV prevention measures have certainly moved beyond ABC. This should not mean discarding ABC for the newer measures of ARTs and addressing gender roles; but re-inforcing the former with the latter. It is sad, however, that in some communities in Ghana, (and I suspect in others in sub-saharan Africa) especially in places with a perceived, strongly religious culture, some people still believe that promoting the use of condoms for young people rather leads them into promiscuity. Most people in these areas cannot seem to distinguish between a public health issue and a religious one. When will we "upright christians" come to realise that if we believe in imposing our moralities on others and deny them access to some preventive measures simply because we hold a certain view this menace can only get out of hand; and everyone, christians (and other religious groups) included, will suffer? Some communites have not even grasped ABC yet to move beyond it to address the underlying causes of the spread of the disease! Competing interests: Frances Owusu-Daaku is the chairperson of the Children's Sunday Schools Committee, Protestant Chaplaincy,KNUST.
ABC is a (social) vaccine against HIV with high effectiveness 12 February 2005
Dr Hans-Christian Raabe, General Practitioner Toronto, Ontario, Canada M5S 2W8 Send response to journal: Re: 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
An Alternative to existing ABC of HIV prevention 14 February 2005
Udaya S Mishra, Takemi Fellow, department of Population and International Health Harvard school of Public Health, 665, Huntington Avenue, Boston, MA 02115, USA Send response to journal: Re: An Alternative to existing ABC of HIV prevention	While alternative evidence emerges in support of ABC formulae working towards arresting the spread of HIV/AIDS, the ultimate secret lies in behavioural change. The unending debate on whether to emphasise treatment or prevention lead us no where because new behavioural change can only reduce new infections. The existing ABC of HIV prevention may well be effective but its effectiveness would perhaps call for a transformation and recognition of male responsibility in materialising the same on ground. On the other hand the autonomy of sexual negotiation by women would perhaps take us a long way in successful implementation of ABC. Hence, the alternative ABC could be thought of in terms of autonomy of women, ensuring basic needs and creating awareness (ABC). Women’s autonomy as well as ensuring basic needs (i.e. addressing extreme poverty) may serve as a positive environment for effective prevention and creating awareness will add in terms of recognition of male responsibility. Competing interests: None declared
HIV - much more than sexual health 14 February 2005
Jeffrey V. Lazarus, Advocacy and community relations officer Sexually transmitted infections/HIV/AIDS programme, WHO/Europe, Martin C. Donoghoe Send response to journal: Re: HIV - much more than sexual health	By Jeffrey V. Lazarus [jla@euro.who.int] and Martin C. Donoghoe, public health officer, Sexually transmitted infections/HIV/AIDS programme, WHO/Europe EDITOR--The editorial "Rising rates of HIV infection" [1] provides an almost comprehensive picture of the unresolved issues related to reducing HIV transmission globally, and specifically in the UK. A critical look at the reduction in HIV incidence in Thailand and Uganda is provided and the authors conclude with a call for sexual health to be prioritised in the UK. While we do not contest the urgent need for this, and agree with the authors that a substantial investment is needed in order to have any impact, two key points were neglected. They refer to non-sexually transmitted HIV and the often overlooked transition countries of central and eastern Europe. Injecting drug use is driving the HIV epidemic in central and eastern Europe, and these countries report the greatest increase in incidence in the world since 1999. There, specifically in the 15 countries of the former Soviet Union, including Estonia, Latvia and Lithuania, which have recently acceded to the European Union, some 80% of reported HIV cases are male and about the same amount are injecting drug users. While sexual health programmes need to be strengthened, as evidenced by outbreaks of sexually transmitted infections throughout the 1990s, the main priorities should be drug dependence treatment, harm reduction services and improved access to highly active antiretroviral treatment for injection drug users, as called for in the Dublin Declaration to fight HIV/AIDS in Europe and Central Asia[2] and the recently published report of the UN Millennium Project taskforce on HIV/AIDS.[3] While access to treatment is currently severely limited, it is even more so for drug users, who often face punitive measures if they seek to be tested or treated. Figures from a recent survey we implemented show that in eastern European countries where injecting drug users represent more than half of all reported HIV cases, there are gross inequities in terms of who is treated. In some countries this group only represents 9-35% of those on treatment. There is strong evidence that where targeted interventions are implemented rapidly on a sufficient scale, HIV epidemics among injecting drug users can be averted 4 and that by reducing HIV incidence in drug injectors, generalised epidemics can be avoided. In addition, the priority in central and eastern Europe is to ensure universal access to treatment, which means correcting current inequities by reaching out with appropriate, evidence-based services to injecting drug users. References 1. Robinson JA and Gazzard BG. Rising rates of HIV infection BMJ 2005;330: 320-321. (12 February). 2. Breaking the Barriers. Partnership to fight HIV/AIDS in Europe and Central Asia conference (2003). "Dublin Declaration on Partnership to fight HIV/AIDS in Europe and Central Asia". http://www.eu2004.ie/ (accessed 14 February 2005). 3. UN Millennium Project. Combating AIDS in the developing world. Task Force on HIV/AIDS, Malaria, TB, and Access to Essential Medicines, Working Group on HIV/AIDS, 2005:5-6. 4. Des Jarlais DC. Maintaining low HIV seroprevalence in populations of injecting drug users J Am Med Assoc 1995;274: 1226-31. Competing interests: None declared
Global Management of HIV/AIDS: Disparities in Prevalence and Treatment Access 18 February 2005
Memoona Hasnain, Director of Research & Assistant Professor of Public Health in Family Medicine Dept of Family Medicine, College of Medicine, University of Illinois at Chicago, IL 60612 USA Send response to journal: Re: Global Management of HIV/AIDS: Disparities in Prevalence and Treatment Access	According to World Health Report 2004, AIDS has killed more than 20 million people and is now the leading cause of death and lost years of productive life for adults worldwide. The AIDS epidemic takes on different prevalence patterns and epidemiological profiles in different parts of the world. The continent of Africa, particularly the southern region, continues to have the highest HIV/AIDS incidence and prevalence rates globally. It is estimated that 34-46 million people are infected with HIV around the world; about 30 million of them live in Africa. Many of the highly industrialized countries of the Western Hemisphere, including the United States, report declining epidemiological trends in AIDS overall, however, their incidence rates in certain subpopulations are rising. In the Eastern Hemisphere, countries that once formed the Soviet Union confront a fast growing epidemic. Latin America and the Caribbean also face a growing threat, while East and Southeast Asia, which include countries like China and India that contain some of the world’s largest populations, may eventually exceed Africa in terms of their absolute number of cases if their current escalating rates of HIV/AIDS go unchecked. The socioeconomic disparities that factored into the original disparities in disease prevalence in different parts of the world also are associated with disparities in treatment access, and hence continue to fuel the spread of the epidemic. Ironically, those that are the hardest hit in developing countries find it the most difficult to get appropriate treatment. The exact cost of antiretroviral therapy in a particular geographical location varies and is determined by a complex set of factors including global politics, the existence of donor funds, public and private insurance and/or entitlement programs, and the policies and drug- testing activities of large pharmaceutical firms. The high cost of antiretroviral drugs places therapy beyond the range of many individuals living with the virus. The World Health Organization estimates about six million people infected with HIV in the developing world need access to antiretroviral therapy to survive, but only 400,000 have access to treatment. These people will die in the next two years if they do not receive antiretroviral treatment. In sub-Saharan Africa, an estimated 4.3 million people need AIDS home-based care but only about 12 percent receive it and in South Asia, coverage drops to 2 percent. Developing countries cannot afford the expensive drug therapies for HIV; the costs run approximately $10,000-12,000 per year and need to be taken on an ongoing basis according to precise protocols with ongoing immune monitoring. Although a number of global programs are facilitating or providing treatment, the demand throughout the world far exceeds the numbers to be served. There is an urgent need to step up the efforts to make available the required therapies to those who need it. Millions of lives could be saved with today's knowledge and resources. Failure to address this crisis would be a moral failure. Competing interests: None declared