The authors argue that limited resources mean that concentrating on condom use and treating sexually transmitted infections are of limited value. They dismiss traditional explanations for the high prevalence of HIV in the 9 African countries where it is over 12%, such as poverty, gender inequality and war, pointing out that HIV prevalence is higher in the richer portions of African society and not always brought into the relationship by the man. They add that Rwanda, Congo and Angola, countries that have suffered war, genocide and rape, have a lower HIV prevalence than their stable and peaceful neighbours Swaziland and Botswana.

However, where multiple and concurent sexual partners are uncommon, and where male circumcision is common, such as Niger (with an HIV prevalence of less than 1%), HIV prevalence is low. They point out that at the moment, the largest donor investments are being made for interventions for which the evidence for large-scale impact is increasingly weak. They state that promoting condom use may be successful only for high-risk populations such as gay men and sex workers, but that promoting condom use has not lead to reductions in prevalence in countries with large scale epidemics. Voluntary counselling and testing has little use among people who test negative, they argue, and recent studies on the effect of treating sexually transmitted infections have been disappointing. Equally unlikely to be of value in the near future are vaccines and microbicides, leaving the most common - and most politically sensitive - issue of multiple concurrent partners, that appears to be the main reason for the high prevalence in the 9 African countries.

They are also optimistic about the effects of male circumcision, citing 45 observational and biological studies from the past 20 years that have shown that male circumcision reduces heterosexual transmission of HIV. I wonder how they explain the high HIV prevalence among Xhosa men in South Africa - but otherwise their reasoning appears sound.

[13 May 2008 10:18]

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