Mark Weston
10 November 2006
Johannesburg — TECHNOLOGY is the new new thing in the battle against HIV/AIDS. Antiretroviral drugs have saved the lives of thousands of people infected with the virus, and the search is on to find successful prevention technologies.
At the International AIDS Conference in Toronto in August, scientists displayed their wares to an audience of 24000 donors, journalists and activists. Among the magic bullets on show were microbicide gels, diaphragms, prophylactic drugs and the ultimate holy grail, vaccines. Delegates lapped it up.
The success of antiretroviral drugs shows that investment in technology can help fight AIDS, but in the prevention field it has so far proved fruitless. An HIV vaccine is as elusive as ever and no microbicide has passed trials. Millions more will become infected before a new prevention tool becomes widely available. Those societies that have prevented or reversed the spread of HIV have done so by changing behaviour.
From local campaigns in gay communities in the US to national efforts in Brazil and Senegal, low-technology solutions based on persuading people not to have unsafe sex have been the key to preventing infection.
Other countries too have tried to promote behaviour change. Many have failed -- 4,1-million people were infected last year. This failure may explain the attraction of new technologies, but the millions of individuals at risk of infection cannot afford to wait for a panacea that may never arrive.
Instead, governments should redouble their behaviour-change efforts. In 1900, tuberculosis killed one in 10 Americans, but because of changes in behaviour the death rate fell 90% in the following 20 years, before the advent of an effective TB drug. Similar advances are possible with HIV/AIDS today. The traditional methods used in Thailand, Senegal and elsewhere, including public education campaigns, condom distribution, and treatment of sexually transmitted infections, remain vital. But in those countries where these have proved inadequate, new approaches are needed. Several low-tech prevention strategies have recently been gaining currency:
-Circumcision: A recent trial in SA of the effectiveness of circumcision for lowering the risk of contracting HIV was so successful it was halted and the control group advised to have the snip quickly. The circumcised group had a 60% lower risk of becoming infected than the control group.
-Better safe sex: Sex with a condom, although safe, is unattractive to many couples. Ways must be found to make safe sex pleasurable. Fortunately, no technology is required for this, as we already have tried and tested solutions. Oral sex, for example, is much less infective than vaginal or anal sex. If couples have more oral sex and less unprotected vaginal sex, HIV infection rates will fall. Intercrural sex, or thigh sex, is another option. The ancient Greeks engaged in thigh sex, and it was practised by Zulus until recent times. Like oral sex, thigh sex is both pleasurable and safer than unprotected vaginal sex, but few AIDS campaigns ever mention it.
-Voluntary counselling and testing (VCT): VCT centres are springing up all over Africa and Asia. Infection rates are lower where people know their HIV status and have received prevention messages from counsellors. Many such centres are in distant hospitals or clinics, however, and bringing them closer to communities might encourage more people to test.
-Social network analysis: Social networks are sweeping the business world. Social networking websites such as MySpace are worth millions, and word-of-mouth advertising has moved into the mainstream. Social-network analysis offers great promise for transmitting HIV-prevention messages. In every community there are individuals who influence others' behaviour. Be it through giving advice, setting trends or simple persuasion, these well-connected people are better equipped than others -- and than governments -- to deliver HIV-prevention messages. There are tools that can help identify such people, and their use could transform AIDS education campaigns.
-Professional influencers: Finding a community's trendsetters is one thing, persuading them to encourage their networks to use condoms or present for testing quite another. Many will work more effectively if they are given incentives. For some influencers, the opportunity to learn new skills will be sufficient. For others, cash, cellphone credits or concert tickets will prove a stronger inducement. In countries with high unemployment, paying people to spread HIV messages could help solve two big problems at once.
-Incentives for business: The private sector has both a natural interest in stopping HIV -- the virus is decimating workforces and customer bases -- and the ability to make a difference. Skills in marketing, strategic development and product distribution, and an accessible audience of employees, suppliers and customers, mean businesses are well placed to tackle the disease. Those firms that have not yet acted may be spurred by tax breaks or access to credit or training. The involvement of business associations and chambers of commerce in developing prevention programmes will help spread the cost.
There are many underused methods of preventing HIV infection through behaviour change. Policy makers, wearied by years of failure, should not put all their hopes in technology. Even if a new prevention technology becomes available, behaviour change will be needed if people are to adopt it. Until then, unglamorous and protracted though it may be, it remains our only hope of stopping the epidemic.
Weston, an independent policy consultant, is co-author of the World Economic Forum's annual Business and HIV/AIDS report.
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