Thursday, December 18, 2008

Calling the (Self) Righteous

Recent research shows that HIV attacks normal, healthy genital tissue in women. Previously, it was thought that skin had to be broken or damaged to be infected. No doubt, breaks in tissue or other damage may increase the risk of infection. But it seems that even healthy women are far more vulnerable to HIV than previously thought.

The researchers conclude that treatments such as vaccine are needed. But they also conclude that condoms are clearly needed as they protect against infection. Those favouring the 'ABC' (Abstain, Be faithful, use a Condom) approach to HIV prevention must take note that abstaining and even being faithful are not enough. Many monogamous women are infected by their husbands or by their partner. Yet some people involved in HIV prevention insist that abstinence on its own or abstinence combined with faithfulness are enough.

Abstinence on its own, or even abstinence plus being faithful (where abstinence alone is not possible), are not enough to protect people from HIV. Abstinence is just not an option in many circumstances and being faithful can also be elusive. Abstinence, faithfulness and using condoms are only three aspects of avoiding HIV, other sexually transmitted infections (STIs) and unwanted pregnancies.

Those working in HIV prevention who are squeamish or downright bloody-minded about the use of condoms need to reconsider their stance. Are they interested in preventing HIV or are they merely interested in prognosticating at the expense of the people whose interests they claim to be protecting? People have sex. They may 'abstain' or refuse to have sex or avoid having sex under certain circumstances. But when they have sex, and most people do sooner or later, they need to know what the dangers are and how to protect themselves.

Those who are forced to resort to commercial sex work will need to be particularly careful, of course. But they will also need the protection of the law against violence, rape and other forms of abuse. They will need access to information, to health care and to legal services. These are not readily available to commercial sex workers at present.

Indeed, they are not readily available to the majority of Kenyans. ABC is not enough to protect most people from HIV and other sexually transmitted infections. It never was enough and it never will be enough. When will the moral crusaders realise that they are wrong and that they are creating and upholding the conditions that allow HIV to spread in Kenya and other countries?

Some argue that ABC and other campaigns are suitable for adults but not for children. I would argue that such campaigns are not enough for adults but also that children are even more vulnerable than adults. Therefore children need, not just more strategies and education, but more protection.

Children themselves, when asked, say they feel they are being denied access to knowledge about how to protect themselves from HIV. Under the UN Declaration of Commitment on HIV/AIDS, 2001, children are those below the age of 15. Most young people over the age of 15 don't even receive the vital information they need but the ones who are not targeted, those under 15, are exceptionally vulnerable.

Many of them are already sexually active, often having sexual experiences that they do not choose to have. In other words, they are being coerced or somehow pressurised into having sex. It seems unlikely that those forcing minors to have sex are taking precautions against HIV. So what chance have those minors?

Questions about how to inform children about sexuality and the dangers involved are difficult and may take some time to resolve. But they won't be resolved by pretending that it is unnecessary to even discuss sex and sexuality with them. The belief that children who are informed about sex are more likely to have sex has long been discredited.

Children who are informed about sex are more likely to put off having sex for the first time till later in life, often till they have finished school. They are more likely to understand risks, for example, the risks involved in sleeping with men who are older than them. They are more likely to know about and use condoms. They are more likely to be able to negotiate safer sex.

Perhaps it's not children who have a problem with knowledge of sex and sexuality, perhaps it's adults; parents, guardians and teachers. This problem is not confined to developing countries. Where I grew up, Ireland, teachers and parents alike had problems talking about sexuality. I suspect that many still do. Having spent much of my adult life in the UK, I know that most people there find sex and sexuality difficult to talk about.

That's a problem that needs to be faced, not denied and avoided. The sooner we, as adults, sort out our problems with the subject, the sooner we can protect our own children and young people.

On the subject of moral crusades and righteous indignation, the Kenyan HIV and AIDS Prevention and Control Act, 2006, worries many people. For many years, those involved in HIV prevention and the care of those infected with HIV have been fighting to reduce stigma. This act may increase stigma. If people are to be encouraged to know their status, which is said to be the first step in reducing the spread of HIV, they need to know that they will not be discriminated against in any way if they happen to be HIV positive.

Once everyone knows about the dangers of HIV, once everyone has access to HIV testing and HIV care, once the health and welfare of Kenyans are adequately accounted for, then the question of willful transmission can perhaps be addressed more equitably. But we are nowhere near that stage yet. It would be a mistake to put any obstacles in the way of wider testing and greater openness.

More women than men are infected with HIV, but also, more women know their HIV status than men. Already, women have been the victims of stigma and discrimination, despite the fact that they are not more responsible than men for the spread of HIV. How will this law affect women, who are usually tested when they are pregnant, and those who are willing to be tested? Whoever the law is designed to protect, it seems likely to fail.

Reducing transmission of HIV requires that the rights and responsibilities of everyone be upheld, not just the rights of those who are uninfected. The fight against HIV will necessarily involve those who are infected, just as much as those who are not infected. If their rights had been upheld in the first place they would not now be HIV positive.

Don't exclude HIV positive people, children or anyone else from the prevention equation.


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