Ten Myths and One Truth About Generalised HIV Epidemics

In this Lancet, Vol 370, James D. Shelton explores 10 misconceptions about widespread or generalised HIV epidemics.
They are:

1. "HIV spreads like wildfire" - HIV is highly infectious in the first few weeks. But for the next many years, infectiousness is much lower. This early period of high infectiousness makes concurrent sexual partner networks very risky. "This pattern allows rapid dissemination when a new infection is introduced and probably involves more frequent risky sex than in sporadic or exclusive relationships."
2. "Sex work is the problem" - In the generalised epidemics in Eastern and Southern Africa, "fewer than 2% of men reported paying for sex in the previous year, although 29% reported multiple partners", leading the author to conclude that focusing prevention campaigns on sex workers has limited usefulness.
3. "Men are the problem" - The article states that though male behaviour, including "cross-generational and coercive sex, contributes substantially to the establishment of generalised epidemics", statistics show that in generalised epidemics, a high proportion of women, and not their partners, in discordant relationships is HIV positive.
4. "Adolescents are the problem" - Statistics show that generalised epidemics span all reproductive ages, so, according to the author, interventions in young people, including abstinence, although important, have limited usefulness.
5. "Poverty and discrimination are the problem" - A decline in HIV where poverty has increased, and an increase in HIV, now more common in wealthier people than in economically poorer people, may suggest that wealth and mobility support concurrent sexual partnerships, increasing the spread of HIV.
6. "Condoms are the answer" - "Many people dislike using them (especially in regular relationships), protection is imperfect, use is often irregular, and condoms seem to foster disinhibition, in which people engage in risky sex either with condoms or with the intention of using condoms."
7. "HIV testing is the answer" - Very newly infected people, who are highly infectious, do not yet test HIV-positive; yet, behavioural change for reduced risk for those knowing their status does not seem to be normative or sustained.
8. "Treatment is the answer" - "...[N]o clear effect has emerged. Indeed these salutary effects might be outweighed by negative effects, such as resumption of sexual activity once those on antiretrovirals feel well, and disinhibition when people realise that HIV might no longer be a death sentence."
9. "New technology is the answer" - "[A]ny success appears to be far off ."
10. "Sexual behaviour will not change" - Sexual behaviour can change, as stated here, as a result of fear of infection, according to evidence among homosexuals in the United States in the 1980's and among heterosexuals in Kenya and eastern Zimbabwe, presumed to be caused by large drops in multiple partners.

The author recommends behaviour change techniques - including explicit messages sensitive to local cultures that raise perception of personalised risk, which focus on what people have adopted spontaneously: cessation of concurrent partnerships. "Even modest reductions in concurrent partnerships could substantially dampen the epidemic dynamic."