Tuesday, December 30, 2008

Kenya's Neighbours, Uganda and Tanzania

How does Kenya’s HIV epidemic compare to those of neighbouring Uganda and Tanzania?

Well, HIV probably arrived first in Uganda, next in Tanzania and then in Kenya. After that, it took very different courses in each country. It spread quickly and rose to a peak prevalence of 14% in Uganda. It spread less quickly in Tanzania and peaked at below 8%. And, having started later in Kenya, it spread quickly and prevalence peaked at just over 10%.

As the graph below shows, there has been a gradual decline in prevalence in Uganda and in Tanzania. However, the decline in prevalence in Kenya reversed around 2004 and now stands at 7.8%, higher than it was back in 2002.

The next graph shows that death rates also have very different patterns in each country. Aids deaths started later in Kenya, as you would expect if HIV arrived later. But the number of deaths rose very rapidly and peaked at perhaps over 140000. This is far higher than Uganda and Tanzania, whose rates peaked at 120000.

Death rates in all three countries are now declining. One would expect this trend to be enhanced as anti-retroviral therapy (ART) is rolled out because this keeps more people living with HIV alive for longer.

The graph below plots the estimated numbers of people living with HIV and Aids. The rising number in Kenya is probably due to a combination of new infections and people living longer because of ART. The fact that the number in Tanzania is stable could be for similar reasons, except that there, the death rate is still pretty high. This is, of course, just one analysis and a quick and dirty analysis, for that matter. It’s possible that Uganda has a low rate of new infections at present; I don’t have access to recent figures.

Personally, I think the above figures alone can tell us very little about how the HIV epidemics stand in these three countries at the moment. I think the way HIV affects a country, how the epidemic spreads, waxes and wanes, depends on many things. Of particular importance are health and health services, education and literacy, various economic factors, social services, infrastructure and much else.

The annual Human Development Report collects national figures and uses them to calculate indices of various aspects of development. Thus, the gender development index shows inequalities between men and women in health, education and economic welfare; the life expectancy index shows the relative achievement of a country in life expectancy at birth; the education index brings together adult literacy and school enrolment; and the human development index (HDI) brings together health, education and economic welfare, being a composite of the education index, the life expectancy index and the GDP index. The GDP Index shows the gross domestic product per capita for a country.

There is a large amount of overlap among these figures, but they are all reproduced here to show how the three countries stand in relation to each other. From this chart, they would all seem pretty close together. In most cases, Kenya is a little better off than Uganda and Uganda is a little better off than Tanzania. If these factors also have an influence on the course a HIV epidemic takes in a country, each country’s epidemic may become more and more alike, despite their initial differences.

However, if you look at trends in the HDI (the only one for which historical trends are supplied), Kenya is not only out of step with Uganda and Tanzania, after being ahead of them for many years; Kenya’s HDI has also been declining for a long time. Over the same period, Uganda and Tanzania’s HDI has been improving.

Well, putting all these figures together doesn’t really put one in a position to analyse each country in sufficient detail to make predictions about what will happen next. Out of the three countries, only Kenya is seeing prevalence increase, after an initial improvement. It’s possible that Uganda and Tanzania’s prevalence are levelling off and will rise, but it’s hard to say.

However, a recent paper shows that prevalence is still increasing in Tanzania in more rural areas, though it is declining in less rural areas. Bear in mind, over 80% of people in Tanzania live in rural areas. Another paper suggests that the behaviour change that was said to have reduced HIV prevalence in Uganda substantially in the nineties and early 2000s is now reversing, that condom use is declining and unsafe sex is increasing.

Rural areas in Tanzania are less likely to benefit from HIV education, perhaps any education, from health services and other social services. And those in Uganda who are deciding to ignore the safe sex message, if the message is still being broadcasted, may need to be approached in a different way. What worked during a time of high prevalence followed by a time of high death rates, may not work now that the word ‘Uganda’ is usually accompanied by mentions of the country’s success in reducing HIV prevalence.

Among all the indicators relating to sexual behaviour that are collected by Demographic and Health Surveys, none show that one of the three countries is significantly ‘better’ or ‘worse’ than the other. These figures, even taken all together, don’t suggest why Tanzania’s prevalence never reached as high as Kenya’s or why Kenya’s never reached as high as Uganda’s.

Some health indicators show Tanzania to be in a far better position than the other two countries, despite public expenditure on health being lower. However, some of Tanzania’s health indicators are far poorer than the others. Other figures are very similar to those found in Uganda and Kenya. Education indicators are similarly mixed, though Kenya again has the highest level of public expenditure in education.

Some gender related figures do differ greatly. Kenya has very few female MPs, just over 7% them being women. For Uganda and Tanzania, the figures are 29.8% and 30.4%, respectively. More births are attended by skilled health personnel in Tanzania. And the rates of female genital mutilation are much higher in Kenya (32.2%) than in Uganda (0.6%) or Tanzania (14.6%).

Figures for communications, access to communications and media, water and sanitation vary somewhat here and there but there is still a surprising amount of similarity in these areas. All three countries have seen high population growth in the last thirty years and are predicted to continue growing. Demographic figures are also reasonably similar.

A notable exception is the urban population as a % of the total population, which stood at 20.7% in Kenya in 2005, 24.2% in Tanzania but only 12.6% in Uganda. Uganda also had a low urban population in 1975 and this is expected to continue. Urban population is thought to be a highly significant factor in the spread of HIV by some analysts. However, it is also argued that the HIV epidemic was unusual in Uganda, having started in rural areas and spread from there. In Kenya and Tanzania it was said to have started in urban areas.

In a nutshell, I think HIV spread readily in these countries because of poor health, education, social services, water and sanitation, governance, social cohesion and many other things. Many measures have been taken to reduce the spread of HIV, in the fields of health, education and other areas. However, unless the original development conditions that allowed HIV to spread are improved vastly, HIV will continue to spread.

The people of Kenya, Uganda and Tanzania may well need HIV education, but they are in far greater need of teachers and affordable, accessible schools. HIV health programmes are great, but only where there is an affordable, accessible health service. There is little point in educating people about sexual health and behaviour while ignoring reproductive health, sanitation, nutrition and other aspects of health.

As long as HIV is seen as a short term (or even medium term) crisis that will be resolved by crisis measures, it will continue to spread. Small gains may be made here and there, but without ensuring a healthy, well educated, secure population, HIV will never be conquered.

The conditions that allowed HIV to take hold and reach high levels in so many countries have been around for a long time and the HIV community seems to have allowed itself to be distracted by crises and crisis measures. It is the long term issues that need to be resolved, the same problems of poverty, exploitation and underdevelopment that have been around for as long as anyone can remember.


Sunday, December 28, 2008

Gender and HIV

There are numerous factors involved in the spread of HIV in Kenya. For example, high levels of disease and bad health, especially sexual and reproductive health, under funded health systems, poor nutrition, low levels of food security and sanitation, crumbling education systems, high levels of urbanisation, high population density and demographic imbalances, high levels of circular migration and dangerous labour practices.

A lot is known about curing some diseases but, more importantly, it is well known that many diseases are avoided by good nutrition, sanitation and healthy lifestyles. Again, it doesn't take a genius to work out that large groups of men working in cities and around mines will eventually be followed by small groups of commercial sex workers. It's not difficult to provide transport for the men to return home regularly or even to provide accommodation for wives, families and partners. It's not difficult, just rare. The point is, we know what would alleviate some of these factors, even if we don't necessarily know how to implement these measures or are not in a position to do so at present.

However, all these factors have played a part in the transmission of HIV because, for various reasons, they have been given very little attention (unless lip service counts as attention). The reasons for this could include poor leadership and governance or greed and selfishness on the part of a powerful few. The powerful few are not just leaders and other people in Kenya; one must include interested parties who neither come from nor live in Kenya, nation states, economic partnerships, multinationals and even international organisations that usually represent the wealthy, despite a pretence of representing everyone equally.

But one of the less tractable factors in the spread of HIV is gender, a factor operating at many levels. From the top down, slightly more than half of all Kenyans are female. Yet only around 7% of Kenya's MPs are female. Females are also more likely to be poor, have less access to education and health services, are less likely to be employed in the formal sector and are more likely to be dependent, economically and in other ways (usually on men).

At a guess, 100% of Kenyan MPs are in the wealthiest 20% of the population. In contrast, nearly 50% of Kenyans live on less than 2 dollars a day. Put all this together and most Kenyans are not particularly well represented by their elected leaders, this being especially true of Kenyan women.

From the bottom up, around half of Kenyan women have experienced violence as adults, around one quarter in the 12 months preceding the interview (Kenya Demographic and Health Survey, 2003). There are high levels of gender violence across income brackets, employment status, educational levels, rural or urban residence and province, although levels do vary somewhat. This violence is most likely to be perpetrated by a partner, though teachers and mothers are second and third, respectively, in the list of most likely perpetrators.

A specific form of violence that most affects females is Female Genital Mutilation (FGM), sometimes referred to as 'female circumcision'. This is thought to affect more than 30% of females. It is still practiced in some areas, despite being prohibited by law for some years. As well as violating human rights, FGM renders women more susceptible to infection with HIV and other sexually transmitted infections (STI). FGM also contributes to maternal deaths and many serious reproductive health problems. The operation is usually carried out by women but the demand for it is said to come from men.

The practice of FGM is declining but it is far higher in Kenya than neighbouring Uganda or Tanzania. Another practice, which is also said to be declining, is violence against children. It, too, is prohibited by law but still practiced and defended on the grounds that children need to be disciplined. Of course, violence against children is not gender based but it is odd that what is seen as justified on the grounds of discipline in the case of children is also seen as justified on the grounds of discipline in the case of women, but not in the case of men.

But perhaps the most worrying thing about gender violence is the percentage of people, including women, who think it is acceptable for husbands to beat their wives, either as punishment or to assert authority. It is not hard to find people who defend violence against women (and children) or who see it as a normal part of life and not, therefore, a problem.

Nor are these the only gender issues. Women often have little or no right to inherit land or property from their husband. In some places, when a woman is widowed, she herself is 'inherited' by a member of her husband's family. Girls are often encouraged to marry early, sometimes to save their family the cost of their upkeep. They often marry older men who are more likely to be sexually experienced and even infected with HIV or other STIs. In fact, despite the popularity of 'abstinence only until marriage' HIV prevention programmes, married women in Kenya are more likely to be infected by their husbands than unmarried, sexually active women.

Despite being more likely to be responsible for the health and education of children and dependents (including those infected with HIV), women have less access to education, health and other health services and they are, partly for those very reasons, more vulnerable to HIV and other STIs.

So the issue of gender and how it relates to the spread of HIV is not just intractable, it is also multifaceted. I am not able to do it full justice in such a short space. I hope to return to it, often. But I don't want to end with the impression that 'gender' only refers to the female gender.

For several years after HIV was identified, more men were found to be infected than women. In some areas, that is probably still the case. If a small number of commercial sex workers gather round a mining town where the population is predominantly male, more men than women may end up infected. However, if those men return home and infect their partners, it is likely that there will eventually be more HIV positive women.

In Kenya, the ratio of infections was 1 female to 1.2 males in 1986. In 2006 that ratio was 2 females to 1 male. However, in 2007, the ratio had moved in the opposite direction again and now stands at 1.6 females to 1 male.

This may have happened because men are taking more risks and/or fewer precautions, because women are taking fewer risks and/or more precautions or some other reason. I admit, this analysis is fairly speculative. But if a higher proportion of males are infected now, the potential for them going on to infect other women, perhaps several women each, is very high. (In Kenya, most women are infected by men, as opposed to intravenous drug use, blood transfusion, etc). In addition to reversing the ratio of females to males infected, this could also result in a substantial increase in national prevalence.

Now, men, generally, are less likely to become infected with HIV, are likely to become infected later in life than women, are often in a better position to protect themselves (and, therefore, their partners) against HIV and other STIs and they have often received more education.

Therefore, it may be possible to intervene with measures that specifically target men. Men may need to be targeted with different HIV messages than women and, for various reasons, there may be more time and opportunity for effecting such interventions.

For example:

- men who work away from home for long periods, in tea, sugar or cut flower industries, need to be able to return home regularly (using affordable transport); or their family needs to be able to visit or live with them (in decent, affordable accommodation)
- delays at borders that give rise to men visiting commercial sex workers need to be reduced, presumably by those interested in reducing the costs of, and barriers to, trade
- men need to be engaged in dialogue with women and other men to identify and influence attitudes that result in women’s lower status in commerce, politics, marriage, sexual relations and many other areas

There are others (and I must make it clear, I adapted these examples from Eileen Stillwaggon’s AIDS and the Ecology of Poverty), but most intervention efforts at present seem to emphasize a ‘one size fits all’ approach. There are many problems involved in HIV prevention but also, many approaches.


Monday, December 22, 2008

Circumcision for All. Then What?

Male circumcision (MC) as a protection against HIV has been a controversial subject for some time. It is believed to protect against male-to-female transmission of HIV. I shall leave much of the controversy to the experts and consider two questions that the literature, as far as I know, doesn't address:

1) To what extent can Kenya benefit from a mass MC campaign?
2) How feasible is a mass MC campaign in Kenya, under present conditions?

I raise the question of the extent to which Kenya can benefit because rates of MC are already very high in most provinces. The only province with relatively low rates of MC is Nyanza. Just over 50% of men are uncircumcised and HIV prevalence is 15.3%, the highest in the country. Around 20% of men in Nairobi are uncircumcised and HIV prevalence is 9%, the second highest in the country.

That sounds like a strong case for mass MC for those two provinces. However, one would also need to look at other factors in the transmission of HIV, such as population density and demographic balance (between males and females) in Nairobi, say.

One could also look at cross-generational marriages and rates of other sexually transmitted infections, such as herpes simplex virus, in Nyanza. (Cross-generational marriages referring to those where the man is considerably older than the woman.) No doubt, additional factors would also be relevant.

But the other six provinces have high rates of circumcision, standing at over 90% in four of them. Of course, they all have lower HIV prevalence than Nairobi and Nyanza. But in two of them, Rift Valley and Coast, HIV is increasing faster than in any of the other provinces. The absolute numbers involved here are worrying as well, the population of Rift Valley alone exceeding that of Nairobi and Nyanza together.

If a mass MC campaign is beneficial and feasible, quite a substantial number of people could benefit. A liberal estimate would suggest that four million men could benefit directly by being circumcised and another six million could benefit indirectly (these figures being VERY rough estimates). That would be almost one quarter of the population of Kenya.

It would be hard to argue against a campaign that could benefit so many people. Even if I have overestimated the number who could benefit, the numbers would still run into millions.

The second question is more difficult and I would compare it to the question of how feasible it would be to test every sexually active Kenyan, perhaps once a year, and put all those who are HIV positive on ART (antiretroviral therapy).
Similar questions arise: what sort of health service capacity does Kenya have, how many trained health service employees are there and how much capacity will be left for HIV prevention and care for the 75% or so of Kenyans who will neither directly nor indirectly benefit from mass MC?

It may well be the case that mass MC, universal testing and ART are desirable, but their feasibility is still in question once the experts have discussed all the other issues. Preventive medicine is desirable, so is health surveillance and so is treatment. They should all help to reduce HIV transmission.

But general health is also desirable, so are adequate nutrition and food security, water and sanitation, education, environmental protection and many other things. Why spend so much time and effort on something that may protect a minority of people, albeit a substantial minority, and ignore all these things that will benefit everyone?

Ok, I have listed some intractable problems and I agree, let's do something we know how to do rather than despairing about the things we may not know how to do. But I would seriously question the feasibility of safe mass MC in Kenya. Health services, education and other social services have been run down over several decades, the ratio of health personnel to patient is low and even though more health personnel are being trained, this is not keeping up with population growth.

The desirability of reducing transmission of HIV is not in question, but how will it be achieved? Will the Kenyan government build up the health service, develop educational programmes that will support this mass MC campaign and address all the other social conditions that contribute to the transmission of HIV? If so, then we should support such a campaign.

But I suspect these measures are not on the agenda and that mass MC will be rolled out as if HIV were a short term emergency. HIV is not a short term issue, it's been a long time building up and the conditions that allowed it to build up go back many decades. Allow those conditions to persist and HIV will not be eradicated.

Those conditions include structural problems that would make a mass MC campaign very unlikely to succeed without many adverse effects and complications. Circumcision carried out in modern, well equipped, well funded health institutions may suffer few adverse effects and complications but how many hospitals and health institutions meet those criteria in Kenya, and how many will do so in the next five or ten years?

MC is sometimes compared to a vaccine. Indeed, so is education. In fact, neither of them is particularly like a vaccine. People who are circumcised and people who are educated are still vulnerable to HIV, especially in a country with high prevalence. MC is just one more way of reducing HIV transmission, education is another. Combined with all the others, they may even reduce transmission considerably.

Unfortunately MC can be like a vaccine in the sense that those who are vaccinated may think they don't need to be careful. A circumcised man may assume he will not be infected, even if he doesn't use a condom. I have heard this belief many times and I am also aware of how much men dislike condoms and would avail of any argument to avoid using them.

Even if this so called 'risk compensation' behaviour has not been has not been detected yet, it does exist. People soon forget the safety messages or start to ignore them, especially if the death rate from HIV is seen to be dropping substantially.

So I'm not against mass MC if the experts can settle their differences, and there are many differences to settle. I also realise that those arguing for mass MC are not talking of circumcision on its own, that they would include counselling, testing, behaviour change messages, condom provision, STI treatment, etc.

In answer to my first question, I believe that Kenya would only benefit to a certain extent from a mass MC campaign and needs also to avail of all known types of prevention programming.

In answer to my second question, I don’t think a mass MC campaign is particularly feasible in Kenya at the moment. But if the conditions that make such a campaign unfeasible are addressed, the benefits will go far beyond those of a mass MC campaign alone. In fact, the benefits will go far beyond HIV prevention.


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.


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.


Thursday, December 11, 2008

Who Paid for those Christmas Presents?

I will probably say this many times in one way or another on this blog:

HIV may well be mainly sexually transmitted in Kenya, but under what circumstances do people have sex? Why do some have sex frequently and with many different people? Why do they not take precautions, perhaps by using a condom, avoiding people they know to have a sexually transmitted infection (see note below about health) or people they know to be violent? Why do they agree to more dangerous sexual practices, such as anal sex or dry sex?

IRIN ran an article recently about a young woman who had to have sex with her supervisor in order to be guaranteed regular work. She works in an Export Processing Zone (EPZ). EPZs were set up with the specific intention of allowing companies to operate their production units where labour is cheap.

This is not to say that EPZs were set up with purely evil intentions. Countries with EPZs could have had strong labour laws that protected their labour force and that punished employers who flouted these laws.

But competition ensured that the country with the fewest employee protections would win the contracts. Laws in Kenya governing EPZs rarely mention employees but are pretty explicit when it comes to the companies that are flocking to the country to take advantage of the cheap labour.

The companies setting up production units in Kenya and other countries with the 'unique selling point' of cheap labour are ones that produce fashionable clothes, popular brands of watches, pharmaceuticals and other things bought by most people in developed countries, the 'minority world'.

The number of people implicated in the abuse suffered by employees of EPZs is high, taking in multinational corporations, governments and the very population driving the process: the market.

That means you and I; the people who buy sports shoes, laptops, MP3 players, mobile phones and various other things that are only affordable because of a high level of exploitation. Cheap labour ensures our access to these goods.

Don't buy the popular media reflex that developing countries are poor because of corrupt governments. Serious corruption is global.

I almost forgot to mention the part played by the organisations that are supposed to be assisting developing countries to develop: those international financial institutions whose names shall remain the World Bank and the International Monetary Fund. They loan money to desperate countries with certain conditions attached. Those countries must be 'flexible', they must deregulate, they must reduce 'barriers to trade' and public services, they must reduce the civil service...

... many civil servants being involved in the 'anticompetitive' practice of regulating employers, ensuring workers rights, inspecting companies to reduce dangerous conditions and exploitation. In fact, EPZs are not bound by the Factories Act and do not have unions because such things would seriously reduce their competitiveness. EPZs don't even make people redundant, they only 'retrench' them, which is completely different. Well, it’s far cheaper for employers, anyway.

These measures keep international financial institutions, governments, consumers and employers happy. With EPZs, the world is almost perfect.

Except for the majority world; the place where over five billion people live (out of a global population of over six billion). The people who work in these EPZs are not guaranteed work, they must accept any conditions without complaint and they cannot strike. As the Kenya Human Rights Commission say in their report 'Manufacture of Poverty', employees 'report to the factory gates every morning without pay to check whether or not there is work'.

So what makes a prospective employee more 'competitive', more likely to work today and subsequent days? Aside from being silent about flouted fire regulations and other safety measures, impossible production targets, compulsory overtime and other abuses?

Well, agreeing to sleep with the person responsible for choosing who works and who doesn't work would be a start. Sleep with the supervisor. And every time the question of who to employ comes up, the question of what price is to be paid must also be answered. The woman interviewed in IRIN's article is not the only one who suffered abuse and continues to suffer abuse in this way.

So this is a whole field of scenarios where HIV is transmitted. But the issue here is not the transmission of HIV, alone. There is a whole range of human rights being abused with impunity, with the tacit acceptance of most of the people and institutions in the world who could and who should be objecting.

So instead of criticizing people's sexual practices, perhaps we could examine our own purchasing practices.

Note about health:

The International Monetary Fund and World Bank, mentioned above, have also given loans on condition that the number of people employed by public services such as health, education and infrastructure be fixed at low levels. Spending on such services is severely limited and this has many consequences for people’s overall health.

For example, intestinal parasites are very common, as is TB, malaria and many waterborne diseases like cholera. Sexually transmitted infections are also common, especially Herpes Simplex Virus. All of these make people more susceptible to HIV. The health of Kenyans is severely compromised by these loan conditions.

The HIV ‘experts’ who implement prevention programmes do so with the expectation that existing health, education and infrastructure will ensure the success of these programmes. Even the World Bank itself funds such programmes.

So, when they find that there are very few health and education facilities and very little infrastructure in Kenya and other developing countries, one hopes they will also know who to call on to find out why: themselves.

Maybe I am hopelessly idealistic.


Tuesday, December 9, 2008

HIV Eradication

HIV eradication means different things to different people. Some have suggested that HIV could be substantially reduced by universal voluntary counselling and testing (VCT) and universal antiretroviral therapy (ART) for those found to be HIV positive. If it were possible to test every sexually active person around once a year in any population in the world, then it may also be possible to put all those found to be positive on ART.

Personally, I think the chances of testing every sexually active person in a country like Kenya, where a sizable proportion of births are not even registered and many people never see a health professional, are slim. Even testing people once has eluded the Kenyan Government's efforts to date and around 80% of people do not know their status.

I have no doubt that, when the people who came up with such a proposal also come up with a plan on how to implement it, the event will be met with the same level of press coverage. But until that time, I'm sure there will be other plans for eradicating HIV. And if you think universal VCT and ART for those found to be HIV positive is crazy, there is a crazier suggestion and it is already being trialled in Kenya.

Many have heard of post-exposure prophylaxis (PEP), something a bit like the morning after pill for HIV. If you think you have been exposed to HIV infection, through sexual assault, needlestick, accidental exposure to infected blood or any other way, you can visit a suitable medical facility and ask for it. That's if you are lucky enough to live in a country with easy access to such facilities, of course. PEP involves a short course of antiretroviral drugs and it can ensure that you do not become infected with HIV.

That's not the crazy suggestion, by the way. The crazy suggestion is called pre-exposure prophylaxis (PrEP). Anyone deemed to be at risk of becoming infected with HIV can be put on antiretrovirals. This should result in them being much less likely to be infected. If they are already HIV positive but don't know their status, PrEP should result in them being less likely to transmit HIV to others.

That's great, but in a generalised epidemic like Kenya's, all sexually active people are at risk of either contracting HIV or transmitting the virus. Of course, commercial sex workers, men who have sex with men and intravenous drug users are much more likely to contract and transmit HIV. These are known as 'vulnerable groups'. But most HIV here is found among the general population. A relatively small percentage of the country's HIV positive people are members of those groups.

For some, the very idea of providing expensive drugs to commercial sex workers instead of providing them with an alternative to sex work could obscene. And there are other, less radical, harm reduction programmes that could be of use to intravenous drug users.

But another group of people who may be offered PrEP if its trials are successful is 'discordant couples'. Only one member of a discordant couple is HIV positive. Often, the HIV negative partner remains HIV negative for many years, even though the couple may have unprotected sex.

HIV is much more likely to be transmitted in the first two or three months after infection and in the last few months or years, after the progression towards AIDS has started. The period in between can be 10 or 11 years and during this time, HIV positive people are less likely to transmit the virus. Of course, this is a long period of time, and HIV positive people may have many sexual experiences. They may also have other sexually transmitted infections, for example, that could make them more likely to transmit HIV.

The potential for PrEP seems obvious, except that we have not always been very good at assessing what the most important factors are in the spread of HIV. Some point the finger at multiple partners, some say poverty is the main problem, genetic differences in Africans or people of African origin have been blamed, tribal practices, commercial sex work and all manner of things have been blamed.

The problem is that all of these could be important factors and all could play a greater or lesser part in different places and at different times. If we are not very clear about exactly how HIV spread in various countries, that is, the history of the virus's spread, we may not be in a position to make predictions about its future.

At present, people are not always good at taking drugs regularly. Sick people, though, are likely to be better at taking drugs than people who are not sick. That's only a guess, but I can see problems with many people remembering or even bothering to take drugs when they are not sick. The drugs may even have side effects or interfere with other drugs they are taking.

Taking drugs for a large part of your life requires certain changes in lifestyle that many may not like to make, if it were even possible for them to make those changes. Drugs can also fail for various reasons. And resistance can develop among people using a drug for a long time, especially if they don't always stick to the recommended regime.

PrEP, if it is ever practicable, will be a very expensive and dangerous shot in the dark if we are not able to predict what the major trends are in each country and, indeed, in each part of each country. But then, some people are unworried by danger when lots of money is involved. Especially if the danger affects other people, far away from home.

And if HIV is eradicated? Well, then we can go on to other transmissible diseases, non transmissible diseases, poverty, malnutrition, food insecurity, fuel insecurity, exploitation, water and sanitation and, well, there are just too many things to list. These, I would suggest, are some of the underlying conditions that allowed HIV to spread in the first place. In Kenya, many of these are getting worse; we are losing sight of them as we allow ourselves to be distracted by grand proposals for the eradication of HIV.

Of course, we could try to deal with some of those other problems first or at the same time as trying to prevent the transmission of HIV. And then, by the time transmission of HIV is reduced as substantially as the mathematical models predict it will be, we may truly have something to celebrate.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)


Monday, December 8, 2008

Empty Pocket Finances

Firstly, the Dr X, and colleagues that I mentioned earlier were not able to come up with an estimate of how many voluntary testing and counselling facilities would be required for a country the size, population and population distribution of Kenya. In a one liner, Dr X thanked me for the question but said he didn't know. I'll keep an eye on this particular issue and hope that there are people who are able to help in this matter.

I need suggestions for ways of making money or saving money in places where there is very little money or resources. For example, I have mentioned Solar Cookers, which have numerous advantages and can be made cheaply or for free. Solar Cookers and other sources of renewable energy are sometimes referred to as 'intermediate technology'.

Another example of a way of making or saving money is the production of reusable sanitary towels using recycled materials. However, I am thinking of these for areas where there is little or electricity, such as Kibera. What would the hygiene implications be? At present, a community based organisation I am in touch with in Kibera are using donations to buy and distribute sanitary towels but they are made in China. They also distribute antiseptic wipes, but these are made in the USA.

Surely it is possible for a country the size of Kenya to produce certain products that use indigenous and perhaps even recycled materials? I know there are people who produce all sorts of things and I really need advice from them. I believe you can make soap using meat fat, ash and probably some other things. Can you use other oils, that could perhaps be produced cheaply here?

I have heard of oil producing trees in parts of India being used to make lamp oil. Here, many people spend a lot of money on kerosene. Is this necessary? Ok, if you are thinking I could just research this myself, you're right, and I will do that when I have the opportunity. But getting time online can have complications.

There's is a range of attitudes among people working in community based organisations towards secrecy and openness. Some want to talk to other people and share ideas. Others keep their ideas to themselves. Some people I have spoken to have lots of experience and they will happily share it with others. Some feel that they should be careful about what they tell other organisations who may be 'competitors'.

If there is a lot of emphasis on funding, which organisations must get from somewhere, then 'commercial' principles may be at stake and each organisation may be competing. But a major difference between non-profits and commercials is that the former aim to reduce the market, whereas the latter aim to expand it. The commercial wants to maximise sales, the non-profit, hopefully, wants to reduce suffering.

Well, maybe I'm misrepresenting things a bit, but let's look at two small community based organisations applying for 5000 pounds which is available to help 50 commercial sex workers to give up or reduce their dependence on sex. Are the two in competition? The donor could give it all to one or half to each. But would the funder suggest that the two organisations join together and share the 5000?

I suggest that the 5000 pounds could go a lot further if it's administrated by twice as many brains, but perhaps I'm hopelessly idealistic. As a matter of fact, I would like it to go on record as being idealistic, whatever about being hopelessly so.

I came to what may seem like an absurd conclusion about how a country like Kenya is going to dig itself out of the hole it is in at present. Firstly, Kenyans are going to have to do most of the digging. Secondly, they will have to do it on virtually no funding. Therefore, they need to discover something that is of very high value but costs absolutely nothing.

So the challenge is to find things that are accessible to Kenyans, have a high value and cost little or nothing. While I can see the absurdity, I think there are such things. After all, some things may seem intrinsically valuable, but other things have value because people value them. Some people value being able to convert their waste to biogas and fertilizer, some value being able to pump water using the wind, others enjoy the benefits of cooking by solar energy.

The working title for my quest is Mfuko Mtupo, the empty pocket. It can stay empty, of course, that's the point, really.

I need more suggestions, I need suggestions till they come out my ears, I need help, only free, non-monetary help, and only help that costs little or nothing to implement.


Friday, December 5, 2008

A Solution to Age Old Problems?

For many years now, writers on HIV and AIDS have been warning that all infectious diseases involve a pathogen, hosts and a certain type of environment. There's no reason why HIV should be an exception to this way of analysing disease. Yet many proposed approaches to HIV relate to the pathogen, some relate to the host, but very few relate to the environment.

Antiretrovirals (ARVs), proposed vaccines and microbicides are examples of fighting HIV at the level of the pathogen. Behaviour changes such as partner reduction, treatment of other sexually transmitted infections and mass male circumcision are examples of approaches that address the hosts. The first set of interventions are highly technical and very expensive. The second set are very difficult to evaluate, slow acting and potentially expensive. Also, they are not enough on their own, they do not provide 100% protection, not even 50%.

Examples of fighting disease by improving the broad environment in which people live is probably the most long term and expensive of all. Such improvements would include better health services, education, social services, infrastructure, economic conditions, lifestyle, air quality and many other things. Such improvements are not so often discussed and even less often implemented. Of course, these don't guarantee 100% protection either, but they are all good and desirable things in themselves. They will reduce many other diseases and types of human hardship.

The question is, to what extent can the first and second kind of approach work without the third kind also being involved? Take ARVs, for example. A certain level of health service is required to test and monitor a population; other treatments are often required, too. People taking ARVs must take them every day, at the right time, for the rest of their lives. They need to change their lifestyle and their diet and, doubtless, other things.

This requires some of the very environmental conditions listed above. Of course, it requires money, but maybe the international community are thinking of providing the money, as they are so keen on technical interventions. They already provide condoms and various other supplies and services needed for prevention, treatment and care of people infected with and affected by HIV.

Which takes me back to the proposal I mentioned a few days ago to roll out universal testing and universal ARV therapy for all infected individuals. How many countries have the structural conditions that would be necessary to achieve even a fraction of what this proposal intends? The countries with the highest HIV prevalence are developing countries. That means that they have poor and declining health services, they have high disease burdens, they have low literacy, they lack a proper infrastructure!

Putting it a different way, people are poor, many live in very small houses made of corrugated metal, have no access to clean water or sanitation, collect firewood to cook basic and relatively innutritious food and I could go on, I probably will, but maybe something I have said so far is clear?

These problems all existed before HIV was identified, we know a lot about how to alleviate them, but in Kenya, many of these conditions have been getting worse for several decades. Are we going to continue to ignore them just because clever scientists have come up with a solution to one of a vast number of diseases that infect many people?

A country where such a proposal would be feasible is a country where there wouldn't be high rates of HIV in the first place. It would be a rich, developed country, where people don't depend on commercial sex for their income, where people don't have to migrate to a dangerous, all male environment for much of the year to find work, where people have proper nourishment and health services, clean water, nice houses and all the things the more prominent members of the international community probably have.

This is not to say that universal testing and ARV therapy should not be rolled out. If the international community is willing to pay for everything that would be required for this proposal to work, I look forward to an end to world hunger, poverty, disease and human degradation. In fact, if the authors of this paper can just say how they will achieve universal testing (without the use of extreme force), I'll grant them all the rest and not question them any further.


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.


Wednesday, December 3, 2008

Centres and Peripheries

The trip back from Mumias to Nairobi was long, hot and often bumpy. But there were no incidents, flat tyres, etc. Only the usual poorly surfaced roads and traffic jams in Nairobi. It’s only about 350km so nine hours is slow, but not the worst.

Infrastructure is a big problem in Kenya and East Africa in general. So many projects assume a certain level of telephone, mobile, rail and internet connections and quickly run into difficulties.

For example, there are hundreds of internet cafes in Nairobi but try to find one where you can do everything you need to do online and you may have difficulties. I tried today for three and a half hours and just as I was about to compromise and try to achieve only some of my objectives, there was a power failure throughout the city. How long it will last is anyone’s guess.

There is a tantalising possibility that the poor roads in Kenya, Tanzania and other countries played a part in protecting many people from becoming infected with HIV early on in the epidemic. People in more isolated areas were not infected in large numbers in the early years.

However, that is not the case any more. As mentioned in the last few days, people in rural areas and more isolated areas in both Kenya and Tanzania are being infected now in greater numbers than before. They are not receiving the prevention education that is sometimes found in towns and cities and testing facilities are scarce or non-existent.

Countries with relatively good infrastructures sometimes have much higher HIV prevalence than Kenya or Tanzania. Examples of this phenomenon are Zimbabwe, Malawi, South Africa and Botswana. Of course, there are probably other reasons why HIV prevalence is so much worse there, but demographic balance, mobility and circular migration play an important part in the transmission of HIV.

One of the reasons why urbanization may be so strongly associated with high and fast transmission rates of HIV is the high number of males in urban populations. Botswana, one of the richest countries in Africa, with one of the highest rates of HIV in the world, has also experienced rapid urbanization, economic growth, population growth, high levels of income inequality, a history of mobility and high levels of commerce with surrounding countries.

Botswana's economy depends to a large extent on extractive industries and they, typically, employ large numbers of men who live in all-male accommodation. This results in high levels of commercial sex and a consequently increased risk of contracting and spreading HIV and other STIs.

Employees are not just from Botswana, so when they return home, they can transmit HIV and other conditions to their home countries, which are often poor, with high unemployment rates.

Ok, Kenya doesn’t have a lot of mining, certainly not on the same scale as Botswana. But there are industries that give rise to circular migration and the resulting demographic imbalances and consequent spread of HIV and other diseases.

Kenya’s number one product is tea. As mentioned, Mumias is dominated by the sugar industry. Some coastal areas grow little but sisal. And there are natural resources here, such as soda and uranium. Other examples are the massive cut flower businesses around Lake Naivasha and the fruit and vegetable growing farms.

All these industries depend on large supplies of casual labour, very often for only part of the year. People arrive and stay for as long as the work lasts and then go back to their homes. Many of these economic migrants are male and they live away from their families for much of the year.

This kind of circular migration, often driven by rural poverty, is common in developing countries and is associated with many health hazards, for example, TB. Labour practices in South African diamond and gold mines result in similar conditions and again, the HIV related effects were transmitted to surrounding countries that suffered worse HIV prevalence than that of South Africa.

Eileen Stillwaggon, in AIDS and the Ecology of Poverty, talks of the “circular migrant streams” that are fuelled by mines, factories and plantations and the consequent slums and shanty towns with their poor sanitation and high rates of disease and malnutrition. It must also be noted that circular migration transmitted HIV from urban to rural regions in earlier years but later the transmission was in both directions.

John Iliffe, in A History of the African AIDS Epidemic, cites the “male predominance in urban populations” in East Africa as one of the reasons why levels of infection were higher there than in western equatorial Africa. In the early 1990s, “Kigali had 50 per cent more men than women aged 20-39” (page 21). In Nairobi in 1979 there were 138 males for every 100 females, the imbalance was even higher among adults and many of the males were unmarried.

A high male to female ratio in the population does not just affect urban dwellers. Fishing communities in rural areas around Lake Victoria were predominantly male and HIV rates there are very high. Nyanza province has the worst HIV rates in Kenya. Rural dwellers are also affected by these imbalances because the migration is temporary and people come and go, perhaps for much of their working life.

There are also certain occupations that involve high levels of mobility. Iliffe mentions urban immigrants, truck drivers, alluvial miners, their female partners and labour migration as examples of particularly mobile groups. Towns along trade routes often have higher rates of HIV than other towns.

This problem is especially prominent at borders. Border controls are very slow moving and truckers often have to spend several days in border towns because of slow administrative procedures. It can be cheaper for them to stay with a casual partner there than to put up in a hotel, so it’s an ideal place for commercial sex workers to look for business.

These are all major factors in the history of the transmission of HIV in Kenya and East Africa in general. They crop up constantly in the literature and mobile people were among the first ‘vulnerable groups’ to be studied, along with commercial sex workers.

It was Zimbabwe's “excellent transport system” and circular internal migration between urban and rural areas that transmitted HIV out into rural areas, according to Iliffe (page 39). In the case of Malawi, Iliffe makes a further connection between higher education and greater mobility, perhaps elucidating the phenomenon of higher HIV prevalence sometimes being associated with higher levels of education.

Iliffe tracks the transmission of HIV from Western Equatorial Africa to East Africa, Southern Africa and West Africa. He makes it clear that mobility is the chief driver of the epidemic at the regional level.

Indeed, obstacles to mobility from east to west is one of the possible reasons Iliffe suggests as to why West Africa's epidemic was less severe than that of some other African regions. Where HIV rates were high in West Africa, one of the principle drivers was mobility, especially among commercial sex workers.

Tantalising as it is to suggest that poor infrastructure reduces the spread of HIV, it is not really true. It is true, but trivially so, that complete isolation is a protection against HIV and any other transmissible disease. In reality, people are not completely isolated, even in the most remote parts of Kenya.

Isolation explains why HIV spread slowly to rural areas and more quickly and earlier in cities and densely populated areas. It also demonstrates the critical situation that many towns, villages and rural areas are in, right now.

The situation is critical because we really don’t know what HIV prevalence is in more remote areas. People there are less exposed to HIV prevention publicity, they have less access to health and other social services and especially, to voluntary counselling and testing centres.

The further people are from urban centres, the more isolated they are, the less we know about HIV rates in those areas. The difference in prevalence between urban and rural areas may be merely apparent.


Tuesday, December 2, 2008

UNGASS and Others Floating on Top

In May of this year, the NACC (National AIDS Control Council) completed the UNGASS (United Nations General Assembly Special Session on HIV and AIDS) report that purported to indicate how Kenya was doing in the fight against AIDS. The report hails Kenya’s success in halving HIV prevalence, from 10% in 1997/98 to 5.1% in 2006. They report that there is “strong political will and commitment at all levels” and that some of the factors that contributed to Kenya’s success include “the improved harmonization and leveraging of resources with and among development partners and" various other technical jargon.

It was surprising that the UNGASS report should have come to these conclusions because the data to back them up was mostly incomplete or simply not supplied. In July of this year, the KAIS (Kenya AIDS Indicator Survey) found that HIV prevalence had actually increased between 2003 and 2007. Prevalence now stands at 9.2% for women and 5.8% for men, with a national prevalence of 7.8%. Rates are usually higher for women as they more easily become infected with HIV.

People working with HIV, including myself, were unsurprised by the KAIS findings. HIV increased in 6 out of Kenya's 8 provinces. It fell slightly in Nairobi and Central provinces. The biggest increases were in Coast and Rift Valley provinces. Increases, in general, are higher for men than for women, suggesting a real increase, rather than an apparent one.

Of more significance to a place like Mumias and the surrounding towns is the fact that the number of people becoming infected in rural areas is far higher than the number in urban areas (1 million people and 400,000 people, respectively). The percentage of infections is higher in urban areas but most Kenyans, around 75%, live in rural areas. Prevalence is 7% in rural areas and 9% in urban areas.

Even the UNGASS report notes that in Kenya, “rural populations continue to trail behind urban ones in the pace at which infection rates drop”. These authors go on to say that 60% of VCT sites are in urban or peri-urban areas and that ways of addressing that imbalance are presently being ‘promoted’. Whatever being 'promoted' means, I hope that after nearly thirty years of HIV, they will find a way of reaching the majority of the population, the same people who are also denied adequate levels of health, education and other social services.

Considering men are being infected in higher numbers now than they were in 2003, it is worrying that far more women test than men and the increase in testing among men has been disappointing. In fact, in both Kenya and Tanzania, I have talked to people who say that men will often get their wife or partner to test and then get tested themselves if the result is positive. In many couples, only one partner is positive, so these men are playing a kind of Russian roulette.

Similarly, apparently people sometimes ask other people, perhaps their partner, to collect antiretroviral (ARVs) drugs on their behalf. This has more serious consequences when both parties are infected as they then end up sharing the drugs, which runs the risk of drug failure and of building up resistance.

Those who are isolated from testing facilities, many rural dwellers, are also isolated from ARV facilities. Malaha, Shibale and Shianda are just three examples of that phenomenon. Because there is no VCT there, there is no outlet authorised to distribute ARVs.

It is not a well kept secret that many Kenyans live in rural areas, nor is it a secret that most VCTs, indeed most public services, are found in urban areas. The need for more voluntary councelling and testing (VCTs) is pressing but even more pressing is the need for mobile VCTs. That is, unless the government is going to pay for people's transport costs to visit a clinic and perhaps compensate them for loss of earnings. I don't see that happening.

UNGASS claims that there are almost 1000 VCTs in Kenya, but that is not enough for the Kenyan population, in excess of 38 million. Nor are the clinics distributed widely enough to be of benefit to most people. This would be the case even assuming that all VCTs are working to capacity, a very risky assumption.

UNGASS also claim that VCT, ARVs and TB medication are given free of charge in government facilities. But as we have seen in Western Kenya, access to those services and other costs are not free. Nor are the other things that people need when on ARVs or TB drugs, such as treatment for various illnesses and nutritional supplements.

(This is similar to the claim that all children are entitled to free primary and secondary education. There are many costs involved in education which are not met by the government and many children are not going to school or their attendance is not very high.)

World AIDS Day in Mumias was great, insofar as many people turned up. I hope the photographs speak for themselves. There was a number of organisations there of various kinds, a UN organisation promoting the AIDS vaccine initiative, the NACC, a big project in partnership with USAID called Aphia II, a Western Kenya based organisation and SAIPEH. The last two are the closest to the people on the ground, but they don't seem to see any of the millions of dollars that are said to go to Kenya every year. Yet they have been round for longer than most of the others.

There was a temporary VCT clinic and a real mobile VCT clinic. Which is wonderful, except that Mumias is the one place out of the four I visited that actually has its own permanent VCT clinic. Not so many people queued up to be tested yesterday, which is a pity, because I'm sure they had plenty of testing kits this time.

But on the subject of VCT, we have probably all heard about how confidential they are, and that's supposed to protect people against stigma and discrimination. Well, if you go to the VCT clinic in St Mary's Hospital, Mumias, you will notice that it is a separate building, outside the hospital compound. Everyone passing can see who is waiting in line outside the clinic and there is only one thing to go there for.

Eileen Stillwaggon, in her excellent book AIDS and the Ecology of Poverty, makes the point that when HIV and AIDS are seen as separate from health and welfare in general, this contributes to the stigma and discrimination suffered by people who are known to be HIV positive. In fact, there are many health conditions that have little or nothing to do with HIV, but that make people more susceptible to HIV.

Stillwaggon suggests that instead of setting up separate, standalone clinics for HIV, governments could set up clinics that treat others of the many conditions affecting people in developing countries. Only by improving health in general will sexual and reproductive health be improved. And reductions in the transmission of HIV will follow.

But more about this sort of argument another time. The top down approach to HIV in Kenya has failed and needs to be changed radically. There are many people who can advise on what sort of changes need to be made. It's time the government started talking to them.


Monday, December 1, 2008

Aid is for the poor? Really?

One of the most interesting people I met last week works for Solar Cookers International. I have long been interested in solar cookers because they appear to have numerous advantages. In the field of international development this is very significant. Some people see development as being just one thing, population control, globalisation, political circumstances, corruption or whatever. I don't wish to define development but rather to say that, if the problem is malnutrition, food security is an issue, if the problem is a health risk factor such as acute respiratory infections, health is an issue, etc. They all relate to development; development is not just one thing.

Solar Cookers International make cheap solar cookers and other 'intermediate' technologies. More importantly, they give demonstrations and courses on using these technologies. This could play a part in development because it addresses nutrition, health, the environment and many other things. Using a solar oven, then, is not just a matter of cooking; it has implications for the nutritional value of the food, the environment, the economic circumstances of the user, the health of the user, the amount of time spent on domestic tasks, water and sanitation, using recycled materials and a whole lot more. Here's a partial list:

1) They don't require expensive fuel (that means time saved and less environmental degradation)
2) Reduced levels of smoke inhalation, experienced by women cooking and other occupants of kitchen
3) They preserve nutrients in the food because the food cooks more slowly
4) They can be used to pasteurise water and other utensils in areas where water may be contaminated
5) They can be used to heat water for cleaning and washing
6) Training in their use gives people knowledge about many other practical health and social issues
7) Recycled and cheap materials can be used to construct solar ovens, creating employment
8) They are light, portable and take up very little space when stored, compared to other cookers
9) They contribute to increased self reliance and self sufficiency

Another organisation I visited was called SHOFCO, based in Kibera, Nairobi. They carry out a number of activities relating to HIV, education and poverty reduction. I found their details when I was researching the use of income generation schemes as a way of allowing women to reduce and even eliminate their need to resort to commercial sex work.

Kibera is not an ideal place for solar cookers. There is not much space and Nairobi has less sun than many areas. However, there are communal areas in Kibera and there is enough sun to cook on many days of the year. Given the costs and advantages, the cost of a solar cooker would be recouped in a couple of months, perhaps less.

In addition to reducing household costs, it is possible that solar cookers could be produced by people in Kibera as a way of raising income. That's what I'm hoping, anyway. The problem is that many people adopting income generation schemes are undercutting each other's market. In Kibera, some women make and sell bead jewellery. However, there are so many people making and selling bead jewellery that it's getting harder and harder to make any money from it.

If you can't make enough money from your job, whatever it happens to be, you still need to resort to commercial sex work. If times get hard, and they are getting harder in Kibera, each woman needs to have more clients and to engage in more dangerous kinds of sexual intercourse, for example, agreeing not to use a condom. Bad economic conditions increase the vulnerability of people who are already poor, exposing them to HIV and other risks.

I look forward to meeting and hearing from others who have tried out income generation schemes of various kinds, and those who have successfully adopted intermediate technologies.
Renewable energy, of course, is not the only type of intermediate technology. Solar Cookers International also sell cheap and easy to use water testing kits. Many diseases in a country like Kenya are water borne, eg. cholera, E Coli and the many diseases caused by various intestinal parasites. Water and sanitation also play a part in the spread of malaria as mosquitoes breed in stagnant water.

If I seem to hop from one subject to another, I apologise, but these matters are all connected, really!

Cholera and Malaria relate to one of the largest sources of funding for the search to eliminate these problems; I'm referring to the Bill and Melinda Gates Foundation. Far from wishing to criticize an organisation that contributes so much to good causes, I'd like to look at disease a different way. The Gates Foundation is putting a lot of money into finding a vaccine for cholera. Yet cholera only exists where there is little or no water and sanitation infrastructure, where people don't have access to clean water.

The cure for cholera is clean water. Dying from cholera means dying of dehydration, perhaps after repeatedly drinking contaminated water. Countries who once had a problem with cholera no longer have that problem because they have addressed water and sanitation issues. A vaccine would be brilliant, except that it would not solve all the other water borne diseases, and there are many. What is the point in surviving cholera only to die of E Coli or hepetitis E?

Malaria is not so simple but again, countries that now have good water and sanitation no longer have malaria. The Gates Foundation has, quite rightly IMHO, been criticized for taking human resources from other projects, overlapping with existing health projects and distorting health funding. The Foundation has prioritised a few diseases when it's not the diseases that are the main problem. It's the risk factors, such as water and sanitation or acute respiratory infections that we should be concentrating on.

There are two other concerns that receive a lot of the Foundation's money: HIV and genetically modified crops (GM). The foundation is interested in finding a cure for HIV or treating HIV positive people and 'feeding the starving', allegedly. But only if these solutions involve intellectual property, it seems, intellectual property being something very close to the Gates heart.

Anti retroviral drugs (ARVs) and GM technologies are pieces of intellectual property. There are very cheaply produced drugs that do the same thing, but US money goes into expensive ARVs, produced by Americans in America. Does this make you think of the free condoms distributed in Mumias?

GM corn is a modified version of the corn that you see hundreds of hectares of between Mumias and Eldoret. But it costs a lot of money and it belongs to the company that produces it, not the person who grows it. A farmer can grow one crop with GM corn before buying more seed, from the GM producer, of course. Using the non GM version, they can save seed and grow corn every year.

Where was I? Oh yes, intermediate technology, such as renewable sources of energy. This technology is owned by whoever uses it. This can be contrasted with high technology, which belongs to very rich multinationals. So, would you choose a cheap technology that eradicates cholera and most other water borne diseases and has many other advantages, or would you choose a very expensive one that only eradicates cholera for those who can afford it? It only works for as long resistance to it is not developed. But then, a new version can be found, at a cost.

Finally, for those working with HIV and AIDS, I hope you have a productive World Aids Day! I'll post the news from Mumias later today or tomorrow.