09 January 2009

Comment on Helen Epstein "AIDS and the Irrational" (BMJ 337, 2008)

Helen Epstein's 'AIDS and the irrational', (BMJ 2008;337; a2638; online 29 Nov 2008, p 1265-1267), framed as an open letter to the new director of UNAIDS, argues that much more attention should be paid to what she and others call 'partner reduction' strategies in AIDS prevention campaigns. Her main complaint is that UNAIDS and other agencies such as USAID do not focus sufficiently on this factor. She argues that while circumcision is also an effective but neglected method, both evidence and argument indicate that 'partner reduction' holds the key. She takes issue with the 'irrational' failure of UNAIDS and other agencies to take this seriously enough.

The 'irrationality' in the title refers to two things. First, the 'irrationality' of the UNAIDS policies toward AIDS prevention that are not always based on good science. They may be based instead on religious and political commitments of the UN's member nations, and on deeply held beliefs about what will work in AIDS prevention.
The second cloud of references to 'irrationality' is her assertion that some of the UNAIDS policies contribute to the impression that sex, especially in Africa, is in fact 'irrational' and that only technical, bio-medical solutions will stem the tide of HIV in these populations. This is predicated, however, on the apparent evidence that "irrational beliefs about AIDS persist" in Africa such as beliefs that "traditional medicine is more effective that antiretroviral drugs," and the resort to witchcraft to explain and deal with AIDS infections.

The idea that African beliefs about sex and AIDS are 'irrational' is, of course, controversial. Thabo Mbeki, former president of South Africa, rejected the hard evidence that HIV causes AIDS and that it is especially prevalent in South Africa in part because he believed that it implied that Africans were "irrational." Nevertheless, African beliefs about AIDS do appear to be irrational. Is there a better way to understand them?

One way in which southern Africans appear to be particularly 'irrational' is their involvement in long-term concurrent sexual partnerships. In some areas and age groups there is almost a one-in-two chance that any new partner will be HIV positive. Yet southern African men and women continue to have unprotected sex under these conditions, and do so with multiple partners. This is clearly "risky sex." In order to understand it, however, we have to examine more critically the notions of 'multiple partnership', 'concurrency', and 'risk'.

As Epstein points out, there is every reason to recommend "partner reduction", even to make it the central part of all HIV/AIDS education campaigns and interventions. However, UNAIDS prefers to recommend what Epstein calls 'needlessly overcomplex … combination prevention,' that is, multiple approaches including the usual ABC, VCT, treatment of other STIs, education, together with bio-medical research on vaginal microbicides, vaccines, and pre-exposure prophylaxis. A great deal of money has been spent on the bio-medical approaches despite the fact that none of them has shown much evidence of success.
It is eminently clear that 'partner reduction' does indeed break up the AIDS 'superhighway' of transmission that a densely connected set of 'multiple partnerships' creates (Thornton 2008). The term 'multiple concurrent partners', however, directs our attention to small ego-centred groups rather than to larger social contexts. This can limit our vision.
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