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Local practices lead to global HIV?

Behavior change campaigns for years in the African region have targeted high-risk sexual behaviors in attempts to prevent HIV infection. The discourse at times has veered into culturally naive assumptions of sexual exceptionalism. Yet, as some researchers have observed, some fundamental measures human sexual behaviors appear consistent across cultures and geographies -i.e. average lifetime number of partners. Granted, distinct regional patterns emerge on closer look – i.e. long-term concurrent partnerships and serial monogamy are alternatively dominant in different regions of the world (see April ’06 post “Concurrency and a Campaign for Serial Monogamy”).

Other transmission routes have been largely overlooked in the mainstream discussion of HIV in Africa. This blog has mentioned before the largely unaddressed plight of MSM populations in Africa (see Feb ’06 post “MSMs finally address”). Although blood bank management has improved since the 1980s, even in low-income countries, unclean syringe and needles have been associated with 20-40% of HIV infected cases, according to one controversial 2003 study (“HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission”). Important to note that a 2004 rebuttal observed “inadequately sterilised skin-piercing instruments” likely cause no more than 2.5% of HIV-1 infections in Africa (“Transmission of HIV-1 infection in sub-Saharan Africa and effect of elimination of unsafe injections”)

In an article today (“Traditional Ways Spread AIDS in Africa, Experts Say”), The New York Times reports on local rites of passage and social behaviors that risk HIV transmission among children in Cameroon and elsewhere.

As researchers spend more time studying Africa’s overwhelming pediatric AIDS problem, they are finding that the routes of transmission may be different than in the industrialized countries, and that strategies for preventing the disease’s spread must be adapted to local realities. In developed countries, the only real risk factor for children is that they can get H.I.V. from their mothers at birth.

But here, researchers have come to agree, a host of traditional ceremonies and practices is creating transmission routes unique to Africa — dangers that have, up to now, been ignored.

In scarification ceremonies for ethnic identification and cutting for ritual healing, blades are used in sequence again and again. There is also the practice of communal breast-feeding a single baby by numerous women, common in many tightly knit villages.

In a country like Cameroon, where more than 5 percent of the population and 11 percent of pregnant women are infected with H.I.V. — the vast majority unknowingly — such practices could lead to a wildfire spread.

“If we are only biology, biology, biology, then we are only doing half of our mission,” said Marcel Manny Lobe, director of the new International Reference and Research Center for H.I.V.-AIDS in Yaoundé. “We need also to do the sociology and anthropology and then make biological interventions.”

The emphasis on locally tested interventions makes sense. And pediatric HIV prevention is certainly a critical area for HIV intervention. But consider the HIV plague at greater granularity as many epidemics – pediatric, MSM, IDU, heterosexual ‘sugar daddies’ and others that at times overlap. In light of limited resource availability, I wonder if the focus on transmission due to cultural practices is where we should be placing greater attention or if, in the end, the magnitude of other HIV epidemics pulls us to where the need and risk are largest.

The answer lies in determining what is truly the largest need and risk. Without more precise measurement, we cannot do much when the fraction of HIV infections attributable to dirty needles ranges anywhere from 2.5 to 40%.

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