[afro-nets] Failure of Vaccine Test Is Setback in AIDS Fight (4)

["Kelly Curran" <kcurran@jhpiego.net>]

About a month ago Anny Peters asked why there is so much excitement about Male Circumcision compared to the female condom. The excitement about Male Circumcision (MC) stems from the fact that, following one minor surgical procedure, a man's risk of acquiring HIV will be reduced by 60% for the rest of his life. Scaling up MC has the potential to prevent millions of new HIV infections among men, women and children, and to begin to bring the epidemic under control in the hardest hit countries of East and Southern Africa.   

Male and female condoms are of course very effective if they are used consistently and correctly. However they require a consistent supply to the most remote areas as well as (and this is the really difficult part) an ongoing commitment to use them consistently and correctly. While female condoms are technically a female-controlled method, anyone who has seen, let alone used, a female condom knows that they can not be utilized without the knowledge or consent of the male partner. If and when it becomes available, a microbicide may be able to be used in secret, but still presents the same challenge of needing to be applied correctly before each and every sex act.  

East and Southern Africa has a mature, generalized HIV epidemic, fueled by high rates of concurrent partnerships and low male circumcision prevalence. At this point in the epidemic, most transmission events in the region do not take place in the context of commercial or even casual sex, but rather, among people in relatively stable (but not always monogamous) relationships. And we have a wealth of evidence from around the world to show that while many people are willing to use condoms for commercial or casual sex, most people do not and will not use them with their regular partners in any kind of consistent way. Condoms are a great technology and have no doubt done a great deal to contain the spread of HIV in concentrated epidemic settings,  but it is naïve to expect condoms, whether male or female, to reverse a mature, generalized epidemic like the one in East and Southern Africa.   

I recognize that MC is not a "magic bullet". It is only 60% protective, and it is very important that men, women, parents and communities understand that circumcised men can and do become HIV infected. Circumcised men still need to use other prevention measures, such as partner reduction (particularly avoiding concurrent partnerships) and male or female condoms. However, MC represents the first "new" tool to be added to our prevention toolkit, and the current status of the vaccine and microbicide trials suggests it may be a long, long time before we get another new prevention tool. MC may not be perfect, but it is one of the few evidence-based prevention strategies that we have. 

To paraphrase my colleague Emmanuel 'Dipo Otolorin, if we had an HIV vaccine that was 60% protective we would not be having any debates or discussions about whether to scale it up. The donors would be falling over themselves in their haste to fund the roll-out of the vaccine and someone would likely be getting the Nobel Prize for Medicine. 

Ironically, we already have an HIV vaccine that is 60% protective. It just comes in the form of a surgery rather than a shot. History will judge us if we fail to scale up MC because we were waiting for a vaccine or we were hoping that people would start to use condoms more often. Let's implement this proven intervention before we lose another generation to the epidemic.

Kelly 

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Kelly Curran
Technical Director, HIV/AIDS and Infectious Diseases
JHPIEGO--an Affiliate of Johns Hopkins University
1615 Thames St. 
Baltimore, MD 21231
Tel: +1.410.537.1820
Fax: +1.410.537.1477
mailto:kcurran@jhpiego.net
http://www.jhpiego.org