• Vaccines

Vaccines

This editorial from the Lancet outlines ten commonly held misconceptions about HIV epidemics that impede prevention efforts.

• HIV spreads like wildfire: Typically it does not. HIV is very infectious in the first weeks when virus levels are high, but not in the subsequent many-year quiescent phase.
• Sex work is the problem: Formal sex work is uncommon in these generalised epidemics.
• Men are the problem: The behaviour of men, including cross-generational and coercive sex, contributes substantially to the establishment of generalised epidemics. But a heterosexual epidemic requires some women to have multiple partners.
• Adolescents are the problem: Generalised epidemics span all reproductive ages.
• Poverty and discrimination are the problem: These factors can bring about risky sex. But HIV is paradoxically more common in wealthier people than in poorer people, perhaps because wealth and mobility support concurrent sexual partnerships.
• Condoms are the answer: Condom use, especially by sex workers, is crucial to containing concentrated epidemics. But condoms alone have limited impact in generalised epidemics.
• HIV testing is the answer: Although it seems obvious that learning one's HIV status should lead to behavioural change and reduced risky behaviour, real-world evidence suggests this is not the case, especially for the large majority who test negative.
• Treatment is the answer: Theoretically, treatment and counselling might aid prevention by lowering viral levels (and infectiousness) in those treated, reducing denial about HIV, and promoting behavioural change. However, no clear effect has so far emerged.
• New technology is the answer: Many resources are devoted to vaccines, microbicides, and prophylactic antiretrovirals. Unfortunately any success appears to be far off and may only target certain populations.
• Sexual behaviour will not change: Actually, facing the prospect of deadly illness, many people will change their behaviour.

The report concludes that the priority must be on the key driver of generalised epidemics: concurrent partnerships. Limiting the number of partners should be encouraged, particularly through explicit messages sensitive to local cultures, which can raise the perception of personal risk.

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