We've been fighting the AIDS pandemic for decades but still are losing ground. Why? James D. Shelton, MD, MPH, science advisor at the U.S. Agency for International Development, has a radical suggestion.
Before offering his suggestion, however, Shelton challenges 10 "myths" that impede HIV prevention. It's a controversial position - one that irks Gordon Dickinson, MD, chief of infectious diseases at the University of Miami and the Miami VA Medical Center.
Shelton's provocative commentary, appearing in the Dec. 1 World AIDS Day issue of The Lancet, focuses on the "generalized HIV epidemics" in Africa. Dickinson's objections focus on how these comments might be counterproductive in the U.S. and other developed nations.
"Myth" 1: HIV Spreads Like Wildfire
It does not, Shelton argues, noting that only 8 percent of people whose heterosexual partner carries HIV become infected each year.
"This low infectiousness in heterosexual relationships partly explains why HIV has spared most of the world's populations," Shelton writes.
That may be true, Dickinson counters. But when a person is first infected with HIV - and still is negative on most HIV tests - that person is extremely infectious. This means that in certain circumstances HIV can spread fast.
"Let's say you are a young adult and single and living on South Beach and you go clubbing every weekend and are somewhat promiscuous," Dickinson tells WebMD. "If you have an acute HIV infection, it will spread like wildfire. This is not a conflagration that will cover a whole continent. But in individual places, HIV spreads rapidly."
"Myth" 2: Sex Work Is The Problem
Relatively few men with multiple sexual partners pay for sex with a prostitute, Shelton notes. In areas of Africa where HIV is widespread, men often have financial arrangements with women who do not think of themselves as prostitutes. But targeting prostitutes does not reach these women and will not have a major impact on the epidemic.
"Myth" 3: Men Are The Problem
Shelton notes that in areas where HIV is widespread, women are just as likely as men - in some areas, more likely - to be the sexual partner first infected with HIV.
Kathleen Squires, MD, director of infectious diseases at Thomas Jefferson University, Philadelphia, says the myth in the U.S. is that HIV is a disease of gay men.
"If you look at newly diagnosed HIV infections, the proportion among women has steadily risen," Squires tells WebMD. "This clearly impedes diagnosis - and prevention messages. Moreover, HIV disproportionately affects women of color and women in disadvantaged populations."
"Myth" 4: Teens Are The Problem
If HIV prevention efforts emphasize preaching abstinence to teens, they won't have much effect on the epidemic, Shelton suggests. He notes that people of all ages get and spread HIV - and that where HIV is epidemic, HIV becomes more common among women in their 20s and older.
Squires says one of the biggest myths in the U.S. is that abstinence until marriage will keep people from getting HIV.
"The fact is that many young people are sexually adventuresome. Just telling them not to have sex won't help them," she says.
And there's another U.S. myth, Squires says. That's the myth that teaching young people about safe sex will make them promiscuous.
Dickinson agrees, and says that safe-sex education should start early.
"There needs to be openness in discussions about sexual behaviors and the consequences of sexual behavior. And it needs to start early in the home," he says. "Education is the most important weapon we have for this particular disease as well as for many other diseases. It is sad that we have the tools and the know-how o stop HIV since the '80s, when we first learned how it is transmitted."
"Myth" 5: Poverty And Discrimination Are The Problem
In the developing world, Shelton writes, HIV is more common in wealthier people than in poorer people. And some nations have reduced the spread of HIV without reducing poverty levels.
Dickinson strongly disagrees with the suggestion that poverty and discrimination don't matter.
"With poverty comes poor education, and with poor education people don't know how to avoid health threats," he says. "Poverty certainly is part of the HIV problem here in Miami. And discrimination drives people underground."
Dickinson says that one of the main HIV/AIDS myths in the U.S. is the myth that HIV infection no longer carries a dangerous stigma.
"HIV certainly still is a major stigma," he says. "It is a major concern for many people who have HIV - such a concern that they will not divulge it. It is such a concern that they will not even risk finding out whether they are infected."
"Myth" 6: Condoms Are The Answer
Shelton does not downplay the major role condoms play in preventing the spread of HIV and other sexually transmitted diseases. But he notes that where HIV is widespread, people tend to have intimate relationships with more than one person at a time. In these regular relationships, he notes, condom use is inconsistent at best.
Dickinson says that while condom promotion certainly cannot end the AIDS epidemic, it has a tremendous impact.
"If I am faced with an epidemic, and condoms are, say, only 50 percent effective, that is still great. A 70 percent effective vaccine is one that works well. It beats the hell out of preaching abstinence," he says.
"Myth" 7: HIV Testing Is The Answer
There's a widespread belief that people who know they are infected with HIV will act responsibly and change their risky behavior.
"Real-world evidence of such change is discouraging, especially for the large majority who test negative," Shelton writes.
And he notes that people recently infected with HIV are the most infectious - yet test negative for HIV.
Dickinson says that while testing is not the sole answer to the HIV epidemic, it does help people reduce their risk behavior.
"Myth" 8: Treatment Is The Answer
Shelton notes that there is no clear evidence that anti-HIV treatment makes people less infectious or less likely to engage in risky behavior. In fact, he suggests, such effects may be outweighed by resumed sexual activity by infected people who feel better. Moreover, risky behavior may increase if people no longer see HIV as a death threat.
Squires says the myth in the U.S. is that HIV can be cured.
"While we have very effective therapy, we don't have a cure," she says. "I don't see that in the offing for the next several years at least. The best thing is not to get HIV in the first place."
"Myth" 9: New Technology Is The Answer
There's a huge amount of research into HIV vaccines, microbicides to block HIV, and drugs to prevent HIV infection.
"Unfortunately, any success appears to be far off," Shelton notes.
And even if such breakthroughs occur, they won't stop the AIDS epidemic unless people reduce risk behavior.
"Myth" 10: Sexual Behavior Will Not Change
Shelton notes that when HIV was still a death sentence in the U.S., gay men made radical changes in their behavior. And the drop in HIV prevalence in Kenya and in Zimbabwe was marked by a large drop in multiple sexual partners.
Truth 1: Fidelity Helps
Shelton's main point is that people who have multiple sexual partners drive the spread of HIV. In areas where HIV is widespread, people may not have a large number of sex partners, but they have more than oe at the same time.
Once HIV enters one of these small networks, the entire network is likely to become infected. That makes having multiple concurrent partners more dangerous than serial monogamy, in which a partner has one partner for a time, and then another.
Squires notes that different researchers have different views on Shelton's suggestion. But she notes that in the U.S., monogamy is not the same as safe sex.
The important thing to understand is that while you may be having sex with only one person, you are being exposed to the risk from all the people with whom that person has had sex," she says. "It may be reassuring to have sex with only one person. But you still have to take personal responsibility for having safe sex."
By Daniel DeNoon
Reviewed by Louise Chang
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