including non-governmental organisations, schools, businesses, faith communities, and the health system. Counselling and testing provides one such invaluable interpersonal channel. Moreover, focusing counselling eﬀorts intensively on those in the late, advanced stage of infection seems especially attractive. Infectiousness then increases substantially,10 and ongoing care and treatment allows for more continuity and intensive counselling. And technology might improve. A practical test for acute infection could substantially improve prevention if accompanied by very intensive counselling. Or a technological approach such as provision of antiretroviral drugs to reduce transmission in those who test positive might emerge. Despite its limitations, the counselling and testing platform is here to stay. We must maximise its use for prevention. James D Shelton Bureau for Global Health, US Agency for International Development, Washington, DC 20523, USA [email protected]
My views in this Comment are not necessarily those of USAID. I declare that I have no conﬂict of interest. 1
WHO/UNAIDS/UNICEF. Towards universal access: scaling up priority HIV/ AIDS interventions in the health sector. Progress report, June 2008. http:// www.who.int/hiv/pub/towards_universal_access_report_2008.pdf (accessed July 1, 2008).
Bunnell R, Cherutich P. Universal testing and counselling in Africa. Lancet 2008; 371: 2147–48. Halperin DT, Epstein H. Concurrent sexual partnerships help to explain Africa’s high level of HIV prevalence: implications for prevention. Lancet 2004; 364: 4–6. Denison JA, O’Reilly KR, Schmid GP, Kennedy CE, Sweat MD. HIV counseling and testing, and behavioral risk reduction in developing countries: a meta-analysis, 1990-2005. AIDS Behav 2008; 12: 363–73. Muller O, Sarangbin S, Ruxrungtham K, Sittitrai W, Phanuphak P. Sexual risk behavior reduction associated with voluntary HIV counseling and testing in HIV infected patients in Thailand. AIDS Care 1995; 7: 567–72. Farquhar C, Kiarie JN, Richardson BA, et al. Antenatal couple counseling increase uptake of interventions to prevent HIV-1 transmission. J Acquir Immune Deﬁc Syndr 2004; 37: 1620–26. Xu F, Kilmarx PH, Supawitkul S, et al. Incidence of HIV infection and eﬀects of clinic-based counseling on HIV preventive behaviors among married women in Northern Thailand. J Acquir Immune Deﬁc Syndr 2002; 29: 284–88. Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Eﬀects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985-1997. Am J Public Health 1999; 89: 1397–405. Allen S, Tice J, Van de Perre P, et al. Eﬀect of serotesting with counseling on condom use and seroconversion among HIV discordant couples in Africa. BMJ 1992; 304: 1605–09. Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis 2005; 191: 1403–09. Kipp W. Kabagambe G, Kode-Lule J. Low impact of community-wide HIV testing and counseling program on sexual behavior in rural Uganda. AIDS Educ Prev 2001; 13: 279–89. Sherr L, Lopman B, Kakowa M, et al. Voluntary counseling and testing: Uptake, impact on sexual behavior, and HIV incidence in a rural Zimbabwean cohort. AIDS 2007; 21: 851–60. Matovu JKB, Gray RH, Makumbi F, et al. Voluntary counseling and testing acceptance, sexual risk behavior and HIV incidence in Rakai, Uganda. AIDS 2005; 19: 503–11. Corbett EL, Makamure B, Cheung YB, et al. HIV incidence during a cluster-randomized trial of two strategies providing voluntary counseling and testing at the workplace, Zimbabwe. AIDS 2007; 21: 483–89.
Condoms in concentrated and generalised HIV epidemics
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in adolescents were more varied, and eﬀects much more modest. Three of six studies—two from southern Africa and one from China—reported positive ﬁndings in men’s condom use with casual partners, but rates of condom use at last intercourse did not exceed 50% in any study after the intervention. 11 studies examining primary sexual partnerships noted that interventions leading to increased condom use were in the highest-risk populations, primarily in African countries with generalised epidemics, or those in Asia where condoms were used for contraception; condom use at last intercourse in these studies was between 24% and 33%. 14 studies, mostly from Africa, measured condom use in young people; eight were able to document signiﬁcant but small increases in condom use at last intercourse (6–19% absolute increase). 19 studies examined whether interventions for condom promotion increased sexual risk taking; 13 studies from countries with
The printed journal includes an image merely for illustration Still Pictures
The promotion of male condoms is fundamental for programmes for prevention of HIV. Interventions resulting in consistent use of condoms by clients of female sex workers in Thailand, together with a reduction in the number of men who have sex with sex workers, show the eﬀectiveness of condoms in curbing the incidence of HIV.1 However, for condoms to be eﬀective, they must be used consistently and properly. Anna Foss and colleagues, in a recent systematic review,2 examined 62 condom-promotion studies since 1998 in generalised and concentrated HIV epidemics in Africa and Asia, most of which had non-controlled study designs. These studies measured self-reported condom use as their endpoint. Interventions undertaken for sex workers and their clients were most likely to show positive eﬀects, with condom use doubling in eight of the 15 positive studies, especially in areas of concentrated epidemics. However, results of studies in casual and primary partnerships and
both generalised and concentrated epidemics reported a signiﬁcant decrease in the number of sexual partners after the intervention and only one, in sex workers in Côte d’Ivoire, an increase. Moreover, ﬁve of six studies had no evidence that non-sexually-active young people who were exposed to condom-promotion interventions became sexually active because of the intervention. These results are both reassuring and troubling, especially since rates in study settings might be higher than in non-study settings. Although clear eﬃcacy data are scarce and a placebo-controlled trial is impossible, data for condom eﬀectiveness gleaned from rigorous cohort studies estimate that condom eﬀectiveness ranges from 80%3 to 94%.4,5 Furthermore, condoms prevent 85% of unintended pregnancies over the ﬁrst year of typical use.6 Why are condoms not more widely used by people living in areas with epidemics? First, condoms are contraceptives and thus are not used in primary sexual relationships in which pregnancy is a goal. Second, condoms are diﬃcult to use consistently and correctly. Many factors might underlie this ﬁnding—eg, alcohol, denial, discomfort, lack of control, poor communication, and insuﬃcient education. Third, condoms might not be widely available. In 2001 a worldwide condom gap was postulated;7 what the population-level eﬀectiveness of condoms would be if they were more available, especially at the point of use, is not known. Overall, possibly with the exception of sex workers, condom use is not especially high, even in non-primary relationships and after condom promotion campaigns; an analysis of sexual behaviour in single African women reported that condom use at most recent intercourse was only 28%.8 However, strong evidence suggests that decreases in HIV prevalence can be achieved in areas of generalised epidemics without especially high levels of condom use. In Uganda, for example, large reductions in HIV prevalence were preceded by substantial decreases in non-regular sexual partners rather than in high levels of condom use.9,10 Much the same pattern has been seen in Zimbabwe.11,12 Nevertheless, condoms are an important and essential component of HIV prevention programmes, especially with a greater proportion of infections occurring in discordant primary relationships in which repeated sexual exposure is unavoidable.13 What can we do to promote condoms and increase their use more widely and eﬀectively? We know that 276
condoms are eﬀective if they are available and used properly, and even more so if users take additional steps to keep their risk of exposure to infection to a minimum—eg, by reducing numbers of sexual partners. They are not, however, a magic bullet, and the real question is how condom promotion should be combined with other interventions for prevention of HIV, such as: information, education, and counselling to reduce concurrent partnerships and delay sexual debut; voluntary counselling and testing; male circumcision; diagnosis and treatment of sexually transmitted infections; and even antiretroviral therapy. These interventions require detailed understanding of the psychological, sexual, and social dynamics of condom use and sexual risk taking, especially in discordant couples, and overcoming whatever condom gap might still exist. How best to design, implement, and assess these interventions will need substantial investment. George W Rutherford Cochrane HIV/AIDS Group and Global Health Sciences, University of California, San Francisco, San Francisco, CA 94105, USA [email protected]
I thank Rand Stoneburner, Stephen Morin, and Norman Hearst for their helpful comments. I declare that I have no conﬂict of interest. 1
3 4 5
6 7 8
9 10 11 12 13
Nelson KE, Celentano DD, Eiumtrakoi S, et al. Changes in sexual behavior and a decline of HIV infection among young men in Thailand. N Engl J Med 1996; 335: 297–303. Foss AM, Hossain M, Vickerman PT, Watts CH. A systematic review of published evidence on intervention impact on condom use in sub-Saharan Africa and Asia. Sex Trans Inf 2007; 83: 510–16. Weller SC, Davis-Beaty K. Condom eﬀectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev 2002; 1: CD003255. Pinkerton SD, Abramson PR. Eﬀectiveness of condoms in preventing HIV transmission. Soc Sci Med 1997; 44: 1303–12. Hearst N, Chen S. Condom promotion for AIDS prevention in the developing world: is it working? In: Thickstun P, Hendricks K, eds. Evidence that demands action: comparing risk avoidance and risk reduction strategies for HIV prevention. Austin, Texas: Medical Institute for Sexual Health. http://www.medinstitute.org/includes/downloads/abc.pdf (accessed Feb 25, 2008). Hatcher RA, Trussell J, Cates W, Stewart FH, Kowal D, eds. Contraceptive technology, 19th edn. New York: Ardent Media, 2007. Shelton JD, Johnston B. Condom gap in Africa; evidence from donor agencies and key informants. BMJ 2001; 323: 139. Cleland J, Ali MM. Sexual abstinence, contraception, and condom use by young African women: a secondary analysis of survey data. Lancet 2006; 368: 1788–93. Low-Beer D, Stoneburner RL. Behavior and communication change in reducing HIV: is Uganda unique? Afr J AIDS Res 2003; 2: 9–21. Stoneburner RL, Low-Beer D. Population-level HIV declines and behavioral risk avoidance in Uganda. Science 2004; 304: 714–18. Gregson S, Garnett GP, Nyamukapa CA, et al. HIV decline associated with behavior change in Eastern Zimbabwe. Science 2006; 311: 664–66. Hayes R, Weiss H. Understanding HIV epidemic trends in Africa. Science 2006; 311: 620–21. Guthrie GL, de Bruyn G, Farquhar C. HIV-1 discordant couples in sub-Saharan Africa: explanations and implications for high rates of discordancy. Curr HIV Res 2007; 5: 416–29.
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