Care and support for people living with HIV/AIDS

Prevention: daunting challenges aheadEven though the weight of evidence increasingly suggests that circumcising menbefore they become sexually active does provide some protection against HIV, thepractical implications for AIDS prevention are not obvious. Circumcision, where it ispractised, usually has links to religious or ethnic identities and life-cycle ceremonies,and may customarily be done after puberty. If the same scalpel were used withoutsterilization on a number of boys, this could actually contribute to the transmissionof HIV. Finally, if circumcision were promoted as a way of preventing HIV infection,people might abandon other safe sexual practices, such as condom use. This risk isfar from negligible – already, rumours abound in some communities that circumcisionacts as a “natural condom”. A sex worker interviewed in the city of Kisumu inKenya summed up this misconception, saying: “I can sleep with circumcised menwithout a condom because they don’t carry a lot of dirt on their penis”. While circumcisionmay reduce the likelihood of HIV infection, it does not eliminate it. In onestudy in South Africa, for example, two out of five circumcised men were infectedwith HIV, compared with three out of five uncircumcised men. Relying on circumcisionfor protection is, in these circumstances, a bit like playing Russian roulette withtwo bullets in the gun rather than three.HIV and other sexually transmitted infections: anopportunity to strengthen preventionThe important links between HIV and other sexually transmitted infections have beenknown for many years. One link is behavioural. Engaging in unprotected intercourseexposes a person both to HIV and to a classic sexually transmitted infection. By thesame token, using condoms consistently can prevent both kinds of infection. Thesecond link is biological. A person with an untreated sexually transmitted infectionis more likely both to contract and to pass on HIV during unprotected sex. Some evidenceexists that prompt diagnosis and treatment of the curable sexually transmittedinfections, such as syphilis and chancroid, can sever this link and reduce thenumber of new HIV infections.New information highlights the challenges raised by these interlinked infections aswell as the opportunities for their joint prevention. On the one hand, there now is evidencethat genital herpes, an incurable viral infection in which patients have recurrentgenital ulcers, may play a more important part in fuelling the spread of HIV thanpreviously thought. On the other hand, recent data point to the enormous potentialof using improved health care for sexually transmitted infections as an entry-pointfor prevention services that could help reduce the rates of both HIV and other sexuallytransmitted infections.In high-income countries, genital herpes – infection with herpes simplex virus-2(HSV-2) – is the leading cause of genital ulcers, although rates are low. HSV-2 is nowassuming that position in sub-Saharan Africa, too, overtaking chancroid and other71