Kids’ Doc in Jos

A BBC news headline reported yesterday, "HIV treatment ‘failing’ in Africa". The news item goes on to say, “More than a third of patients on HIV medication in sub-Saharan Africa die or discontinue their treatment within two years of starting it, a survey shows.” The report is based on a newly-published report in Public Library of Science Medicine.

I have not yet read the article but will soon. Meanwhile, here are two questions for you to think about and, if you want, comment below.

• Is it a “failure” that 61% of patients are alive and continuing treatment after two years in a program taking antiretroviral (anti-HIV) drugs?
• The study includes reports published between 2000 and 2007. Do the results take into account any changes in during that time? That is, are programs more or less effective now than they were 10 years ago? Is there enough information to know? Again, I haven’t read it yet but it’s a good question to consider as you read.

Rosen S, Fox MP, Gill CJ. Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review. PLoS Med 4(10): e298. Oct 2007. doi:10.1371/journal.pmed.0040298. Free access.

I always appreciate receiving links and pointers to interesting articles, and someone recently sent me a copy of “The Fidelity Fallacy: The Link between HIV Infection and Marriage” by Serra Sippel. To oversimplify a bit, the author argues that men will be men, and in some societies marital fidelity is not terribly important, so the American government is wasting a lot of money trying to promote sexual faithfulness as a way to prevent HIV.

In fact, Sippel says, such efforts may be “helping to fuel the spread of AIDS because the approach stigmatizes those who use condoms or those who ask their marriage partners to use condoms.” Her logic here is that couples will be reluctant to use condoms because they are presented as a measure “only to be used if you are sexually immoral.” Hence, she says, we should stop telling people that extramarital sex is immoral, so men won’t feel so bad about using condoms and women won’t feel so bad about asking their partners to use them. Instead of saying that fidelity is more moral than infidelity (which word, by the way, will need a new, positive synonym), we should “associate condom use with masculinity by building on men’s existing sense of responsibility to their families.”

I think that the perspective pushed in this essay is something we need to hear and pay attention to — it’s always important to know how things “really are” and not just how we think they are or should be. We need to be aware that different cultures view marriage in different ways, that infidelity occurs everywhere, and that moralizing can be counter-productive. Yet there are some confusing points in this piece.

First, I don’t understand why Ms. Sippel associates the fidelity issue with morality, while condoms are considered amoral. Not only is fidelity a pragmatic measure and the most effective one (when actually practiced) to prevent HIV, but condoms are, in many cultures, considered a moral issue. So to argue that we should stop moralizing and get practical does not really fit reality too well.

It seems inconsistent to say we should encourage men to use condoms (always, so no one will be stigmatized) in order to be more responsible for their family’s welfare, while de-emphasizing sexual fidelity because it doesn’t fit the culture and since people won’t be faithful anyway. Do condoms fit the culture? Would the author suggest that in deeply Catholic and Muslim countries, we should avoid pressing people to use condoms because their use goes against cultural norms? True, cultural norms have to be considered, but we have to face the fact that many cultural norms in every culture are bad for health. Did we give up on anti-smoking campaigns decades ago when it seemed impossible that we could change such a deeply entrenched habit? Do we now give up on campaigns against obesity and junk food because it’s inevitable that people are going to overeat? Or do we present an ideal and challenge everyone to aspire to it?

Ms. Sippel says, “While it is useful and important to create the conditions necessary for individuals to be able to choose fidelity, the morality of saving lives must take precedence.” Despite this acknowledgment in passing of the value of fidelity (or, as she puts it, “for individuals to be able to choose fidelity,”), the tone of the article as a whole is summed up by its title, “The Fidelity Fallacy.”

I do not have wide experience in US-funded HIV prevention programs. It may in fact be true that moralizing and unrealistic funding restrictions are getting in the way of effective prevention measures. So, I am not trying to detract from the importance of the discussion and analysis of these points. However, I think it is as unhelpful to emphasize “The Fidelity Fallacy” as it is to promote “The Condom Fallacy” from the other side of the ideological spectrum. In our church-based ECWA HIV awareness and prevention program, we stress the importance of sexual abstinence before marriage and fidelity in marriage, and, yes, we even say that fidelity is “moral” (God’s way for us) and that infidelity is immoral (not God’s way, and a destructive path). This article makes me wonder whether we should not, pragmatically, also encourage all couples to use condoms. It’s an interesting question. However, it would be, in my view, irresponsible and a failure of our calling to abandon the quest for a more sexually-pure church and culture.

Yes, let’s recognize that change is difficult, and that sexual fidelity is not an easy answer. Like any discipline, only some will try it, and only some will succeed. Exercise is the challenge for me: I’ve started so many times but rarely persist more than some weeks. Yet, I hope doctors don’t stop encouraging me to exercise simply because I may never achieve a high level of activity.

Serra Sippel, “The Fidelity Fallacy: The Link between HIV Infection and Marriage,” from the Center for American Progress website, http://www.americanprogress.org/issues/2007/08/fidelity.html, accessed Aug 28, 2007.

A report at the recent 14th Conference on Retroviruses and Opportunistic Infections (CROI) has generated a lot of attention under headlines like "Formula and death in Botswana" (UPI), "Anti-HIV Strategy Backfires in Botswana (ScienceNow), "Benefits of Breast-Feeding Might Outweigh Risk of Vertical HIV Transmission in Developing Countries, Studies Say" (KaiserNetwork.org), "Researchers urge mothers in Botswana to breast-feed" (San Francisco Chronicle). It seems a little odd me that this single report is being treated as such a surprise and as if it ought to change policies on HIV and breastfeeding.

The core of the story is that during a period of floods in Botswana, there was a large increase in diarrheal disease and mortality among formula-fed children. Formula feeding had been encouraged in HIV positive women. During the floods there were also local shortages of formula as supply lines were cut off.

It has been recognized all along that there is a balance of risks in the question of feeding of infants of HIV-infected mothers. HIV transmission via breast milk, originally thought to be rather uncommon, is now known to be a major risk. The benefits of breastfeeding are well-known. The safety of formula feeding, however, varies widely depending on the circumstances. In the worst case, formula feeding with contaminated water and insufficient quantity of formula (as in the Botswana floods) is obviously very dangerous. At the other extreme, with plentiful formula, clean water, and educated mothers, it is relatively safe. The hot question is, when is formula feeding safer than breastfeeding?

The existing guidelines are that formula feeding should be used only when it meets five criteria: acceptable, feasible, affordable, sustainable and safe. Naturally, each of these exist on a continuum and cannot be thought of as yes-no issues. However, they show that current standards demand contextualization of the decision rather than a one-size-fits-all recommendation for or against formula feeding.

The Botswana story shows, not surprisingly, that a natural disaster can swing the balance, at least temporarily. It shows that formula feeding is dangerous when there is no clean water and not enough formula. Should this prompt any major changes in policy? It is hard to see why it should. At most, the study reminds us that we need to be careful about assessment of the criteria, and consider the possibility that conditions will deteriorate, putting formula-fed infants at risk. The findings also demonstrate the importance of support for families feeding their babies formula.

If families at risk were all in the same environmental conditions, with the same educational and economic backgrounds, simple recommendations might make sense. However, conditions related to the five criteria vary drastically across Africa and within single countries, single cities or towns, and even within a single clinic or treatment program.

There are mothers who are bright, educated university graduates, and others who are uneducated and not-as-bright. There are mothers who are healthy and those who are in the last stages of AIDS. There are those on consistent antiretroviral therapy and those who have no access to it. There are locations with access to clean water, even for the poor, and there are those without. There are programs that can provide free formula and those that cannot. There are programs with counselors and volunteers who can support individual mothers and family units, and there are programs where little can be done individually. It seems ludicrous to ignore all these differences and to make a single recommendation for everyone.

Rather than advocating major changes of the already-nuanced guidelines, or that health officials "should strongly encourage breast-feeding into the second year of life for infants found to be HIV-infected," as one researcher is quoted as saying (New York Times), a practice known to carry a substantial risk of HIV-transmission, it might be more useful to put more effort into

• improving our ability to assess the risks and benefits in specific situations
• strengthening providers’ ability to individualize recommendations
• putting much more energy into making the formula feeding programs safer.

Of course, more fundamental solutions such as methods of blocking transmission in breast milk (HAART for the mother, immunizations for the baby, ART for the baby, etc.) are important in the long run, but are probably not widely applicable in the immediate future.

In summary, we need to remember that this is a complex issue that needs ongoing time, thought, and attention from policy makers and health care providers at all levels, (including community volunteers), not simply another swing of a monolithic pendulum.

Anti-HIV Strategy Backfires in Botswana. ScienceNOW Daily News, 26 Feb 2007.

Formula and death in Botswana. United Press International, 27 Feb 2007.

Scientists Urge New Look at Feeding in AIDS Fight. New York Times, 27 Feb 2007.