Coital Bleeding and HIV Risks in South Africa

Abstract

To the Editor: We were interested to read the report by Kalichman et al. reporting coital bleeding and HIV risks among men and women in Cape Town, South Africa.1 We have previously identified high-risk sexual practices involving bleeding during sex in black South African men and women in Durban in the late 1980s, initially in men with donovanosis (granuloma inguinale) but subsequently in those with other causes of genital ulceration.2,3 While our study focused on sexual intercourse in the presence of genital ulcers, bleeding during sex was reported by a significant proportion. Clearly, HIV prevention campaigns have impacted little on these biologic behavioral factors that must convey a high risk of HIV transmission. We have also recently reported that the proportion of subjects having sex despite ulcers was at a similar high level in 2004 compared with 1988 at the start of the HIV epidemic, again emphasizing the need to change individual behavior to reduce HIV risk at the biological level.4 Clearly, HIV interventions should include some basic biological input. We do not feel that a randomized controlled trial to identify any possible benefits of abstaining from sex when either blood or genital ulcers are present is justified ethically. But perhaps this very lack of randomized controlled trial data has meant that some of the more obvious risk factors for facilitating HIV transmission continue to be overlooked. It must be accepted that acceptance of condoms in South Africa has been limited and that additional HIV prevention messages are long overdue. Educating individuals about the biological transmission dynamics of HIV that apply to them directly might in turn increase condom use when the level of risk of HIV transmission is perceived to be very high.