Dear Editors,

PLoS One recently published an article by John Talbott (1) which claimed that the high prevalence of HIV in Africa is due to vast numbers of commercial sex workers (CSWs) in the continent. This claim is made on the basis of CSWs data from 77 countries drawn primarily from a study by Vandepitte et al (2). Talbot’s multiple regression ecological study makes the unprecedented conclusion that “a fairly robust correlation between the number of commercial sex workers as a percentage of a country’s population and the HIV/AIDS prevalence rate for the country’s entire population”. A number of responses disagreeing with Talbot’s conclusions have been posted (3,4) to which I write to add my voice.

While Talbot’s paper adds a commendable voice in the need to target CSWs with HIV prevention programs its basis is largely flawed making the conclusions erroneous in two significant ways. Firstly, his definition of CSWs as “women having sex in a formal exchange for money or goods” is narrow and simplistic. It is also culturally insensitive and misplaced to label women who have sex with multiple men (or vice versa) as “prostitutes”. Talbot chooses to be ignorant of findings reported in demographic health surveys (DHS) from many African countries that multiple sex relationships to a great extent do not entail a transactional exchange or ‘pay’. For example, recent DHS reports from two of the countries in Talbot’s study (Ethiopia and Kenya) show that only 1% and 3% of men had paid for sex, respectively, even though the reported multiple sex patterns were much higher (5,6). Multiple sexual relationships, while it cannot be denied is a factor behind high HIV prevalence in some African countries (7), usually do not involve ‘prostitution’.

A second major criticism to Talbot’s analysis is his emasculation of male circumcision (MC) as a significant HIV preventive measure. In this he dismisses the overwhelming evidence widely disseminated and acclaimed in epidemiological and experimental studies showing the efficacy of male circumcision in preventing HIV infection in heterosexual relations (8-12). In the randomized control trials in Kenya, Uganda and South Africa, MC was found to be over 60% preventative. One wonders how he could have disregarded such overwhelming evidence. Furthermore, by using the proportion of men who are Muslim as a proxy to the MC variable, his analysis is misleading. He seems not to be aware that circumcision in many African countries is culturally widely practiced unrelated to Muslim religion (13). For example, according to the DHS surveys in Ethiopia and Kenya over 90% and 80% of men are circumcised, respectively, whereas the majority of men in both countries are not Muslims; in fact, in Ethiopia, circumcision is more prevalent among Orthodox men than Muslim men. In Kenya, HIV prevalence is more than three times the national average among the mainly non-Muslim Luo community where male circumcision is far much lower than anywhere else (16%). In countries such as Congo even fewer men are Muslims, and, like Ethiopia, also a hugely populated African country where nearly all men are circumcised. An argument that MC is a reflection of being Muslim has no basis, and the correlation between MC and HIV cannot be denied.

Talbot projects himself as passionate about Africa and the HIV/AIDS crisis on the continent but his background in banking and now anti-‘prostitution’ campaign are not well informed of the evidence and the solutions to tackling the epidemic which are rooted in complex socio-cultural and political dynamics domestically as well as internationally. On the basis of such sweeping and startling claims made in the article and on the slides in his website (http://www.africansagains...), his motives are also questionable.
As an African and a scholar, and one affected by the scourge (as is everyone who knows or is doing something about it), I am impassioned by efforts to fighting the HIV crisis. The terrain of research and action remains open-ended. It is imperative that demonstrated evidence to prevention be followed through by implementation. MC has been shown repeatedly to be a highly effective preventative tool and has been endorsed by the WHO, UNAIDS, and other international organizations. It is time for its implementation as part of an integrated HIV prevention response. With such standing, it is irresponsible for researchers or other actors to ignore scientific evidence or procrastinate in the face of a crisis that threatens the socio-cultural and politico-economic wellbeing of Africans. Proposals for approaches to tackling the pandemic while welcome should be based on sound and uncompromised evidence which is yearning in Talbot’s paper.

Male circumcision is a relatively simple surgical and onetime procedure and, thus, is a very promising addition to existing arsenals in HIV prevention. There is need to continue promoting condom use, which is already far above average among men who pay for sex in Ethiopia and Kenya; but condoms have not been widely accepted in the region hence the importance for new innovations. Admittedly, behavior change, whether with regard to multiple sexual partners or condom use, will remain a key challenge. However, with high acceptability in communities not traditionally practicing it (13-15) – which reflects a significant cultural change of greater significance than individual behavior change – MC has a potential to be a revolutionary tool in the fight against HIV/AIDS. In communities not practicing it MC would certainly have a great impact as demonstrated in the experimental research and hence should be made available without delay.

Richard G. Wamai (Harvard University School of Public Health).

References

1. Talbott J. Size matters: the number of prostitutes and the global HIV/AIDS pandemic. PloS One 2007 (http://www.plosone.org/ar...).
2. Vandepitte J, Lyerla R, Dallabetta G, Crabbe F, Alary M, Buvé A. Estimates of the number of female sex workers in different regions of the world. Sex Transm Infect 2006; 82 (Suppl 3): iii18-25.
3. Buve et al. The Fatal Attraction of ecological studies. PLoS One. 2007 (July 6).
4. Halperin et al. Male Circumcision Matters. PLos One. 2007 (June 27).
5. Ethiopia DHS (2005): http://www.measuredhs.com... (accessed July 9, 2007)
6. Kenya DHS (2003): http://www.measuredhs.com... (accessed July 9, 2007).
7. Halperin, D. and Epstein, H. Why is HIV Prevalence so devere in Southern Africa? The role of multiple concurrent partnerships and lack of male circumcision: Implications for AIDS prevention. The Southern African Journal of HIV Medicine, 2007 (March):19-25.
8. Bongaarts J, Reining P, Way P, Conant F. The relationship between male circumcision and HIV infection in African populations. AIDS 1989; 3: 373-377.
9. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS 2000; 14: 2361-2370.
10. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005; 2: e298.
11. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: A randomised controlled trial. Lancet 2007; 369: 643–56.
12. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007; 369: 657–66.
13. WHO/UNAIDS. Male circumcision: global trends and determinants of prevalence, safety and acceptability, 2007 (http://www.unaids.org/en/...)
14. Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in sub-Saharan Africa: a review. AIDS and Behav 2006 DOI:10.1007/s10461-006-9169-4).
15. Bailey RC, Muga R, Poulussen R, Abicht H. The acceptability of male circumcision to reduce HIV infections in Nyanza Province, Kenya. AIDS Care. 2002 Feb;14(1):27-40.