LETTER REJECTED BY LANCET RE KAMALI STUDY
In the large, well designed and executed study1 on the effect of sexual behaviour
intervention on transmission of HIV-1 in Uganda, the authors reported a reduced
incidence of herpes simplex virus type 2 ("HSV2- a proxy measure of
unprotected sexual contact"), as well as a significant reduction in acute syphilis,
gonorrhoea, and unprotected casual sex in the intervention group. But there was
no effect on HIV incidence. The lack of effect on HIV transmission with an
"apparently appropriate intervention that reduced other STDs and was
implemented on a huge scale with great care and commitment"2 may be due to
"secular changes [which] are occurring" in Uganda, as the authors claim.
However:
1. the fact that the probability of HIV transmission per coital act in Uganda is
not significantly different from that in the USA, that is, very low; 3,4
2. the prevalence of HIV in Uganda, unlike the USA, is high (10%);
suggests that a high proportion of HIV seroconversions may be acquired by
means other than sex.5,6 This would explain why sex education that is effective
in reducing other STDs has no effect in reducing HIV.
Eleni Papadopulos-Eleopulos Biophysicist, Department of Medical Physics, Royal
Perth Hospital, Perth, Western Australia
Valendar F. Turner Consultant Emergency Physician, Department of Emergency
Medicine, Royal Perth Hospital, Perth, Western Australia
John M Papadimitriou Professor of Pathology, University of Western Australia,
Perth, Western Australia
Barry A. P. Page Physicist, Department of Medical Physics, Royal Perth Hospital,
Perth, Western Australia
David Causer Physicist, Department of Medical Physics, Royal Perth Hospital,
Perth, Western Australia
Helman Alfonso Department of Research, Universidad Metropolitana Barranquilla,
Colombia
Correspondence EPE
vturner@westsnet.com.au
Fax int + 618 92241138
REFERENCES
1. Kamali A, Quigley M, Nakiyingi J, et al. Syndromic management of sexually-
transmitted infections and behaviour change interventions on transmission
of HIV-1 in rural Uganda: a community randomised trial. Lancet
2003;361:645-52.
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt
=Abstract&list_uids=12606175&query_hl=2&itool=pubmed_docsum
2. Stephenson JM, Cowan FM. Evaluating interventions for HIV prevention in
Africa. Lancet 2003;361:633-4.
3. Gray RH, Wawer MJ, Brookmeyer R, et al. Probability of HIV-1 transmission
per coital act in monogamous heterosexual, HIV-1 discordant couples in
Rakai, Uganda. Lancet 2001;357:1149-1153.
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt
=Abstract&list_uids=11323041&query_hl=5&itool=pubmed_docsum
4. Papadopulos-Eleopulos E, Turner VF, Papadimitriou JM, et al. Global voices
on HIV/AIDS. Heterosexual transmission of HIV in Africa is no higher than
anywhere else. British Medical Journal 2002;324:1035.
http://bmj.com/cgi/content/full/324/7344/1034#resp3
5. Brewer DD, Brody S, Drucker E, et al. Mounting anomalies in the epidemiology
of HIV in Africa: cry the beloved paradigm. International Journal of STD
and AIDS 2003;14(144-147).
6. Papadopulos-Eleopulos E, Turner VF, Papadimitriou JM, et al. High rates of
HIV seropositivity in Africa-alternative explanation. International Journal of
STD & AIDS 2003; 14:426-427.
www.theperthgroup.com/SCIPAPERS/PerthGroupIJSAJune3003.pdf