A great service is being provided to readers of The Lancet via a number of highly readable review articles and commentaries on HIV/AIDS prevention strategies and their relative success rates. See full references below for a full and careful reading, but until then, here are some highlights.
Condoms for Men
The first line of defense, apart from abstention, continues to be the use of the male condom. It appears to be 85%-95% effective when used consistently. The problem with the missing percentage points appears to be mostly their selective use, in the sense that many men who are having sex with prostitutes will use them all the time, but will only use them with their wives when they feel there is a good chance of the wife becoming pregnant otherwise. In other words, many men eschew their use during their wives menstruations, when they perceive the chance of pregnancy are minimal. Not only is this a somewhat shaky proposition in terms of birth control, but it exposes the men to HIV picked up by the wife from other means, or it allows HIV which the men picked up , but of which the men were unaware, to be transmitted to their wives.
Condoms for Women
While many are unacquainted with them, female condoms are in use as both contraceptive and HIV preventive methods. They are somewhat less effective, not so much because their construction in theory is in any notable way highly penetrable to the AIDS virus, but because female condoms can be somewhat awkward to insert and keep in place. Female condoms generally consist of a flexible cylinder or sheath of thin latex or polyurethane, with a reinforced ring, largely of the same material as the rest of the sheath, and somewhat reinforced material at the tip that goes into the vagina. Those structures help the female condom stay in place during intercourse. At the opposite end, at the vagina’s entrance, is another ring of reinforced material, acting as an anchor , or it might be in something like a triangle shape. In either case it is open, as opposed to closed off as its opposite end, and it is through this entryway where the man inserts his penis and into into the connected tunnel or barrel of which, the man ejaculates his semen, and any concomitant viruses. The greatest advantage of the system is that the woman is in charge of the insertion and use, and can place it inside her even before her partner has an erection. Women have generally reported either no decline in their sexual enjoyment in using them, and some have reported enhanced sensation. Perhaps unfortunately, their costs are greater, and field trials have generally shown that training women to insist on their partner’s use of male condoms has about the same level of AIDS preventive effectiveness.
Diaphragms and Cervical Caps with Antiviral Lotions or Lubricants
While there is little doubt that these would not be as effective as either male or female condom use, because they expose more internal tissue to possible viral penetration, use of diaphragms or cervical caps with antimicrobials and newly developed antiretroviral gels or creams may yet prove to be a reasonably effective strategy. Its advantage for women is similar to that of the female condom, but without the chance of having the male partner see the external ring at the vulva (and presumably have an opportunity to object).
Treating Other STDs
Public health programs where examination, testing, and treatment for other STDs are made readily available, has some effectiveness in HIV prevention, largely because HIV appears to become more readily established or better established in persons with STDs. This is particularly the case if the region is not already saturated with HIV positive patients.
Encouraging Circumcision of Men
(and Stopping the Detestable Practice of Female Genital Mutilation Masquerading as Circumcision)
Males who are uncircumcised have a somewhat greater risk of developing both sexually acquired and fairly routine bacterial and yeast infections of their foreskins and the underlying penis. This risk increases in countries where daily bathing and hygienic washing of the foreskin-retracted and exposed penis are not common. Secondary HIV virus penetration is more likely when even small surface ulcerations emerge, even if the primary infection is self-limiting. Of course, the use of truly sterile technique is required for any cutting procedure, and this is particularly rarely observed in countries where female genital mutilation is practiced. The latter procedure may well cause a greater risk of HIV owing to both the operation itself, and owing to the follow on infections and chronic irritations. Male circumcision by contrast leads to a penis whose skin is actually toughened after healing and less likely to be penetrable by the virus.
Treating the HIV Infected Partner May Reduce the Risk to an Uninfected Partner
There is some thought and a few clinical trials that suggest that aggressively treating the HIV infected partner and keeping that partner down to a clinically very low or undetectable HIV load significantly reduces the chances of the uninfected partner getting the disease, but this seems to depend on a highly conscientious prescription medication regimen being maintained by the HIV-positive partner, even though the viral load seems extremely low. Alternatively, it has been suggested that giving the non-positive partner antiretrovirals may be of some use, although this raises the risk of increasing strains of HIV that are drug resistant, and may have other adverse consequences.
Vaccines
There is no easy way to say it. Things are not promising.
The Idea that Retrovirals Will Simply Wipe AIDS Out Making Prevention Unnecessary.
Even with the massive infusion of monies today, five new cases emerge for every two that are started on retrovirals. We cannot, one article in this series quotes, “treat our way out of this crisis.”
Horton R & Das P. 2008. Putting prevention at the forefront of HIV/AIDS. The Lancet 372 (9637): 421-422.
Merson MH et al. 2008. The history and challenge of HIV prevention. The Lancet 372 (9637): 475-488.
Padian NS et al. 2008. Biomedical interventions to prevent HIV infection: Evidence, challenges, and way forward. The Lancet (9638): 585-599.
Tony Stankus [email protected] Life Sciences Librarian & Professor
University of Arkansas Libraries MULN 233 E
365 North McIlroy Avenue
Fayetteville AR 72701-4002
Voice: 479-409-0021
Fax: 479-575-4592
Comments