Thursday, December 4, 2008

HIV: Exceptional or Exceptionalised?

Controversy can often lead to a polarisation of views, where neither version is particularly tenable. Some people take the view that HIV is just a result of poverty. Others point to the fact that wealthier people in Kenya are infected in larger numbers than the less well off. Still others may take the view that the truth is somewhere in the middle, but this fails to put a finger on the part that wealth and poverty play in the transmission of HIV.

If a single man goes to a bar, almost any bar in Nairobi, Dar es Salaam, Kisumu, Kigoma, Mumias, Tanga, probably anywhere in East Africa, he will soon be approached by a woman or even two or three women. They could directly ask for a drink or just make idle conversation before the suggestion or implication of sex comes up.

The term 'commercial sex work' (well, there are far worse terms) can be used for this phenomenon. But it would be a mistake to think that money is always involved or that there is always a one for one transaction.

Anyhow, casual sex of any kind carries the risk of the transmission of HIV and other sexually transmitted diseases. It also carries other risks, stigmatisation, violence and abuse, even imprisonment, though these risks are usually experienced disproportionately by women.

Many pronouncements on HIV and how it should be prevented concentrate on casual sex, multiple sex partners, sex without condoms and the rest. In a sense, they are right, these are factors in the spread of HIV. But how about the reasons why large numbers of women (usually women), young and not so young, spend evenings in bars and nights with strangers?

HIV is, I would suggest, not spread merely because of low moral standards. At least, it is not the moral standards of these 'commercial sex workers' that should be in question. There may be people who are quite happy to do sex work but people here that I have talked to only do it because they have to. Being poor is not immoral, neither is being desperate.

On the other hand, the sort of danger, stigma and discrimination faced by people involved in commercial sex work, or reputed to be involved in commercial sex work, should be seriously questioned. There are also some men involved in, what is by definition, a transaction. Yet it is the commercial sex workers that are condemned by the moralists, punished by the law, denied protection and denied health care by the state.

If the moralists find transactional sex so repulsive, why are there not campaigns to give work or financial support to people who otherwise have no alternative? HIV prevention campaigns are all very well, but when you're down and out you'll do anything. You will not 'abstain' or 'be faithful' and you will probably not have the choice about whether to use a condom or not.

So there go the ABC campaigns we hear so much about, to say nothing of the abstinence only campaigns.

In fact, as economic conditions get worse, people engaged in commercial sex work need to take more risks, have more partners and probably use condoms less. Ok, if everyone suffers from worsening economic conditions, even the over paid and under taxed politicians, there will also be fewer customers, or each customer will pay less. But then the sex worker needs to work even harder and do whatever guarantees some money rather than none.

So, what is the relationship between wealth or poverty and HIV transmission? Commercial sex workers are, generally, poor. Their clients can be rich or not so rich, influential or not so influential. If you are rich you have many choices; if you are poor you have few choices. If you are a commercial sex worker, you have probably made the last choice you can make.

Some of the women who work in the bars in Kenya work in the informal sector, perhaps selling something in the market, some work in poorly paid jobs and some are unemployed or have too many dependents to think of working outside the home during the day. Even if they have an income, it may not be enough to pay the rent or various costs, such as healthcare or materials for children's schooling or food.

The money needs to come from somewhere, banks here are not falling over themselves to give out loans to the very poor.

In Kenya, most people are very poor, probably equally poor. In other words, about half the people live on an income that is below the poverty line.

Very few people are very rich. However, if wealth quintiles are compared, sure enough, HIV prevalence is higher in the highest quintile. Maybe it is to some extent the very level of inequality that is associated with high HIV rates.

Nairobi is one of the wealthiest provinces in Kenya. This is despite having some of the biggest and worst slums in Africa. Nairobi also has very high levels of wealth inequality and high rates of HIV. North Eastern province has the lowest HIV prevalence in Kenya and low levels of inequality. In North Eastern province, most people are poor, equally poor.

In contrast to this, Central province also has high levels of inequality and low HIV, so the relationship between inequality and HIV is as difficult to define as that between absolute wealth and poverty and HIV.

Whatever people's economic status, it is difficult to legislate over or even indicate how they should behave. Sex is not a crime. And if transactional sex is a crime, it should be a crime that has two (at least) culprits per instance. Perhaps countries like Kenya feel they should go down the route of curbing transactional sex, however they think are going to achieve that. They haven't done so well to date.

But perhaps they will go down the route of figuring out why there are so many poor, vulnerable, desperate people, especially women. Perhaps they will think about the human rights of women and their entitlement to the same rights as those enjoyed by men and by wealthier people.

Poverty and wealth inequalities existed before HIV; if a cure was found for HIV today, there would still be poverty and wealth inequalities, bad health, low levels of education and low levels of social services. These all pertain to human rights and if people feel moral repugnance, it should at the denial of these rights to so many people for so long. People’s rights to these benefits are not conditional on that reducing the spread of HIV.

I don’t know exactly what the relationship is between wealth and poverty and HIV. I think poverty, inequality and HIV are all worth fighting. I also think we know a lot more about fighting poverty and inequality, so maybe we could concentrate on them, rather than on seeing HIV as this extraordinary disease, the first ever disease to be completely independent of all social and economic conditions.



Claire said...

Very interesting. i thought that inequality was the primary driver, but i haven't looked at the literature. This would explain the seeming paradox that hiv infects wealthy people more; transactional sex is frequently offered and cheap, and these sex-workers, or quasi-sex workers, are less numerous than their clients, meaning that prevalence is disproportionately increased among wealthier grous.

Simon said...

I still think there is something else and I would like to know what makes someone a member of the wealthiest quintile. Do wealthy and powerful people abuse their positions? Surely not!