Prevention of HIV spread in developing countries [letter]

With respect to dCruz-Grotes review of prevention of HIV infection in developing countries (Oct. 19 p. 1071) two issues should be highlighted. First with limited resources prevention should be directed towards the links of the infection chain in which more than one case could be averted. In the simplest chain of three links--infection of a woman with multiple partners by a man to infection of a partner of this woman to infection of the wife of this partner--the infection of the monogamous wife represents the final link of horizontal transmission. The chances of preventing the infection in this woman are almost nil in developing countries if the couple wants children. However prevention at links one and two is possible and likely to prevent more than one case of infection; but even at the second link there is a serious decrease in the probability of effective prevention counseling with increasing distance from the site of transmission: to attain behavior change of a farmer and his wife at the village level might be impossible because any HIV problem might well be denied. For example if approached at the market place the farmer would refuse to accept himself to be at risk; if met in a bar after business hours then perhaps problem-oriented learning (which precedes behavior change) might be easier to initiate. Second promotion of condom use is one of the simplest strategies for influencing behavior--much simpler than urging reduction in the number of sexual partners or abstinence. Hopefully those who are persuaded of the wisdom of condom use may be more likely to refrain from sex with casual partners if condoms are not available. (full text)