Innovative responses for preventing HIV transmission

Innovative responses for preventing HIV transmission: The protective value of population-wide

Concurrent partnering contributes to high HIV prevalence. This is in part due to the natural history of the virus. After transmission, an individual’s viral load spikes in a period of ‘acute infection’ during which they are highly infectious. Models estimate that around 10 - 45% of HIV acquisition arises from sex with an individual in the acute infection period. If everyone in a population abstained from high-risk sex for a given period of time, in theory the viral loads of all recent seroconverters should pass through the acute infection period. When risk behaviour resumed there would be almost no individuals in the high-viraemic phase, thereby reducing infectivity, and HIV incidence would fall. Recurring population-wide shifts in risk behaviour are not unheard of. Many, in fact, occur as part of existing religious observances. The month of Ramadan in Muslim communities is perhaps one of the most obvious cases. Ramadan sees significant behaviour changes. In addition to fasting from sunrise to sunset, observant individuals abstain from coitus during daylight hours. There is anecdotal evidence that risky sexual behaviours are also significantly reduced over this period. In Indonesia, for instance, it was reported that research with sex workers was not possible during Ramadan because people ‘abstained from sex from one end of the month to the other….many sex workers returned to home villages during this time.’ This article argues that a population-wide interruption of risk behaviour for a set period of time could reduce HIV incidence and make a significant contribution to prevention efforts. It calls for mathematical modelling of periodic risk behaviour interruptions, as well as encouragement of policy interventions to develop campaigns of this nature. A policy response, such as a ‘safe sex/no sex’ campaign in a cohesive population, deserves serious consideration as an HIV prevention intervention. In some contexts, periods of abstinence from risk behaviour could also be linked to existing religious practices to provide policy options.

notion of population-wide sexual abstinence for a short period was discussed in Swaziland in 2005 after King Mswati III lifted a 4-year ban on unmarried girls under age 21 having sex – young women had to wear tassels as a sign of their virginity. The idea is that population viral load would drop if everyone were to be abstinent for a month because fewer people in the acute phase of HIV infection would transmit HIV to their partners. Whether it would work, even if everyone abstained, might depend on the stage and dynamics of a country’s HIV epidemic. Modelling would have use country-specific parameters to assess potential impact before such a proposal could be seriously considered. Abstinence-only programmes for young people who have never had sex have not been shown to be effective (HIV This Week Issue 45). Secondary sexual abstinence, i.e. sexual abstinence after sexual initiation, whether situational or deliberate, requires social skills and social support. A ‘safer sex-no sex’ campaign would likely be more acceptable and effective than a ‘no sex for a month’ campaign.