A leading researcher on the economic and development effects of HIV/AIDS says new and innovative prevention methods are needed.
South African Professor Alan Whiteside is calling for fresh ideas on breaking the HIV infection cycle by interrupting or delaying risky behavior.
“I think it would be fair to say that prevention is the orphan of the HIV response. We’ve made huge progress with treatment,” he says, “but we haven’t stopped people getting infected.”
Whiteside is executive director of HEARD, the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal in Durban. He’s also co-author of AIDS in the 21st Century. Whiteside and Justin Parkhurst of the London School of hygiene and Tropical Medicine presented their ideas in a recent article in the Southern African Journal of HIV Medicine.
Have prevention efforts failed?
“We can never prove a negative and that’s what’s extremely frustrating. For example, is it possible that if we hadn’t had the prevention, that levels of prevalence would be 60 or 70 percent in Swaziland instead of the 42 percent among the antenatal clinic attenders that there are,” he says.
Whiteside says prevention probably has worked, “just not well enough, particularly in the hyper-endemic countries of southern Africa.”
Out of the box
“We’re calling for innovative thinking. The time has come for stepping out of the box and doing some new things and trying some new ideas,” says Whiteside.
Those new ideas include having a period, perhaps one month, when people make a concerted effort to practice safe sex.
“If you could have a nationwide campaign of either safe sex or no sex – and that means everybody – then you would effectively cut HIV transmission and it would give you breathing space. And we called for perhaps a one month period of safe sex/no sex,” he says.
Some have interpreted this to mean Whiteside and Parkhurst are calling for a month of abstinence only.
“I would say they haven’t read the article properly,” he says, adding, “What we believe would work is that if every act of sexual intercourse [were] protected, then there would be no HIV transmission during the period of a month. And that means people who have just been infected, who have a very high viral (HIV) load, would not be transmitting during that high period of viral load.”
In time, their viral load would fall and “there would be less likelihood of them transmitting beyond that period.”
While this could be done, he says, through abstinence, it could also be achieved through condoms.
“If everybody – married or in a relationship – uses a condom, then you would have the same effect of interrupting HIV transmission. It’s like if you took everybody who had a cold and put them in quarantine for a month. We’re not suggesting for a moment that that’s what you do. But we are suggesting you quarantine against HIV transmission,” he says.
Clues may be found in some Muslim countries, which often have very low HIV prevalence rates. For example, could Ramadan practices of abstinence affect HIV transmission? Further research would be needed.
The Whiteside/Parkhurst article says, “While Islam permits polygamy, it prohibits sex outside marriage and discourages the consumption of alcohol and homosexual sex. All these factors may help explain the lower levels of seroprevalence in countries with large Muslim populations.”
“I think the really important thing to stress is this is a bold idea and we’re going to be hit by a lot of people who don’t like what we’re saying. All we ask is think about it,” he says.
Whiteside thinks critics will accuse them of “moralizing…calling for the impossible. And we’ll be seen as loopy academics.”
During the Bush administration, there were many calls for abstinence as part of HIV/AIDS prevention. Abstinence was once a big part of PEPFAR, the President’s Emergency Plan for AIDS Relief. But Whiteside says their idea is different.
“We’re not talking about the Bush type abstinence, which was abstinence until you were married and then a monogamous relationship, be faithful to one partner. What we’re saying s that we would like a period of safe sex or if you can’t do safe sex (then) no sex. Where you have it on a national basis or a population basis for a month,” he says.
World Cup inspiration
Behavior change has always been a difficult program to implement in HIV/AIDS prevention.
“I think the answer is that in some of the worst affected countries it is a very saleable proposition because we don’t have many choices left,” he says.
Whiteside adds, “Two months ago, I would have felt that we were dancing on the edge of insanity in this proposal. But I’m living in South Africa and I’ve seen how our society has mobilized around the World Cup. And I know it is possible to mobilize an entire society. So I think it is possible to mobilize people around something as life and death as HIV transmission.”
He says the first step is simply to get people to talk about the idea. Whiteside will try to do that when he attends the 18th International AIDS Conference in Vienna later this month.