Tuesday, December 16, 2008

Absolutely Brutal Confident Dogma...

...engendering foolishly grotesque hype in blah blah blah.

I have mentioned before that, despite years of hype about HIV prevalence going down in Kenya and about how this was as a result of ABC (Abstain, Be faithful, use a Condom) campaigns, prevalence is actually rising.

It has been rising for three or four years. It went down earlier this decade, primarily, because of a very high death rate. The prevention campaigns only really started in the early years of the decade, when death rates were high. When death rates started to decline, prevalence started to go up again.

The increase in prevention money and campaign capacity was roughly concurrent with an increase in HIV transmission!

Uganda's HIV epidemic is older than Kenya's. The Ugandan government recognised the threat posed by HIV in the late 1980s and launched a multifaceted approach, one that was appropriate to a multifaceted epidemic. When prevention campaigns were at their strongest many people were dying. This reinforced the prevention message.

Foreign money started to flow into Uganda while prevalence was dropping. However, once death rates started to decline, prevention messages began to have less impact. At the same time, foreign money started to come with more explicit conditions.

Ugandan HIV organisations were encouraged (and eventually instructed) to emphasize the 'abstain' part of ABC at the expense of the other two facets. The emphasis on abstinence (or abstinence only until marriage) increased and spread to other countries because of further pressure from certain donors.

Many years ago, it was already clear that HIV was being transmitted by and to people who were not considered to be at high risk of contracting HIV. Married people were considered to be at low risk. This is odd, because it has long been clear that married people are being infected in large numbers. In some places, married people are at greater risk of being infected that highly sexually active, unmarried people.

You would think this would result in different campaigns evolving to support the ABC campaigns that became ubiquitous early this decade. However, as ample evidence showed that earlier hypotheses about transmission of HIV seemed less tenable, a dogmatic adherence to ABC and abstinence only campaigns became even more entrenched.

On the one hand, there are medical and field practitioners, showing that HIV is spreading among people previously thought to be at little risk of infection. On the other hand, there are political and other 'stakeholders' jumping on a moral bandwagon and referring to their approach as 'evidence based', whatever they meant by that.

HIV prevalence in Kenya will probably be higher next year than it was this year. But there have been warnings for several years that gains made in earlier campaigns in Uganda have also started to reverse. More people are admitting to having multiple partners than before, fewer people are reporting using condoms, even during high risk sex.

It would be surprising if HIV didn't start to show increases in transmission in Uganda similar to those that have occurred in Kenya. If it can happen in these two countries, there may be other countries where earlier declines in prevalence are reversed.

This is also a distinct possibility in countries where death rates are presently declining. Death rates decline around 10 years after peak incidence ( peak incidence being the time when the rate of transmission is highest). Even if death rates from HIV are not carefully recorded, HIV prevalence is under the spotlight in every African country. In any country where prevalence is declining, death rates are also high. It shouldn’t be too difficult to spot the countries most likely to experience an increase in HIV prevalence in the next few years.

At one time, people would ask if Uganda's success in fighting the HIV epidemic could be replicated in other countries. Perhaps this is no longer such a wise question. Perhaps, and this is purely speculative of course, but perhaps ABC doesn't really have that much effect.

Well, I think ABC has its place, but ABC on its own doesn't seem to do very much. Even less would abstinence only until marriage work, but we’ve known that for many years.

It has been demonstrated in many ways that HIV epidemics change over time and vary from place to place. At times, more men than women are infected, at times more women are infected. In the early years in Kenya, more men were infected. Later, far more women were infected. But the latest data shows that men are now being infected in higher numbers than before. At one time richer and better educated people were infected in higher numbers but this, too, is changing.

It may well be the case that HIV was, at one time, predominantly spread by high risk sex, involving sex with commercial sex workers, multiple concurrent partnerships and various other circumstances. But that would have been a long time ago. The HIV epidemics in Uganda, Kenya and many other countries have been 'generalised' for many years. This means that HIV is spreading among the general population, as opposed to specific groups, such as commercial sex workers, men who have sex with men, intravenous drug users, etc.

So, if the epidemic is different, why are the campaigns not different? The Ugandan First Lady has said that ABC campaigns will continue. Why? It is recognised that more infections occur in older people and inside marriages. What good will ABC campaigns do, even if they are supported by strategies that target high risk groups?

You can wag your finger at children and tell them to abstain and you may even be 'liberal' enough to tell them about what they are to abstain from. You may even shock the moral fibre of the nation by going on to tell them that they should be faithful to one partner, use condoms and other precautions and even send them off for VCT (voluntary testing and counselling). But can you wag your finger at adults and tell them what to do?

After all, many adults have sex in order to have children. It's something they have a right to and they are sure as hell not going to use a condom. Even if they want to avoid pregnancy they are likely to use a different form of contraception. Ok, you could, if you felt you had the moral authority, wag your finger at them and tell them to be faithful to one partner and they may not tell you where to direct your finger.

Really, you can have as many health campaigns as you want but they need to be based on genuine health issues, not moral crusades and political posturing. If the international community is worried about HIV transmission, they should take an interest in gender inequalities, economic inequalities (yes, poverty, I know how much they hate hearing that it exists), education, public health that is accessible to poor people, exploitation, water and sanitation and many other instances of people's human rights being compromised.

Of course people need to avoid high risk sex and there are ways of reducing risk. Everyone should avoid risky things, shouldn’t they? After all, they are risky. But there are so many more things that can be done, we needn't limit ourselves to the most difficult strategy of all, the vain hope that human beings will cease to engage in human behaviour.


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