Khulumani Welcomes New Thinking on HIV Prevalence

Khulumani Welcomes the Queries Raised by Former President of the HIV Clinician’s Society, Dr Francois Venter, in the recent A J Orenstein Memorial Lecture, HIV and Sexual Transmission in Southern Africa: Looking in the Wrong Jeans? - 25 November 2011.

Dr Francois Venter, former president of the HIV Clinician’s Society recently delivered the A J Orenstein 2011 Memorial Lecture in which he raised some critical and as yet unanswered questions about HIV and sexual transmission in Southern Africa including suggesting that popular wisdom that HIV is spread through promiscuity, may not be entirely correct.

Dr Venter asked the question, “Why is HIV so bad in such a small area of the globe” - in Southern Africa from Zambia down where half of all people in the world infected with HIV, live. South Africa, he confirmed, alone houses 1 in 5 of the world’s HIV infected population.

Dr Venter suggested that the evidence is starting to emerge that there is something biological that makes sexual transmission far more efficient in this region of the world that anywhere else in the world. HIV is actually not very transmissible when looking at risks per sex act measured in developed countries, he explains. But in South Africa there is a high risk of HIV infection when other factors are the same as in the developed world.

Some of the emerging evidence is that the HIV subtype in our region may be more infectious and for longer than in developed countries and that the genetic makeup of people in this region may make them more prone to contracting HIV.

It is true that high-risk sex remains the major culprit in HIV infection, he explained, but there is greater risk of sexual transmission in this region than elsewhere in the world. While local genital co-infections may play a role and perhaps even a nutritional co-factor, this still does not fully explain the differences between a young woman in Toronto, Rio or Paris who has a lifetime chance of well below 0.5% of becoming infected while a young woman in KwaZulu Natal has a 1 in 3 chance of being HIV positive by the age of 21 years. Men living in Thailand and the United State with 3 times more sex partners have one-tenth of the risk of acquiring HIV compared with Uganda.  

What is the cause of the high prevalence in this region? Is the HIV species here more virulent or are the genes in our populations more susceptible or is there some environmental factor that we haven’t discovered, that makes sex many-fold more risky in southern Africa than anywhere else in the world?  

What is clear, Dr Venter asserts, is that there is little data to support a theory that some sexual behaviour is peculiar to our region. The labels and judgments that are circulated about ‘sugar daddies’, ‘multiple partners’, ‘concurrency’, ‘dry sex’ and ‘prostitutes’ provide easy targets to moralise about, but they do not explain the situation.  

South African men are not more rampantly promiscuous than men in other parts of the world. There is little basis for the other popularly-invoked reasons such as the so-called collapse of the family, the mysterious and sudden deterioration in moral fibre, and promiscuity.

Dr Venter concludes, “I suspect our sex lives are not that different from anyone else’s, and in a while, we’ll have a proper scientific explanation for our extraordinary epidemic.  Till then, those of us in the HIV world will have to put up with politicians not understanding the admittedly complex world of HIV acquisition.”

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