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Prevention of HIV spread in developing countries
THE LANCET
complete the investigations; in 83·1%, the date or the place of transfusion was unknown, and in 16·9% further information was not available because these individuals were treated in other countries. As a result of these investigations, 24 of the 170 (14·8%) TA-AIDS cases were reclassified as having other risk factors, with blood transfusion being excluded as a mode of transmission. In six of the 24 cases, blood transfusion was confirmed, but 23 blood donors involved in the transfusion histories were traced and tested for HIV-1 antibodies, and all 23 were negative. For the other reclassified cases, blood transfusion was not confirmed. In 14 (58·3%) of the 24 reclassified cases, the look-back method allowed for identification of other risk factors: injecting drug use (in one), male-to-male sex (two), multiple heterosexual partners (three), factor VII concentrates (six), transplant of HIV-1-infected organs (two, from the same donor). In the remaining ten (41·7%), look-back was unable to identify any risk factor; 60% of these patients died before the initiation of the active investigations, and 40% of the patients did not declare any risk behaviour. Our results show that 15% of AIDS cases initially attributed to blood transfusion were reclassified into other exposure categories; a result consistent with those from other studies.2,3 Moreover, in at least a third of 24 reclassified cases, factor VII concentrates or organ transplant was involved. Taking into account the sensitivity of the public opinion on possible transmission of HIV-1 infection through blood transfusions, our findings emphasise the importance of lookback programmes, which can contribute to clarifying the role of blood transfusions in transmission of HIV-1. Supported by the Italian National AIDS and Blood Programmes.
*Romano Arcieri, Nicola Schinaia
accept himself to be at risk; if met in a bar after business hours, then perhaps problem-oriented learning (which precedes behaviour change) might be easier to initiate. Second, promotion of condom use is one of the simplest strategies for influencing behaviour—much simpler than urging reduction in the number of sexual partners, or abstinence. Hopefully, those who are persuaded of the wisdom of condom use may be more likely to refrain from sex with casual partners if condoms are not available. Ulrich Laukamm-Josten African Medical and Research Foundation, AMREF, Dar es Salaam, Tanzania; and *PHC Public Health Consult GMBH D-10627 Berlin, Germany
1
d’Cruz-Grote D. Prevention of HIV infection in developing countries. Lancet 1996; 348: 1071–74.
SIR—d’Cruz-Grote1 summarises that sexually transmitted diseases (STDs) impose a great burden on the health of populations in developing countries. However, we do not agree with her rather pessimistic view of the availability of biomedical interventions. The Lancet has published the encouraging results of a trial2 showing improved STD case management based on simple WHO recommendations, integrated into the primary health care structure of an east African country; this rather moderate intervention reduced HIV incidence by 42%.2 This achievement was accompanied by a substantial reduction in active syphilis, and symptomatic urethritis in men,3 and the intervention was economical. This was the first randomised trial to show the efficacy of an intervention against HIV infection in a general population, and the results were summarised in The Lancet’s end-of-year supplement under the most important recent developments in HIV disease,4 and infectious diseases in the tropics.5
Laboratory of Epidemiology and Biostatistics, Istituto di Sanità, Rome, Italy
Gina ka-Gina, *Heiner Grosskurth, Richard Hayes 1
2
3
Mark RP, Sondag-Thull D, Van Hemeldonck LA, Declercq EE. Transfusion-related AIDS and HIV infection in Belgium. AIDS 1993; 7: 1388–89. Bosshard H, Zwahlen M, Marti B, Frey-Wettstein M. Retrospective study of transfusion-associated HIV infection in Switzerland. Lancet 1994; 343: 797. Conley LJ, Holmberg SD. Transmission of AIDS from blood screened negative for antibody to the human immunodeficiency virus. N Engl J Med 1992; 140: 1499–500.
Tropical Health Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, and African Medical and Research Foundation, Tanzania
1 2
3
4
d’Cruz-Grote D. Prevention of HIV infection in developing countries. Lancet 1996; 348: 1071–74. Grosskurth J, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tranzania: randomised controlled trial. Lancet 1995; 346: 530–36. Mwijarubi E, Grosskurth H, Mosha F, et al. Improved STD treatment significantly reduces prevalence of syphilis and symptomatic urethritis in rural Tanzania. Abstract LBC 60623. Vancouver: XIth International Conference on AIDS, July, 1996. Montaner JS?, Schechter MT. A year of transformation in HIV/AIDS. Lancet 1995; 346 (suppl): 12. Squire S. Can we stand the heat? Lancet 1995; 346 (suppl): 25.
Prevention of HIV spread in developing countries
5
SIR—With respect to d’Cruz-Grote’s review of prevention of HIV infection in developing countries (Oct 19, p 1071),1 two issues should be highlighted. First, with limited resources prevention should be directed towards the links of the infection chain in which more than one case could be averted. In the simplest chain of three links—infection of a woman with multiple partners by a man, to infection of a partner of this woman, to infection of the wife of this partner—the infection of the monogamous wife represents the final link of horizontal transmission. The chances of preventing the infection in this woman are almost nil in developing countries if the couple want children. However, prevention at links one and two is possible and likely to prevent more than one case of infection; but even at the second link there is a serious decrease in the probability of effective prevention counselling with increasing distance from the site of transmission: to attain behaviour change of a farmer and his wife at the village level might be impossible because any HIV problem might well be denied. For example, if approached at the market place the farmer would refuse to
SIR—d’Cruz-Grote1 implies that there is little hope for restricting the general spread of the HIV epidemic in developing countries until major changes in the social, cultural, and structural determinants of infection have been achieved. In other words little can be done without changing the world. Despite agreeing with the underling sentiments of d’Cruz-Grote, we find her overall approach negative in the short term. While waiting for these longer term goals of poverty reduction and widespread education, there are surely several other approaches not addressed, or dismissed, by d’Cruz-Grote which have a much greater chance of slowing the epidemic within the next few years and need to be explored—for example, STD control, effective behavioural change programmes (information, education, and communication [IEC]), use of female condoms, and vaginal virucides. Arguably the most promising sign that widescale prevention could be achieved in rural African populations comes from Grosskurth and colleagues,2 who reported a 42% reduction in HIV-1 incidence in those living in communities
1742
Vol 348 • December 21/28, 1996
complete the investigations; in 83·1%, the date or the place of transfusion was unknown, and in 16·9% further information was not available because these individuals were treated in other countries. As a result of these investigations, 24 of the 170 (14·8%) TA-AIDS cases were reclassified as having other risk factors, with blood transfusion being excluded as a mode of transmission. In six of the 24 cases, blood transfusion was confirmed, but 23 blood donors involved in the transfusion histories were traced and tested for HIV-1 antibodies, and all 23 were negative. For the other reclassified cases, blood transfusion was not confirmed. In 14 (58·3%) of the 24 reclassified cases, the look-back method allowed for identification of other risk factors: injecting drug use (in one), male-to-male sex (two), multiple heterosexual partners (three), factor VII concentrates (six), transplant of HIV-1-infected organs (two, from the same donor). In the remaining ten (41·7%), look-back was unable to identify any risk factor; 60% of these patients died before the initiation of the active investigations, and 40% of the patients did not declare any risk behaviour. Our results show that 15% of AIDS cases initially attributed to blood transfusion were reclassified into other exposure categories; a result consistent with those from other studies.2,3 Moreover, in at least a third of 24 reclassified cases, factor VII concentrates or organ transplant was involved. Taking into account the sensitivity of the public opinion on possible transmission of HIV-1 infection through blood transfusions, our findings emphasise the importance of lookback programmes, which can contribute to clarifying the role of blood transfusions in transmission of HIV-1. Supported by the Italian National AIDS and Blood Programmes.
*Romano Arcieri, Nicola Schinaia
accept himself to be at risk; if met in a bar after business hours, then perhaps problem-oriented learning (which precedes behaviour change) might be easier to initiate. Second, promotion of condom use is one of the simplest strategies for influencing behaviour—much simpler than urging reduction in the number of sexual partners, or abstinence. Hopefully, those who are persuaded of the wisdom of condom use may be more likely to refrain from sex with casual partners if condoms are not available. Ulrich Laukamm-Josten African Medical and Research Foundation, AMREF, Dar es Salaam, Tanzania; and *PHC Public Health Consult GMBH D-10627 Berlin, Germany
1
d’Cruz-Grote D. Prevention of HIV infection in developing countries. Lancet 1996; 348: 1071–74.
SIR—d’Cruz-Grote1 summarises that sexually transmitted diseases (STDs) impose a great burden on the health of populations in developing countries. However, we do not agree with her rather pessimistic view of the availability of biomedical interventions. The Lancet has published the encouraging results of a trial2 showing improved STD case management based on simple WHO recommendations, integrated into the primary health care structure of an east African country; this rather moderate intervention reduced HIV incidence by 42%.2 This achievement was accompanied by a substantial reduction in active syphilis, and symptomatic urethritis in men,3 and the intervention was economical. This was the first randomised trial to show the efficacy of an intervention against HIV infection in a general population, and the results were summarised in The Lancet’s end-of-year supplement under the most important recent developments in HIV disease,4 and infectious diseases in the tropics.5
Laboratory of Epidemiology and Biostatistics, Istituto di Sanità, Rome, Italy
Gina ka-Gina, *Heiner Grosskurth, Richard Hayes 1
2
3
Mark RP, Sondag-Thull D, Van Hemeldonck LA, Declercq EE. Transfusion-related AIDS and HIV infection in Belgium. AIDS 1993; 7: 1388–89. Bosshard H, Zwahlen M, Marti B, Frey-Wettstein M. Retrospective study of transfusion-associated HIV infection in Switzerland. Lancet 1994; 343: 797. Conley LJ, Holmberg SD. Transmission of AIDS from blood screened negative for antibody to the human immunodeficiency virus. N Engl J Med 1992; 140: 1499–500.
Tropical Health Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, and African Medical and Research Foundation, Tanzania
1 2
3
4
d’Cruz-Grote D. Prevention of HIV infection in developing countries. Lancet 1996; 348: 1071–74. Grosskurth J, Mosha F, Todd J, et al. Impact of improved treatment of sexually transmitted diseases on HIV infection in rural Tranzania: randomised controlled trial. Lancet 1995; 346: 530–36. Mwijarubi E, Grosskurth H, Mosha F, et al. Improved STD treatment significantly reduces prevalence of syphilis and symptomatic urethritis in rural Tanzania. Abstract LBC 60623. Vancouver: XIth International Conference on AIDS, July, 1996. Montaner JS?, Schechter MT. A year of transformation in HIV/AIDS. Lancet 1995; 346 (suppl): 12. Squire S. Can we stand the heat? Lancet 1995; 346 (suppl): 25.
Prevention of HIV spread in developing countries
5
SIR—With respect to d’Cruz-Grote’s review of prevention of HIV infection in developing countries (Oct 19, p 1071),1 two issues should be highlighted. First, with limited resources prevention should be directed towards the links of the infection chain in which more than one case could be averted. In the simplest chain of three links—infection of a woman with multiple partners by a man, to infection of a partner of this woman, to infection of the wife of this partner—the infection of the monogamous wife represents the final link of horizontal transmission. The chances of preventing the infection in this woman are almost nil in developing countries if the couple want children. However, prevention at links one and two is possible and likely to prevent more than one case of infection; but even at the second link there is a serious decrease in the probability of effective prevention counselling with increasing distance from the site of transmission: to attain behaviour change of a farmer and his wife at the village level might be impossible because any HIV problem might well be denied. For example, if approached at the market place the farmer would refuse to
SIR—d’Cruz-Grote1 implies that there is little hope for restricting the general spread of the HIV epidemic in developing countries until major changes in the social, cultural, and structural determinants of infection have been achieved. In other words little can be done without changing the world. Despite agreeing with the underling sentiments of d’Cruz-Grote, we find her overall approach negative in the short term. While waiting for these longer term goals of poverty reduction and widespread education, there are surely several other approaches not addressed, or dismissed, by d’Cruz-Grote which have a much greater chance of slowing the epidemic within the next few years and need to be explored—for example, STD control, effective behavioural change programmes (information, education, and communication [IEC]), use of female condoms, and vaginal virucides. Arguably the most promising sign that widescale prevention could be achieved in rural African populations comes from Grosskurth and colleagues,2 who reported a 42% reduction in HIV-1 incidence in those living in communities
1742
Vol 348 • December 21/28, 1996