Safer sexual behaviour helps beat the virus

This year marks a watershed. In place of dire forecasts and warnings that the epidemic is not yet under control, this World AIDS Day brings some good news.

According to the United Nations Agency on AIDS, UNAIDS, there are six million fewer people infected than previously estimated. Furthermore, this is the first time that UNAIDS has publicly admitted that the annual number of new infections has been declining for nearly a decade.

While there remain an estimated 33.2m people infected with HIV worldwide, in virtually every country in the world the epidemic is either stable or waning. UNAIDS reports that HIV prevalence, or percentage infected, has declined somewhat among young pregnant women in 11 of the 15 hardest-hit countries, which are mostly in Africa.

The epidemics of eastern Europe and central Asia, largely concentrated among intravenous drug users and other high-risk groups, have slowed since the late 1990s. In India, the country purported to have the world’s largest number of HIV infections, better surveillance resulted in the estimated number of cases falling earlier in the year from 5.7m to 2.5m.

Sub-Saharan Africa continues to account for nearly 70% of the global burden of HIV. A handful of countries in southern Africa account for a full one-third of global infections, with adult HIV prevalence rates of up to 25%. Yet Africa also provides some of the greatest examples of success in combating AIDS.

Fifteen years ago, HIV rates in Uganda began to fall, with national prevalence eventually falling by two-thirds. More recently, HIV prevalence in neighbouring Kenya has also fallen by more than half. Zimbabwe has become the first country in southern Africa to see positive trends, with HIV prevalence among pregnant women falling from 26% in 2002 to 18% in 2006. Similar trends have been seen in urban populations in Cote d’Ivoire, Ethiopia, Rwanda, Malawi and Zambia.

Surprisingly, many of these drops have not coincided with increased access to the common tools of the HIV prevention trade - condoms, HIV testing and treatment of sexually transmitted infections (STI). Uganda’s famous decline occurred before widespread availability of condoms, testing and treatment, and while condom use in Zimbabwe has remained high, the country’s economic and political troubles have resulted in far less availability of health services. Across Africa, greater availability of HIV testing and STI treatment has not necessarily brought about declining HIV rates. While condoms have curbed infections among high-risk groups such as commercial sex workers, consistent usage among the general population has remained low.

Rather, falling HIV rates were preceded by something far more basic and fundamental: changes in sexual behavior. In Uganda and Kenya, the number of men and women reporting multiple sexual partners fell by half, more young people abstained from sex and condom use during higher-risk sex increased. In Zimbabwe and other countries where HIV is declining, similar behaviour changes have occurred.

In the clamour for vaccines, vaginal microbicides and other technological fixes, the fact that the greatest declines in HIV have been achieved by changes in sexual behaviour is often overlooked. The quiet work of communities and community-based organisations, including the religious and traditional institutions that often provide the glue for African societies, often goes unsung.

In a year in which the news for technological ‘silver bullets’ has been dismal - a major vaccine trial and two microbicide trials had to be halted when it was discovered that the products increased the risks of contracting HIV - the potential for low-tech, behaviour-based solutions for generalised HIV epidemics such as those in Africa, seems as bright as ever.

• The author is a research fellow at the Harvard Center for Population and Development Studies, Cambridge, Massachusetts.

This year marks a watershed. In place of dire forecasts and warnings that the epidemic is not yet under control, this World AIDS Day brings some good news.

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