AIDS

AIDS

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A 2006 Reproductive Health Matters. All rights reserved. Reproductive Health Matters 2006;14(27):224–231 0968-8080/06 $ – see front matter PII: S 0 9 6 8 - 8 0 8 0 ( 0 6 ) 2 7 2 3 9 - 2

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ROUND UP

HIV/AIDS Pregnancy increases the risk of acquiring HIV irrespective of other indicators: Uganda The risk of acquiring HIV infection during pregnancy is more than double that at other times. A Ugandan study of 2,188 HIV-negative sexually active pregnant women, compared with 2,887 breast-feeding women and 8,473 control women clearly showed that this increase is unlikely to be due to sexual risk behaviours, as the pregnant women and their male partners reported having fewer external partners than other groups. Though condom use was lowest in the pregnant women group, so were symptoms of genital ulcers, a known pre-disposing factor for the acquisition of HIV. It therefore seems likely that hormonal changes affecting the genital mucosa are responsible for the increase. This has consequences for the approaches used to prevent new infections in women and to reduce mother-to-child transmission of HIV. Pregnant women need to be told of their increased risk as part of a strategy to keep HIV-negative women negative. Testing for HIV during pregnancy needs to be carried out both early and late in pregnancy because of the increased risk of seroconversion during pregnancy and the consequent danger of missing a high-risk pregnancy in terms of mother-to-child HIV transmission. It has been suggested that HIV testing in pregnancy should be abandoned in favour of universal antiretroviral therapy. However, such an approach would also result in a missed opportunity to intervene to prevent new infections.1,2 1. Gray RH, Li X, Kigozi G, et al. Increased risk of incident HIV during pregnancy in Rakai, Uganda: a prospective study. Lancet 2005;366:1182–88. 2. McIntyre JA. Sex, pregnancy, hormones, and HIV [Comment]. Lancet 2005;366:1141–42.

Vietnamese women decline HIV testing or fail to return for their results Just over half (53%) of 500 women at an antenatal clinic in Hai-Phong, Vietnam, accepted an offer of HIV testing. Those who declined gave 224

a range of reasons for refusing including: testing should not be provided, only high-risk women need testing, they never had any intention of being tested, being a housewife, a perception of poor health care support, and concern about their husband’s disapproval. Of those who had a test, just over half (55%) returned for their results. Not returning for results was associated with low educational level. These responses have been common everywhere where HIV-related stigma is high and where people have not been educated at society level as well as through individual counselling about HIV and the value of testing as a means of accessing treatment, care and support for those with HIV. Programmes need to address perceptions of risk as well as husbands’ attitudes by increasing the level of knowledge and understanding of the reasons for and value of testing.1 1. Dinh T-H, Detels R, Nguyen MA. Factors associated with declining HIV testing and failure to return for results among pregnant women in Vietnam. AIDS 2005;19(11):1234–36.

Antiretroviral therapy for mothers reduces HIV transmission through breastmilk The efficacy of antiretroviral therapy in HIVpositive mothers in reducing mother-to-child transmission during pregnancy and childbirth is well established yet there are few studies comparing the risks for different antiretroviral therapy regimens. A study in Botswana showed that the majority (88%) of women on triple therapy had breastmilk RNA viral loads below 50 copies/ml compared with only 36% of the women on zidovudine alone. This statistically significant difference shows that highly active antiretroviral therapy (HAART) effectively suppressed the load of replicating HIV, though it had no effect on the load of non-replicating HIV.1 There are few data on whether such therapy can also successfully reduce the risk of infection

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during breastfeeding. Breastfeeding is believed to account for about 40% of mother-to-child HIV transmission. A recent investigation of 20 women in Botswana receiving highly active antiretroviral therapy showed that breastmilk concentrations of nevirapine, lamivudine and zidovudine were 0.7, 3.3 and 3.2 times the concentrations in serum respectively. Serum concentrations in the infants showed that they were receiving doses of nevirapine well above therapeutic levels, but only 5% of the therapeutic level of lamivudine. All infants were on zidovudine prophylaxis, thus making it impossible to judge the effect of milk-borne zidovudine. The possible consequences for infants ingesting such high and variable doses of antiretroviral drugs may include both beneficial and adverse effects. Infection from HIV may be reduced, but there is also a possibility that a suboptimal level of one of the drugs could result in resistance mutations. There may also be a risk of toxicity in infants, especially those receiving antiretroviral therapy in their own right.2,3

first reported case was in 1995 and since then there have been slight annual rises. Sentinel surveillance of pregnant women in eight provinces shows the number with HIV as 0.4–1.4%, with a figure of over 1% in the provinces of Henan and Xinjiang. The extrapolation of these sentinel figures to the large populations of these provinces has been challenged. For example, Henan has a population of 96 million, yet the sample for that area was of 500 women mainly from the areas where the prevalence of blood donor-related infection is known to be high. Thus, the extrapolation may be overestimating the countrywide risk. Nevertheless, with high local rates and the possible emergence of a more serious HIV epidemic, pilot interventions have been developed by government bodies to promote the use of condoms at places of entertainment. In addition, guidelines to prevent mother-to-child transmission have been published which address issues of testing for HIV infection, provision of antiretroviral treatment and support for infant feeding alternatives.1–3

1. Shapiro RL, Ndung’u T, Lockman S, et al. Highly active antiretroviral therapy started in pregnancy or postpartum suppresses HIV-1 RNA but not DNA in breast milk. Journal of Infectious Diseases 2005; 2:713–19. 2. Shapiro RL, Holland DT, Capparelli E, et al. Antiretroviral concentrations in breast-feeding infants of women in Botswana receiving antiretroviral treatment. Journal of Infectious Diseases 2005;192:720–27. 3. Bulterys M, Weidle PJ, Abrams EJ, et al. Combination antiretroviral therapy in African nursing mothers and drug exposure in their infants: new pharmacokinetic and virologic findings. Journal of Infectious Diseases 2005;192:709–12.

1. Chen KT, Qian H-Z. Mother to child transmission of HIV in China. BMJ 2005;330 (7503):1282–83. 2. Hesketh T, Zhu WX, Zhang J. Mother to child transmission of HIV in China: Chinese HIV sentinel surveillance data were used incorrectly [Letter]. BMJ 2005:331(7509):162. 3. Chen KT, Qian H-Z. Mother to child transmission of HIV in China: authors’ reply [Letter]. BMJ 2005; 331(7509):162.

Prevention of potential rise in mother-tochild transmission of HIV: China In China, the most common forms of HIV transmission are sharing of contaminated needles among drug users (southern and western China), unsafe blood collection (central China) and unsafe sexual practices, particularly among commercial sex workers, men who have sex with men, and migrant workers. There are currently few cases related to mother-to-child transmission but the more common routes can easily lead back to the partners of those affected, thus increasing the potential for mother-to-child transmission. The

Breastfeeding and mortality among HIV-positive women up to one-year after delivery: Zambia Previously, an association between prolonged lactation and maternal mortality generated concern that breastfeeding might be detrimental to the health of HIV-positive women. This study in Lusaka, Zambia, examined whether or not mortality up to two years post-partum increased with breastfeeding for a longer duration. 653 HIVpositive women were randomly assigned to a counselling programme that encouraged abrupt cessation of breastfeeding at four months or one that encouraged prolonged breastfeeding for the duration of the woman’s informed choice. The study found that 12 months after delivery, mortality rates among women who were randomised to early cessation of breastfeeding were almost identical to those who continued breastfeeding. 225

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Analysis based on actual practice, rather than randomisation, also demonstrated no increased mortality due to breastfeeding. HIV-related mortality was high in both groups of untreated HIV-positive women, who were living in socio-economically disadvantaged communities with poor access to adequate daily nutrition. The authors suggest that counselling for HIV-positive pregnant women should include this information.1

of World Health Organization 2005;83(7): 483–484. 2. Coetzee D, Hildebrand K, Boulle A, et al. Effectiveness of the first district-wide programme for the prevention of mother-to-child transmission of HIV in South Africa. Bulletin of World Health Organization 2005;83(7):489–494.

1. Kuhn L, Kasonde P, Sinkala M, et al. Prolonged breast-feeding and mortality up to two years post-partum among HIV-positive women in Zambia. AIDS 2005;19(15):1677–81.

Russia has a potentially massive HIV epidemic but the government has, as yet, done little to address the problem. As a result, the Russian people, while generally highly educated, know little about HIV and have very negative attitudes towards people living with the virus. In this context, pregnant HIVpositive women and new mothers, already vulnerable to discrimination on a considerable scale, have to make decisions as to whether or not to keep their children. The care received during pregnancy by HIV-positive women is poor and sometimes non-existent. Up to 20% of their children may be

Prevention of mother-to-child transmission of HIV (PMTCT) programmes could be the main entry point to HIV-related care and treatment for millions of women infected with HIV, but coverage of these programmes and uptake of services remain limited in South Africa. Provision of antiretroviral drugs to mother and infants is a key intervention for the prevention of HIV infection in newborns. Recent evidence strongly supports the use of combination regimens especially short-course zidovudine (AZT) and single-dose nevirapine (NVP) as simple, highly efficacious regimens that can drastically reduce perinatal transmission of HIV. However, large-scale introduction of this regimen has been problematic. PMTCT programmes should be implemented as an integral component of maternal and child health services.1 A study of the effectiveness of a district-wide programme of PMTCT of HIV in South Africa has demonstrated the feasibility and effectiveness of a large-scale PMTCT programme in an urban setting. A consecutive sample of 658 mother–infant pairs was identified for enrolment, of whom 535 were eventually included and 410 received an effective PMTCT intervention. Infant formula milk was offered to mothers who chose not to breastfeed; uptake was described as high (but not quantified). 24% of infants were delivered by caesarean section. The rate of transmission from mother to child was 8.8%, which is in line with rates using the same or similar regimens.2 1. Ekpini RE, Gilks C. Antiretroviral regimens for preventing HIV infections in infants. Bulletin

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MIKKEL OSTERGARD / PANOS PICTURES

Antiretroviral regimens for preventing HIV infection in infants: South Africa

Stigma and discrimination against HIV-positive mothers and their children in Russia

Sorting drugs in a medical laboratory, Malawi

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abandoned at birth, ending up either in specialised orphanages for HIV-positive children or else in isolation in hospital wards because no orphanage can be found to take them. The report calls on the Russian government to prioritise HIV/AIDS in public policy; ensure access to health care, education and job security; support orphanages and kindergartens to accept infants and children of HIV-positive parents; ensure HIV-positive women receive antenatal, delivery, gynaecological and other medical care; and provide prevention of mother-to-child transmission of HIV.1 1. Babakian G. Positively Abandoned: Stigma and Discrimination against HIV-positive Mothers and their Children in Russia. Human Rights Watch 2005;17(4D). At: bhttp://hrw.org/reports/2005/ russia0605/russia0605.pdfN.

Assisted conception for HIV-discordant couples is ethically acceptable: Europe In the developed world, assisted conception techniques are offered to HIV-discordant couples for one of two reasons, either to reduce the risk of HIV transmission to the other partner and/or the child, or as an option offered to all infertile couples. In a consideration of the ethics of offering this assistance, two fundamental ethical principles conflict – respect for the autonomy of the HIVpositive individuals to decide about their reproduction versus the principle of beneficence as expressed in concern for the welfare of the child. The possibility of a stable and healthy life for a baby born to HIV-positive parent(s) in the developed world is gradually improving. Life expectancy of those with HIV, originally around 13 years from date of infection, with symptoms first appearing about eight years after infection, has been dramatically improved by antiretroviral therapy. However, it is too early to be able to measure the increased likelihood that parents will live to see their children through to adulthood. In the developed world vertical transmission of HIV from a positive mother is less than 3%, and the use of washed sperm or intra-cytoplasmic sperm injection in cases of an HIV-positive father means the risk of a child being infected is far lower than before. Thus, if certain precautions are taken, medical assistance to start a pregnancy for people living with HIV is ethically acceptable. However, the conclusion of the European Society of Human

Reproduction and Embryology (ESHRE) Ethics and Law Task Force, that only HIV-discordant couples should be considered for such assistance at this time, though defended by the taskforce, has been challenged by others.1–3 1. Shenfield F, Pennings G, Cohen J, et al, for ESHRE Ethics and Law Task Force. Taskforce 8: ethics of medically assisted fertility treatment for HIV positive men and women. Human Reproduction 2004;19(11): 2454–56. 2. Taylor GP. Ethics of assisted reproduction for HIV concordant couples [Letter]. Human Reproduction 2005;20(5):1430. 3. Pennings G, for ESHRE Task Force. Reply [Letters]. Human Reproduction 2005;20(5):1430–31.

HIV and the impact of orphanhood on sub-Saharan African adolescents As HIV-infected adults die across sub-Saharan Africa, they leave behind increasing numbers of orphans and vulnerable children. The impact of these deaths on the children and the long-term effects as these children themselves become adults, is only beginning to be evaluated. In Uganda, the prevalence of orphanhood in children 0–14 years, defined as the loss of one or both parents, was estimated at 23% in children of HIV-infected parents, compared with 8% in children of uninfected parents. The annual incidence of orphanhood was 8% amongst children with at least one HIV-positive parent, almost 20 times higher than for a child with two HIV-negative parents. For an individual, the risk of orphanhood was significantly increased with increasing age of the child and increasing maternal age. However, in population terms, becoming an orphan because of HIV was more likely for younger children (0–4 years) and the children of younger mothers (b25 years). Thus parental HIV markedly increases the incidence of orphanhood.1 Currently more than half of those orphaned by AIDS across sub-Saharan Africa are 10–15 years old. A study in Uganda of 123 AIDS orphans and 110 children from intact households, all aged 10–15, used a standardised interview to assess the psychological impact of orphanhood. Although material indicators such as hunger, health problems and school attendance were similar for the two groups, AIDS orphans had a greater risk for higher levels of anxiety (OR=6.4), depression 227

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(OR=6.6) and anger (OR=5.1). The study did not compare these orphans with those orphaned by other means, so it did not assess whether orphanhood by AIDS is responsible for additional psychological stresses compared to orphanhood by other means. Nevertheless, this is an important finding because of the large numbers of children involved across Africa and because depressed children are more likely to become depressed adults.2 A study in Zimbabwe of slightly older female orphans and vulnerable children (15–18 years) showed that they had a higher prevalence of HIV, more experience of sexually transmitted infections and more pregnancies. Maternal orphans and those with an infected parent were more likely to have received no secondary school education and to have become sexually active or married. These indicators are all associated with poor reproductive health, and many of them could be averted by more secondary school education for this vulnerable group, hopefully slowing the cycle of disease. Male orphans and vulnerable children of the same age did not show these associations.3 1. Makumbi FE, Gray RH, Serwadda D, et al. The incidence and prevalence of orphanhood associated with parental HIV infection: a population-based study in Rakai, Uganda. AIDS 2005;19(15):1669–76. 2. Atwine B, Cantor-Graae E, Bajunirwe F. Psychological distress among AIDS orphans in rural Uganda. Social Science and Medicine 2005;61:555–64. 3. Gregson S, Nyamukapa CA, Garnett GP, et al. HIV infection and reproductive health in teenage women orphaned and made vulnerable by AIDS in Zimbabwe. AIDS Care 2005;17(7):785–94.

Vulnerability of migrant sex workers in Europe In recent decades, the context of prostitution in Europe has changed considerably. The sex industry has expanded rapidly, and there is now a minority of local sex workers and a migrant majority in many countries, with local and foreign criminals controlling the markets. Migration of women sex workers around central and eastern Europe since EU expansion in 2004 has grown. Migrant sex workers are often under age and among the most vulnerable. They frequently suffer from being trafficked, pimped, stranded without residence permits, drug dependent, perceived as criminals and compelled to work in violent and abusive environments, unable to practise 228

safer sex. Yet government responses are increasingly repressive. The European Network for HIV/ STI Prevention and Health Promotion among Migrant Sex Workers is providing services for sex workers that include HIV/STI interventions, general health promotion, and a human rights approach to address prostitution, migration and trafficking. Outreach includes sex workers and their partners, owners of sex work establishments, the police and judiciary, the media, politicians and policymakers. Outreach in street work and other venues must be systematic, frequent and intensive to create trusting relationships. It cannot include only dis tribution of condoms, lubricants and information, but also psycho-social and legal assistance, language courses, health care, antiviolence protection, harm reduction strategies and advocacy for the rights of sex workers.1 1. Morgan Thomas R, Brussa L, Munk V, et al. Female migrant sex workers: at risk in Europe. In: Matic S, Lazarus JV, Donoghoe MC, editors. HIV/ AIDS in Europe Moving from Death Sentence to Chronic Disease Management. Copenhagen: WHO Europe, 2006.

Premature death the major reason for decreasing HIV prevalence in Uganda An as-yet unpublished study presented at the 12th Conference on Retroviruses and Opportunistic Infections suggests that Uganda’s declining HIV prevalence may be the result of increased condom use and premature deaths from AIDSrelated diseases rather than abstinence and fidelity. These findings are based on interviews with and blood samples from 10,000 people aged 15–49 living in 44 villages in Rakai district, about 85% of the residents in that age group, from 1994 to 2003. In that period, the number of men reporting two or more partners increased from 28% to 35%, while the number of teenagers who were not sexually active declined from 60% to 50% (though young women not sexually active stayed the same, about 30%). Although HIV prevalence fell in both men and women, the incidence of new infections rose. The researchers concluded that the single greatest factor in the declining prevalence was premature death.1 1. Condom use or abstinence. SAfAIDS News 2005; 11(1):8–9.

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Cell phones for HIV prevention: Kenya In Kenya, the Program for Appropriate Technology in Health (PATH) brought together activists, policymakers and local and international companies to reach out to young people and promote safer sex through text messages on their cell phones. Project partners designed appropriate, interactive messages about HIV/AIDS and communicated them through SMS (Short Message Texts). The project, known as ‘‘eQuest’’, also involved young Kenyan hip hop musicians, and aimed to encourage boys and girls to use their phones for instant messaging while participating in a treasure hunt for information, with the opportunity to win prizes each week. The hunt involved reading 52 messages and sending back answers to questions on living with HIV, stigma, care and support. The information was linked to youth role models and personalities in music, sports, politics, fashion and entertainment. The project aimed to run in four-week cycles in different parts of the country. Answers to the questions could be found in newspapers or radio programmes, and correct answers were published in Sunday newspapers each week.1 1. Neondo H. Catching youth via cell phones in Kenya. SAfAIDS News 2005;11(1):14–15.

Promoting gender equity among young men: India Following formative research with young men in low-income communities in Mumbai, India, on the links between gender, masculinity, sexuality and health risks, a number of interventions were developed. These included a curriculum for group education and training of peer educators. A variety of research methods were used to measure the feasibility, acceptability and impact of the intervention. The Gender-Equitable Men (GEM) scale, developed by Horizons and PROMUNDO, was used to measure changes in attitudes towards gender norms. A gender-equitable man was defined as one who: 1) supports relationships based on respect, equality and intimacy rather than sexual conquest; 2) is an involved father, financially and in terms of providing care; 3) takes responsibility for reproductive health, including disease prevention; and 4) is opposed to intimate partner violence. Almost all the 126 young men recruited by the project participated consistently during the six-month

project, which included a week of group educational activities and then 2–3 hour sessions every week, and they were greatly interested in the topics. Initially, they were most interested in information about biology and facts about sex and HIV but then got more involved in discussing gender-related attitudes, sexual violence and power dynamics. They also moved from denial of existing norms and their links to risk, to acceptance and interest in how to change these, and from inequitable to more egalitarian gender attitudes. Self-reported harassment of girls declined and there was also a trend towards increased condom use with casual partners and sex workers. The next steps involve working with larger groups of young men in Mumbai, Goa and Uttar Pradesh.1 1. Verma R, Pulerwitz J, Mahendra VS, et al. Promoting gender equity among young men. Positive experiences of the Yari-dosti project in India. Sexual Health Exchange 2005;2:5–6.

HIV testing, treatment and education campaigns: Lesotho, Botswana and Swaziland Lesotho, Botswana and Swaziland, with some of the highest HIV infection rates in the world, are scaling up HIV prevention and treatment. Lesotho will use the same models employed by immunisation programmes: extensive community mobilisation and education, followed by door-to-door visits offering HIV testing and counselling. Local committees will be responsible for deciding how and when people will be offered testing and counselling and for ensuring that testing is voluntary and confidential and that post-test services including treatment are provided. Botswana began offering HIV counselling and testing to everyone entering health facilities in 2004, significantly increasing the number who now know their HIV status and are accessing other services. In Swaziland, where more than half the country is in need of antiretroviral treatment, there are plans to implement an essential package of HIV/AIDS prevention, treatment and care in 80% of all health facilities, including in primary care, by the end of 2007.1 1. World Health Organization. Lesotho launches groundbreaking HIV campaign on World AIDS Day. News Release WHO/64, 30 November 2005.

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Rationing antiretroviral treatment: ethical and equity implications Increasing global commitment to the provision of antiretroviral therapy (ART) is not, as yet, matched by availability. This raises ethical dilemmas concerning who should have access to publiclyfunded ART programmes. This paper reviews the eligibility and targeting criteria employed in four country case studies – Mexico, Senegal, Thailand and Uganda – at different points in scaling up ART provision. The aim was to draw lessons concerning ethical and equitable approaches to rationing. Categories of explicit rationing criteria include biomedical factors, adherence to treatment, prevention-driven factors, social and economic benefits, financial and ethically-driven factors. The initial criteria for determining eligibility are typical clinical criteria and assessment of adherence prospects. In order to ensure that explicit rationing criteria reflect societal values, the authors argue that widespread consultation with stakeholders, including but not limited to policymakers and physicians, is critical to ensure equitable access. Monitoring who has access to these programmes is also vital. Among patients considered to have priority in Uganda were mothers who had previously participated in PMTCT programmes. This is not only to reward those who seek testing and participate in prevention strategies, but also because it would be wrong to deny mothers further treatment after they have given birth and important to prevent even greater increases in the number of AIDS orphans. Postexposure prophylaxis for health workers and rape victims was also prioritised. In the other three countries, very different criteria were applied and women were not prioritised in the same ways.1 1. Bennett S, Chanfreau C. Approaches to rationing antiretroviral treatment: ethical and equity implications. Bulletin of World Health Organization 2005;83(7):541–47.

High levels of sexually transmitted infection in Mongolia must be controlled to prevent an HIV epidemic A study of 2,000 pregnant women in Mongolia showed that 19.3% had Chlamydia trachomatis, 6.7% had Trichomonas vaginalis, 6.1% had Neisseria gonorrhoeae and 6.4% were seroposi230

tive for syphilis. Almost one-third of the women (30.3%) had at least one of these infections, and one in 14 had two or more. None of the women was seropositive for HIV, but these high rates of sexually transmitted infections, some of which predispose to HIV, indicate the need for treatment and prevention of future infection in order to prevent an HIV epidemic emerging in Mongolia.1 1. Amindavaa O, Kristensen S, Pak CY, et al. Sexually transmitted infections among pregnant women attending antenatal clinics in Mongolia: potential impact on the Mongolian HIV epidemic. International Journal of STD and AIDS 2005;16:153–57.

Cervical abnormality in women with and without HIV: prevalence and risk factors In developing countries, women often present with advanced cervical cancer for care, although this condition is preventable with regular screening and early treatment. This study identifies the prevalence and risk factors for cervical dyskaryosis among 200 women with and without HIV in Zimbabwe. Overall prevalence of cervical dyskaryosis was high (19%) and significantly higher among women with HIV (30%) compared with 13% among seronegative women, with a peak at a younger age among HIV-positive women. Factors associated with cervical dysplasia included use of intra-vaginal herbs, intra-vaginal cleansing, being single, a history or three or more lifetime sexual partners and a history of previous STIs. The high frequency of cervical abnormality calls for implementation of regular screening programmes, health education1 and condom promotion. 1. Mbizvo EM, Msuya SE, Stray-Pedersen B, et al. Cervical dyskaryosis among women with and without HIV: prevalence and risk factors. International Journal of STD and AIDS 2005;16(12):789–93.

Male circumcision found to reduce risk of female-to-male transmission of HIV In July 2005 French researchers announced that male circumcision reduced the risk to men of female-to-male transmission of HIV by about 65%, that is, it prevented 6–7 out of 10 potential infections in the 21-month period of the study. The study took place in South Africa and included more than 3,273 healthy, sexually active men,

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aged 18–24, in a rural area where about 32% of women are HIV positive. About half of the men were circumcised by medical professionals with local anaesthesia, and the rest remained uncircumcised. All participants received intensive safer sex counselling and condoms, but 18 men in the circumcision group and 51 in the control group had seroconverted at 21 months, which is a significant difference. The findings were so clear that the trial was stopped early and the men in the control group were all offered circumcision. This was the first randomised, controlled trial of male circumcision. Although it demonstrates a strong protective effect, it is a short-term study and cannot be used to predict long-term protection. Statements from both WHO and UNAIDS state that the findings need to be confirmed in further studies, which are currently taking place in Kenya and Uganda and are due to be reported in 2007. Scientists believe the results call for discussion on the use of male circumcision as a public health measure.1 UNAIDS believes it is premature to recommend male circumcision services as part of HIV prevention, but there is heightened interest from governments and the public in a number of African countries.2 However, there are concerns that men might mistakenly believe that circumcision is the only protection against HIV they need, which is not the case. Those at particularly high risk of infection, e.g. from anal intercourse, unsafe blood and injecting drug use may experience little if any protective effect. Furthermore, circumcision by traditional healers should be avoided in developing countries; men should seek circumcision only from providers with adequate training and with counselling on all the parameters of effective HIV prevention. Although the study did not look at protection of women from HIV with HIV-positive circumcised partners, another study in Rakai, Uganda, not yet published at this writing, was said to be showing a protective effect for women.1 Researchers believe circumcision helps to cut infection risk because the foreskin is covered in cells that the virus seems able to infect easily. The virus might also survive better in a warm, wet environment like that found beneath the foreskin.1 A UK study on whether 150 uncircumcised men had lower standards of genital hygiene than 75 circumcised men attending an STI clinic, based on reported washing of the whole penis, found that circumcised men were more likely

to wash the genital area more than once a day (37% vs. 19%). Not always washing the whole penis, including retracting the foreskin in noncircumcised men every time they washed, was eight times more common in non-circumcised than circumcised men (26% vs. 4%), which is a highly significant difference. The authors recommend that studies investigating the relationship between male circumcision status and other outcomes, including HIV infection, should include assessment of genital hygiene.3 Catherine Hankins, chief scientific advisor to UNAIDS, said it was still too early to encourage widespread circumcision as a way to prevent the spread of HIV. She also said many men would resist circumcision, even if other studies confirmed the findings. ‘‘We know this is a sensitive issue, and I don’t just mean biologically’’, she said.1 Even so, according to Reuters, in Swaziland, UNICEF and other local health officials are already promoting male circumcision. Men were said to have almost rioted at a private hospital in the capital earlier this year to book themselves in and two doctors at the Family Life Association were working full-time to keep up with waiting lists. After the study was published in the Public Library of Science Medicine journal, its findings filtered down to Swazis through newspapers, talk shows and politicians, including to mothers wanting to protect their adolescent sons. Swaziland’s King Mswati II banned male circumcision in the late 1800s. The country now has one of the world’s lowest circumcision rates, while also having the world’s highest rate of HIV, with around 40% of the adult population believed to be infected.4 1. Cairns G. IAS: circumcision prevents three out of four female-to-male HIV infections. Report on: Auvert B et al. Impact of male circumcision on the female-tomale transmission of HIV. International AIDS Society Conference on HIV Pathogenesis and Treatment, Rio de Janeiro, July 2005. Abstract TuOa0402. At: bhttp://www.aidsmap.com/en/news/BA448CC37935-43E6-947C-987D69B82D54.asp?wk=1N. 2. WHO, UNFPA, UNICEF, UNAIDS. Statement on South African trial findings regarding male circumcision and HIV. Rio de Janeiro, 26 July 2005. 3. O’Farrell N, Quigley M, Fox P. Association between the intact foreskin and inferior standards of male genital hygiene behaviour: a cross-sectional study. International Journal of STD and AIDS 2005;16(8):556–59. 4. Harrison R. Circumcision makes comeback in AIDS-hit Swaziland. Reuters, 24 February 2006.

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