Four major misconceptions about the global HIV/AIDS epidemic

July 19, 2010

The following is a guest post by Daniel Halperin, who is on the faculty of Harvard School of Public Health and is finishing a co-authored book on AIDS. The opinions expressed are his own.

During the biannual International AIDS Conference this week in Vienna, there will be a strong push to increase funding for HIV/AIDS, along with calls to focus more on prevention of it. Given the poor track record of technological advances in HIV prevention, there is eager anticipation about a possible new vaginal gel that could help protect women from getting the virus. While future possibilities, such as the gel, and rhetoric in Vienna are well-intentioned, some of the assertions about AIDS are quite flawed. Here are four key misconceptions about AIDS:

1) Providing AIDS medications to everyone is the best prevention method. A new buzz phrase in the AIDS world is the “test and treat” notion. Some mathematical models have suggested that if tens of millions of people across Africa were tested for HIV, and everyone who tested positive was immediately placed on life-long antiretroviral medications, it would eventually end the epidemic. Such assertions are financially unrealistic, and rely on extremely optimistic and flawed modeling.

Real world evidence, in places such as America and Europe, suggests that although widespread treatment probably helps to reduce the infection rate, it does not eliminate it. So, instead, we should provide life-saving drugs to the people who urgently need them, rather than diverting expensive drugs, which can often have serious side effects, to millions of otherwise healthy individuals for a mainly speculative prevention benefit.

Preliminary research about potential “antiretroviral vaginal gels” will be presented Tuesday in Vienna. Such approaches could eventually help protect some women but, like condoms, they would need to be applied each time prior to sex. The gels may also have long-term toxic side effects and carry the risk that people will stop using more effective methods, like condoms or mutual fidelity, on the assumption they are now “protected” against HIV.

2) Behavior change doesn’t work. Some long-standing prevention approaches, such as condoms, are effective at reducing risk, though the actual impact of programs vary considerably depending on the nature of the local epidemic. In countries where the driving force of AIDS is sex work, such as in Thailand or Cambodia, “100% condom” promotion programs have often been quite successful at reducing the rate of new infections.

In the much more severely affected countries in southern Africa, however, there is less indication that the heavy investment in condom programs has slowed the epidemic. That’s mainly because it is notoriously difficult to maintain consistent condom use in the more long-term – and often overlapping – sexual partnerships where most HIV transmission in Africa occurs. Thus, in such settings it is crucial to also promote having fewer sexual partners.

3) There are no magic bullets. While this statement is certainly true, it masks another important truth, which is that the international prevention community has generally done a dismal job of prioritizing the best way to prevent HIV. The new mantra in the HIV world is “combination prevention,” which means let’s keep doing what we’ve been doing. Sadly, while many of the standard approaches, such as HIV testing and counseling, have important public health benefits, they have not been shown to reduce HIV infections in any major way.

By shying away from prioritizing the most effective interventions, some newer and potentially powerful approaches may not receive the attention and resources required to help stem the flow of new infections. Male circumcision, for example, is not as effective as condoms in reducing risk for each sex act but it lowers lifetime risk by at least 60% and confers protection every time a man has sex.

On that front, there has been some good news lately. In the part of western Kenya, where President Obama’s father was born and which has been the most severely affected by AIDS, more than 100,000 men were circumcised last year. President Zuma of South Africa has also recently endorsed the procedure, which his ethnic group, the Zulus, abandoned two centuries ago.

Moreover, and especially in the current global economic recession, there is an urgent need to pursue the most cost-effective strategies, such as male circumcision. There is not sufficient funding to “do everything” to prevent — and treat — the millions of new HIV cases continuing to occur each year.

4) HIV/AIDS is different from all other epidemics. At the end of the day our objective should be healthy people, and HIV is just one of many diseases. AIDS is not the overriding health problem in most poor countries, where more-mundane problems such as lack of access to clean water overshadow it. HIV/AIDS receives billions of dollars in foreign aid annually. Meanwhile, diarrhea and pneumonia kill many more people globally yet receive a tiny fraction of aid. Luckily, the Obama administration and others are increasingly realizing the importance of finding ways to leverage HIV/AIDS funding to improve overall health.

While we must continue to search for new technological approaches, let’s not forget that millions of lives have already been saved through using basic prevention approaches and common-sense changes in behavior.


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[…] Posted on July 21, 2010 by abrahk Daniel Halperin of the Harvard School of Public health, inthis commentary published by Reuters,   takes a contrarian   look  at the strategies for HIV/ AIDS prevention […]

Posted by Cost effective strategies for HIV/AIDS prevention « Global Public Health | Report as abusive

The studies being used to promote circumcision fail to correlate with a few harsh realities:

In America, for example, 80% of men are already circumcised from birth. The rates of infant circumcision are dropping, but at large, the population remains circumcised. These rates are at their highest in the East Coast, where cities such as Philadelphia and Washington DC rival HIV hotspots in South Africa. In the 1980s, when the AIDS epidemic first hit, the rate of circumcised men in America was at 90%. One needs to question how something that never worked here in our own country is suddenly going to start working wonders in Africa.

In other countries, the “protection” remains to be seen as well. AIDS is a rising problem in Israel, where the majority of the male population is already circumcised. On Wednesday, July 7th, two weeks ago, Malaysian AIDS Council vice-president Datuk Zaman Khan announced that than 70% of the 87,710 HIV/AIDS sufferers in the country are Muslims (in other words CIRCUMCISED). The Muslim, circumcised population accounts for 70% of the incidence of HIV, but only 60% of the population, which would mean that the circumcised population is getting HIV at a much higher rate than the non-circumcised population.

Posted by JLC981 | Report as abusive

Usually, medical studies tend to study how to preserve the human body, not vilify it and justify its destruction. For example, the study of cancer is a tedious one, and usually researchers are trying to find ways to avoid the loss of organs, such as the testicles, the prostate, and/or the mammary glands. Circumcision “studies” are unique. They’re the only ones of their kind that seek to preserve a procedure, and not the human body.

Has there been any research for alternatives for HIV/STD prevention WITHOUT having to circumcise? Is the WHO or UNAIDS doing anything to eventually move past circumcision? Is there research looking for ways in which men don’t have to consider circumcision anymore, and is the WHO considering it?

Let’s get real here. Circumcision, for all intents and purposes, is the mutilation of a person’s healthy genitals. The WHO and others are promoting male genital mutilation and HIV/AIDS “prevention” is the pretext. It should strike the reader as odd that these “researchers” are fixated on trying to legitimize a particular surgical procedure, male circumcision of all things. Recommending female circumcision would NEVER fly, no matter how much “research” the WHO or UNAIDS presented.

How is it we’ve let male circumcision go as far as promoting “mass circumcision campaigns” for it? Would we ever endorse the “mass circumcision” of women? What if “studies” showed conclusively that female circumcision cut down the risk of AIDS transmission by 100%? Why is there all this “research” surrounding male circumcision, but not female circumcision? You gotta wonder what it is they’re smokin’ up there at the WHO.

Posted by JLC981 | Report as abusive

“Male circumcision, for example, is not as effective as condoms in reducing risk for each sex act but it lowers lifetime risk by at least 60%.” That is a LIE. Based on what, other than the author’s own bias? The flawed studies showed a reduction over a short period of time, due in part to the men injured from circumcision not being able to have sex. There has been NO proof of any value over a man’s lifetime. FACT CHECK PLEASE.


Last, how about a Conflict of Interest disclosure? Halperin, the author, is a major backer of circumcision as AIDS prevention method, and his reputation depends on propogating this garbage science.

Posted by IntactNYC | Report as abusive

Seriously, IntactNYC. Right along with his partner Robert Bailey. Aesop’s “The Fox Without a Tail” teaches us to be wary of interested advice.

Both Halperin and Bailey were advocates of male circumcision before hopping onto the HIV/AIDS gravy train. Bailey is a known long-standing advocate for male circumcision, particularly INFANT circumcision. Look up his track record and you’ll realize he’s been trying to make “universal circumcision” his legacy. Halperin is on record saying he wants to make his grandfather proud (his grandfather was a mohel).

So we have some researchers that have a vested interest in legitimizing circumcision. They set out to “study” to see if “circumcision reduced the risk of HIV.” Is it any wonder that this is PRECISELY WHAT THEY FOUND?

What would we think of “resarchers” who were trying to legitimize FEMALE circumcision? What would we think of them if they were proposing governments take up “mass female circumcision” campaigns? I think they would be immediately dismissed. One needs to wonder HOW anyone up at the WHO could let this happen. What are they smoking? How much were they paid?

We need to put professional medical organizations and medical journals to task; the “study” of trying to connect male circumcision to the “prevention” of whatever disease has been raging on since it was first introduced into western medicine over 100 years ago. I think it’s time we ended the “study” of trying to vilify a perfectly healthy and normal part of the human body.

Medical “research” that focuses on seeking to necessitate a destructive procedure is backwards. Imagine “research” that focuses on finding the “benefits” blood-letting and trephination. The time has come we have treated circumcision “research” accordingly.

Posted by JLC981 | Report as abusive

I found there will be a strong push to increase funding for HIV/AIDS, along with calls to focus more on prevention of it.

Posted by ethan90 | Report as abusive