[afro-nets] Not A&B but C&D reduce HIV prevalence

[Claudio Schuftan <claudio@hcmc.netnam.vn>]

Not A&B but C&D reduce HIV prevalence
-------------------------------------

The sharp decrease in HIV prevalence in Uganda during the last
decade, has been attributed by some to the ABC programme (absti-
nence, be faithful and use condoms). The cohort study recently
come out from Rakai district in Uganda shows that in fact A and
B components of the program have had no impact on HIV preva-
lence. The main factors attributable for this decrease in fact
are C and D (Condom and Death). Death has contributed to the re-
duction of 5% and Condom of 1.2% for Rakai HIV prevalence. It is
worthy to note that the same researchers had done the credible
Rakai controlled trial on STI mass treatment.

Below you will find the abstract presented at the recent Confer-
ence on Retroviruses and Opportunistic Infections, and a news
article from British Medical Journal and Reuters Health about
the same study. The two news articles provides us with some more
findings from the research. An encouraging finding is that regu-
lar condom use help to reduce HIV acquisition by 70% but it is
also disturbing to know that men who are recently seroconverted
had as much as twice more number of partners than those who did
not.

***********

DECLINES IN HIV PREVALENCE IN UGANDA: NOT AS SIMPLE AS ABC

http://www.retroconference.org/Search_Abstract_2005/AbstractSearch.aspX

Authors and Affiliations: Maria J Wawer (1), R Gray (2), et al.

Background:
HIV-1 prevalence is declining in Uganda, a finding often as-
cribed to increased rates of safe behaviors, especially absti-
nence and monogamy (be faithful), and to a lesser degree condom
use (A, B, C). We propose to extend the acronym by considering
the contributions of HIV-related mortality (death/D), viral epi-
demiology/early infection (E), and potential future (F) effects
of ART in Rakai, Uganda.

Results:
Between 1994/1995 and 2002/2003, age-standardized HIV prevalence
declined significantly in all adults (17.6% to 11.4% [p =
0.007]) and in young adults aged 20 to 24 (16.9 to 7.7%), but
not in adolescents aged 15 to 19 (3.6 to 3.2%). Incidence did
not decline overall (1.3/100 person-years in 1994/1995 and
1.7/100 person-years in 2002/2003), in young adults (1.1/100
person-years and 1.5/100 person-years, respectively), or in ado-
lescents (1.3/100 person-years and 1.2/100 person-years). In the
same period, age of sexual debut declined in both sexes, and the
proportions of young adults reporting sexual activity, non-
marital relationships, and multiple partnerships increased. How-
ever, condom use with casual partners rose significantly, par-
ticularly at younger ages (for example, from 19% to 38% in males
aged 15 to 19). Mortality among HIV+ persons was 13.3/100 per-
son-years. Approximately half of all HIV transmissions in this
population occurred from index HIV+ partner!
  s who had themselves recently seroconverted and were in early
stage HIV infection.

Conclusions:
We observed no increase in abstinence or monogamy (no evidence
for A or B), but condom use increased in casual relationships
(evidence for C). Mortality (death/D) removed ~70 more HIV+ per-
sons per year than were added through new seroconversions, ac-
counting for much of the observed decline in prevalence. HIV in-
cidence and thus the number of HIV transmissions contributed by
persons in early stage HIV infection (E) remained relatively
stable in this period. ART is unlikely to reduce HIV incidence,
since most transmissions occur prior to index partner ART eligi-
bility. Moreover, ART availability may result in behavioral dis-
inhibition, increased risk behavior, and higher HIV incidence.
In summary, declines in Rakai HIV prevalence in the past decade
are associated primarily with C and D. Prevention of ART-related
behavioral disinhibition is crucial to contain the future course
of the epidemic.

********************

ABSTINENCE PROGRAMMES DO NOT REDUCE HIV PREVALENCE IN UGANDA

By Bob Roehr, Boston

BMJ 2005;330:496 (5 March), doi:10.1136/bmj.330.7490.496-a
http://bmj.bmjjournals.com/cgi/content/full/330/7490/496-a?ecoll

Use of condoms and death explain the substantial decline in the
prevalence of HIV in Uganda in the past decade.

The reduction had previously been credited to ABC programmes
(abstinence, be faithful, and use condoms). A longitudinal
study, presented at the 12th retroviral conference in Boston,
however, challenges the contributions of abstinence and fidel-
ity. The study included a door to door survey of about 10 000
adults aged 15-49 in 44 villages in the Rakai district of south-
ern Uganda.

A surge of infections in the early 1990s is the cause of rising
numbers of deaths. In 2001-2, 125 cases of seroconversion added
to the prevalence, and 200 died. "Death alone accounted for a
six percentage point reduction in HIV prevalence in the one
year," Maria Wawer, a public health researcher from Columbia
University, New York city, said. "Overall, the HIV prevalence
over the last decade declined 6.2 percentage points. We estimate
that mortality alone contributed five percentage points of the
decline."

The remaining share could not be attributed to abstinence. The
proportion of men reporting sexual abstinence in the past year
declined, but the proportion among women did not change. Nor
could the decline be credited to fidelity because the proportion
of men reporting two or more partners in the past year increased
in the decade.

Use of condoms increased dramatically. "Condom use is much
higher with casual partners than with their married partner," Dr
Wawer said. "Condom use is associated with the significant re-
duction of HIV acquisition in this population."

The most troubling aspect of the analysis is that men who have
seroconverted within the past year reported having about twice
as many sexual partners as men who have not seroconverted. The
probability of transmitting HIV per coital act is about 10 times
higher for someone who recently seroconverted. This group ac-
counts for roughly half of all new infections in Uganda. As a
result, the overall incidence has edged upwards from 1.3 per 100
people per year in 1994-5 to 1.7 in 2002-3.

The study began in 1994 and consisted of a behavioural question-
naire and an analysis of collected blood and urine samples. Its
annual compliance rate was 85-90%. Researchers from Johns Hop-
kins University, in Baltimore, Maryland, and Makerere University
in Kampala, Uganda, led the collaborative effort.

HIV prevalence in women was 19.7% in 1994 and fell by a third to
12.9% in 2003, the last year for which full analysis of the data
was complete. For men, prevalence declined by 38% from 15.0% to
9.3% in the same period.

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CONDOM USE AND DEATHS EXPLAIN LOWER HIV PREVALENCE IN RAKAI,
UGANDA
Reuter Health Information
http://www.medscape.com/viewarticle/500121

By Deborah Mitchell

BOSTON (Reuters Health) Feb 23 - The declining prevalence of HIV
infection in Uganda has often been attributed to increased rates
of abstinence and monogamy, but new data suggest that the de-
cline is primarily the result of increased condom use and HIV-
related deaths, investigators reported at the 12th Annual Retro-
viral Conference on Wednesday.

Dr. Maria J. Wawer of Columbia University Mailman School of Pub-
lic Health in New York and colleagues evaluated the impact of
the "ABC" program on mortality over the last decade. The acronym
stands for "abstinence," "be faithful," and use "condoms."

Dr. Wawer's team added "D" (HIV-related deaths) and "E" (viral
epidemiology/early infection) to the analysis.

The researchers have followed 44 communities continuously over
the past decade in the Rakai district in southwestern Uganda.
Over 85% of all adults participated and each year the surveys
included data for about 10,000 adults, she told conference par-
ticipants.

"As in the rest of Uganda, we have seen a significant decline in
HIV prevalence over the last decade," she said. Overall, age-
standardized HIV prevalence declined significantly in all
adults, from 17.6% to 11.4% (p = 0.007) and in young adults,
from 16.9% to 7.7%, but no significant changes were noted in
adolescents.

"The single factor that appears to have the greatest impact on
the downward trend in prevalence continues to be mortality," Dr.
Wawer said. Mortality removed about 70 more HIV-infected people
from the population each year than were added via new infec-
tions.

In addition, "we have seen significant and very encouraging in-
creases in condom use among adults and adolescents and among
both males and females," she said. "Condom use has particularly
increased in casual relationships." Those who use condoms regu-
larly have about a 70% reduction in HIV acquisition.

The overall incidence in young adults and adolescents remained
"relatively stable."

More "discouragingly," among young and old, the rate of multiple
partners and multiple non-marital partners also increased over
the decade. The rate of abstinence also declined among young
people during this period.

About half of the new HIV transmissions were from new serocon-
verters in the early stages of infection. "In a previous study
we found that individuals who have newly acquired HIV infection
have approximately an eightfold higher chance of transmitting to
a partner during a single act of intercourse than people with
established infection" she said. And these individuals are part
of the group most likely to have multiple partners.