Tuesday, March 31, 2009

Hate the Sinner, Love the Sin

Recently, a Kenyan friend of mine posted a question on Facebook the jist of which was 'if a promiscuous woman is called a whore, what is a promiscuous man called'? She got some facetious replies but it is a very important question. Why do we vilify women who sleep with men? There are many words for women seen as promiscuous but I can't think of any for men. There must be a lot of men who love sex but there must also be a lot who hate women. Could it really be common for men who love sex to also hate women? It seems likely.

A workshop in South Africa recently argued that "society's expectations and presentation of women makes them more vulnerable to catching sexually transmitted infections (STIs) and HIV". There appears to be a deficit of respect built into societies, languages and behaviours and it seems so self defeating. The workshop pointed to "the need for woman and girls to be empowered for them to make informed decisions when negotiating safe sex".

We (humanity) are facing a dangerous situation and it seems that several decades of HIV/AIDS has done little to change attitudes. Men are very often in a position to do things and talk about things that women are not able to do and talk about without censure. Men often say that there are things they find it difficult to talk about and they would never talk about them in front of women. Women, too, are expected to remain silent about certain things and to only discuss others with other women.

I have talked to people who run HIV prevention programmes and they often mention how the content needs to be different when the audience is young or female. It's true that the content needs to be produced with a particular audience in mind. But maybe there is also a place for discussion between males and females. Perhaps it would be enlightening if men were to get to know what women think and if women were to get to know what men think, especially what men think about women and sex, for example.

Why is it more shocking to hear a woman swear or to see a woman drinking or spending time in a bar or, god forbid, time in a bar with men? Men go to bars to hang out with their friends, to drink and to meet women. If they think the women they meet in bars are 'whores', why don't they stop going to the bars and go to church halls instead? Or perhaps they could persuade their 'nice' female friends to go to the bar with them. But that would take us back to square one because women who go to bars are just not nice, apparently.

The workshops also argued that “[i]n the rural set up mostly, women who [negotiate] for safe sex are viewed as promiscuous and wayward”. It's sensible for anyone to insist on safe sex, whether they are male or female. There is something wrong already if the woman has to negotiate. The fact that she is considered promiscuous or wayward is almost laughable, especially considering the reasons why she might feel the need to negotiate; perhaps she knows that a lot of men are happy to have sex without a condom.

People here, male and female, often tell me that women are not supposed to be forward, they are not supposed to make the first move. Men see women who ignore this code of conduct as objects of suspicion and even as in some way evil. Is there something inherently about men that makes them better at making decisions that relate to friendship and sexual relationships? I don’t think so, but perhaps I’m just lacking in some way.

When it comes to negotiating about or even discussing sex, there is a need for greater levels of mutual respect and equality. People are people, gender is not a species. This needs to start in classrooms and among young people. So, if people object to teaching children about sex and safe sex, the least they could do is teach about equality and respect.

A person who has sex with other people is just a person. A person who has sex with lots of other people is also just a person, though they need to exercise a lot of care, as do the people they sleep with. But a sizeable majority of women who have sex, do so with men. It’s not as if there is a small group (or large group) of people who, in some way, are responsible for all the illicit sex in the world.

Quite frankly, if I was a woman, I would be called a whore. I go to bars, I meet women, I’ve even had the temerity to sleep with some women. But as a man, calling me a whore just doesn’t have the same import. And I don’t think the solution is to find an equivalent term for men to right the balance. I think it would be preferable to see sex as something that occurs between people, male and female.


Monday, March 30, 2009

The Cherry Picking Theory of HIV Programming

When HIV started spreading across Africa, it hit more densely populated areas first. This is not surprising, given that it is primarily a sexually transmitted infection (STI). It was noticed early on that mobile populations were at particularly high risk, which is also not surprising.

But mobile people come into contact with less mobile people. People in densely populated areas move to, or move to and from, less densely populated areas. Those living in less densely populated areas are likely to be infected later in an epidemic and at a slower rate. But this also means that they are probably not going to be targeted by specific prevention campaigns and they are less likely to be exposed to media and other messages about HIV.

Coupled with this, people in more remote areas are less likely to have access to health, education or other social services. The poor infrastructure and isolation that, at first, gave them protection, now means that they are more likely to be infected with HIV and other STIs without knowing and with less likelihood of finding out.

The fact that they are living in less densely populated areas does not mean that they are not vulnerable. One of their vulnerabilities also turns out to be their relative isolation. This is not a contradiction. Over time, the once protective effect of isolation turns out to imply a whole host of vulnerabilities.

This is one of the reasons why I would argue that HIV is a factor of underdevelopment (and retrogressive development). HIV spreads best where there are multiple vulnerabilities. The virus is also hardest to prevent in these same areas. It is the vulnerabilities that need to be targeted, not the people assumed to be vulnerable.

At present in Kenya, Tanzania and other countries, HIV is spreading in more isolated areas. But health facilities and social services tend to be concentrated in urban and semi urban areas. Between 80 and 85% of these populations live in rural areas. This is changing, many people are moving to urban centres. But this is not a reason to continue to deny the vast majority of people the services they need.

Of course, the process of moving to urban areas, or moving to and from urban areas, exposes people to a new set of vulnerabilities as well. Prevention programmes are not keeping up with changes, nor do they even seem to be aware of trends that have been evident for some time. So there have been many articles recently about HIV infecting isolated populations in greater numbers and these usually express surprise at the trend.

The fact that some people seem less vulnerable now does not mean that this will always be so. Things change. Also, the fact that HIV spreads slower in less dense populations doesn't mean that these populations are ok; HIV spreads among vulnerable people. Prevention programmes need to aim to slow down the spread of HIV. Targeting so called vulnerable groups can often miss people, indeed, the population in general, who are considered not vulnerable enough.

Northern Kenya, which is very sparsely populated, has nomadic people who were once assumed to be safe from HIV. Prevalence there is very low and has been for some time. But HIV is there. Low prevalence can become high prevalence. In fact, people in Northern Kenya are probably the most vulnerable, taken as a whole. Few people have access to health or other social services, education and literacy levels are among the lowest in the country. Now that the HIV community have noticed the problem, they will find that there is very little infrastructure and most programmes will run up against things like lack of attendance in schools and low levels of health and education.

HIV arrived in a very underdeveloped country in the 1980s and has experienced retrogressive development since then. 25 years later, solutions to HIV are still appropriate to a short term emergency. For HIV prevention to work, people need to be well educated, they need a good level of health, water and sanitation and the rest. In other words, they need development. HIV continues to deflect attention from all these other problems which are factors in the spread of HIV. The result of this serious underdevelopment is that the very facilitators of any subsequent prevention programmes are missing.

If aid agencies are just realising that pastoralists and other groups are not 'safe', they have been ignoring evidence that has been around for a long time. They have made a lot of unwarranted assumptions. Everyone is vulnerable to HIV and this been the case for a long time. Whatever the utility in targeting groups, we should forget that people who don't belong to those groups are also in need of attention.

When it looked as if HIV could be eradicated purely by such targeting, these approaches may have been justified, but that was a long time ago. 'Remote' communities are also very mobile and this should have hinted at their relative vulnerability.

At one time, it appeared odd that Northeastern Province was, in many ways, the least developed province. Yet it had the lowest prevalence in the country, at around 1%. That's lower than Senegal, Washington DC and Ukraine, for example. But there is no reason why HIV should stay low, there or in other places where there are a lot of vulnerable people. For example, it should be borne in mind that female genital mutilation is higher there than anywhere else. Young girls marry very young, usually to much older men. These are other worrying issues but these two factors are very significant and they need attention, regardless of the rate at which HIV is spreading.

It’s fashionable to say that HIV is spread by lots of people being promiscuous and careless but only some HIV is spread this way. Many others are infected because they are vulnerable, for numerous reasons. No amount of pure HIV programming will address their vulnerabilities but this is one of the reasons why much of the pure HIV programming to date has been so unsuccessful.


Wednesday, March 25, 2009

UNAIDS: a Development Paradox

A recent UNAIDS newsletter demonstrates the paradox of the existence of such an institution as UNAIDS, whose brief is a single, sexually transmitted virus, HIV. The newsletter concentrates on homophobia, harm reduction programmes for drug users, sex work and the role of condoms in reducing HIV transmission (and, presumably, other sexually transmitted infections and unwanted pregnancies).

The paradox stems from the reflection that all these issues predate HIV, they will probably all continue after the HIV pandemic has subsided, if that ever happens, and they are all very important issues in themselves. That is, their importance goes well beyond their connection with the transmission of HIV. Therefore, there were already programmes to address these issues before HIV was even heard of, so where does UNAIDS fit in?

Homophobia, for example, is abhorrent and an infringement on human rights. There are organisations all over the world fighting homophobia. Does the arrival of UNAIDS add to the work that these organisations are doing or does it water the message down? The message seems to become 'homophobia is bad because it plays a part in spreading HIV'. Homophobes may even see this as an endorsement of their position. Perhaps I'm wrong, perhaps UNAIDS strengthens these organisations and has a genuine role to play.

Harm reduction for drug users is another issue that has been associated with HIV transmission. Yet, evidence that harm reduction programmes work for injecting drug users has been around for a long time. It's only political pragmatism that has prevented such programmes from being implemented in many countries. Does relating these programmes to HIV reduction strengthen or weaken advocacy for harm reduction programmes?

UNAIDS have embraced the view that there is no single approach to HIV, that each country needs to gather detailed data on how HIV spread in their country and implement different approaches as appropriate to that context. I am one hundred percent in agreement with them as this is one of my own findings. But I saw that as an indication that UNAIDS may therefore be superfluous, however well intended. I think of all development issues are addressed, HIV reduction will not be such an intractable problem.

Commercial sex work (or transactional sex) is surrounded by numerous factors in the transmission of HIV. Sex workers are vulnerable because they are poor, or poorer than their clients, they are unprotected by the law and perhaps even victims of abuse by officers of the law, they are stigmatised by the public, they have little access to health and other social services, stemming from their poverty, lack of those services, their legal position, etc.

Sex workers suffer terribly, they have multiple vulnerabilities and, as a result, they often play an important part in the transmission of HIV. But they have suffered abuse and been denied their rights for as long as anyone can remember. This relates to HIV but HIV transmission stems from many other problems that are not just about HIV. Where does UNAIDS fit in here? Do they become advocates for the decriminalisation of sex work? This would be great but should they join other organisations already involved in such advocacy or is there a niche for them, somewhere?

The (male) condom is something of a symbol of the fight against HIV. They appear on websites about HIV, in particular, on UNAIDS's site. But condoms have been around for a long time and played a significant part in the decades of work carried out by those who believed that development simply meant population control. Those organisations, FHI (Family Health International), PSI (Population Services International), TFGI (The Futures Group International), and others, were spectacularly unsuccessful in getting condoms accepted. However, they were considered the most deserving recipients of hundreds of millions of the dollars that were subsequently ploughed into HIV reduction.

Is UNAIDS going to become one of them, a family planning organisation? There is no doubt that sexual and reproductive health are very important issues; they are also an important part of the fight against HIV but I think UNAIDS see themselves as playing all of the above roles. Yet they are playing all of those roles in an importantly qualified way. It seems that they are playing those roles to the extent that this will reduce HIV transmission.

Every single factor in the transmission of HIV needs to be addressed but also, every single factor that I can think of needs to be addressed, irrespective of its part in HIV transmission. Each factor in the transmission of HIV is also an area of underdevelopment. HIV spread in places where there are high levels of economic and gender inequality, poverty, poor health, low standards of education, low levels of social services, poor infrastructure, especially in the area of water and sanitation. Governance, legal institutions and civil society are also factors in the transmission of HIV.

UNAIDS have some of the best personnel in the HIV world, they have some of the best resources and they have access to pots of money. But I'm still at a loss to understand why HIV has been singled out from all other diseases and development problems and given this special UN institution. Especially as many of these other diseases and development problems played a crucial part in the spread of HIV.

I suppose the paradox is that there is a sense in which UNAIDS is concerned with all of these issues but is, at the same time, only concerned with HIV.


Tuesday, March 24, 2009

A Role for the Christian Churches in Africa?

Those who refuse to accept that condoms have a role to play in reducing transmission of HIV should take note of the following findings from a study carried out in Hlabisa district, South Africa. It was found that HIV incidence (the number of new infections per year) was high and remained unchanged over a five year period, despite large scale prevention work being carried out over the same period.

HIV prevention needs to pull out all the stops. Abstinence is great if it works, being faithful is great too. Using condoms is vital where the first two don’t happen, but there are still many other things that need to be taken care of. People need education, health services, social services, they need jobs, economic security and a viable future. There are multiple vulnerabilities that allow HIV to spread and no single intervention or single set of interventions will be enough to cut transmission significantly. Transmission should be reduced by every means possible.

The South African research found that half of all new infections occurred in people who had already received a negative test result. Those who have been tested have also been counselled and thus could be expected to change their behaviour, but clearly testing and counselling are not enough.

This and other studies show that people’s behaviour is only likely to change if they are found to be HIV positive. It’s good to know that people who find they are HIV positive reduce their risky behaviour but the aim of HIV prevention should be to prevent new infections. Too much money and emphasis has gone into spectacularly unsuccessful finger wagging exercises about abstinence and Christian morality, other ill informed ‘moral’ pronouncements and downright lies and misinformation.

Most of the people who became infected during the study period were young people. Many interventions, especially school based interventions, have been shown to have little effect. They have some influence on people’s knowledge about sex, even some influence on their self-reported sexual behaviour. But most have had little or no influence on transmission of HIV or other sexually transmitted infections or even unwanted pregnancies.

In Uganda and later in Kenya, it is possible that the effect of so many people becoming visibly ill and dying resulted in behaviour change speeding up. Sadly, the pace of behaviour change may be slowing down now as a result of death rates going down. But even this doesn’t seem to have happened in the South African area in question. There are many families with several HIV positive people, some already on antiretroviral therapy (ART). Others hadn’t even heard of ART (so their behaviour could not have been affected by ‘disinhibition’, thinking that one doesn’t need to take precautions against HIV infection because treatment is available).

It is noted that Hlabisa has little employment and is mainly agricultural. Many areas of Kenya, Tanzania and other African countries are like that, the majority of people living in rural areas and living at subsistence levels. Even many of the urban dwellers live in slums and are as badly off or even worse off than rural dwellers. Most people are denied basic health, education and other social services.

It is not surprising that people receiving small amounts of schooling, or even large amounts of schooling, learn very little. Educational standards are low and those who get through school have little to look forward to. Developing countries have high disease burdens but very few health services, which are of poor quality anyhow. Water and sanitation, communications networks, transport infrastructure and other utilities have been run down for decades in Kenya and other African countries. These areas of underdevelopment need to be part of any programme intended to reduce transmission of HIV.

Given the huge following that Christian churches have in African countries, perhaps Christian leaders could preach to the as yet unconverted political leaders, business people and financiers in Africa and beyond. Perhaps they could preach abstinence from greed, dictatorship, imperialism and exploitation (although some may say these leaders are guilty of these themselves). After all, I assume they come not to call the righteous, but sinners, to repent.


Monday, March 23, 2009

Belt and Braces but no Trousers

On a number of occasions on this blog, I have expressed scepticism about technical solutions to the HIV epidemic. Such solutions include mass male circumcision (MMC), universal testing and treatment (UTT) and universal condom distribution. I am not suggesting that these technical solutions do not work, on the contrary, they are effective. But there are two major problems; no single solution is likely to work on its own and structural conditions in developing countries mean that technical solutions face serious, often insurmountable, barriers to success.

Even condom distribution requires some level of infrastructure, education and communications. MCC faces the problem of seriously scarce, under funded and understaffed health facilities. Large scale testing has been dogged by the fact that many facilities are static and centralised, whereas the majority of Kenyans live in rural areas. Recently, it was demonstrated that many people are receiving incorrect results, either false positives or false negatives. This results from lack of training and quality control and probably many other things. And treatment has had problems as a result of disruptions such as food shortages, civil disturbances and economic problems.

A recent survey carried out in Bungoma, Western Kenya, showed that even in clinical settings, around 17% of people circumcised suffered adverse effects. The figure was about double that for circumcisions carried out in traditional settings. So this would not make circumcision a tempting option for Kenyans unless a huge amount of money is spent on developing health facilities. I don't oppose circumcision as long as it is an elective operation but I don't think circumcision in traditional settings will ever be a wise option.

Testing facilities in Kenya, as well as being in short supply, are just not reaching enough people. Some Kenyan policy documents mention mobile testing units, but they don't seem to be common yet. There continues to be a problem with testing facilities being in urban and semi urban areas. This means that many will not be able to access them, for various reasons. Cost is one factor but people are also less likely to know about HIV and testing when they are isolated from what are highly centralised and relatively inaccessible services. There is also talk about door to door testing and similar methods but this has only been carried out to a limited extent so far.

Those already being treated for HIV have, in many cases, had their treatment interrupted because of post election violence in Kenya, because of ongoing civil disputes in Zimbabwe, because of an economic crisis in Botswana, because of political disputes in South Africa and because of war in Sudan. There are, doubtless, many other instances where treatment has been shown to lack sustainability and this is often a problem with technical solutions.

The history of the epidemic in Kenya shows that there were many factors in the spread of HIV, relating to health, the economy, the environment, infrastructure, labour practices, gender and many other areas. Given this, it is no wonder that a single solution will have little chance of reducing HIV transmission. Condoms will remain in warehouses or on shelves, stay unused or be used incorrectly. Drugs, too, will be unused or misused because lack of support, education or other enabling conditions.

All of these technical solutions are good and together, along with any other strategies, could see HIV decline significantly in the next few decades. But if we ignore the overall development of countries like Kenya, each solution will have little success, perhaps none. Kenya is suffering from underdevelopment, many development indicators are moving in the wrong direction. This has been going on for decades and has been obvious for decades.

Developing health, education and other social services may seem too expensive or too difficult. But this is not an optional extra, it is a prerequisite to the success of any of the currently popular technical solutions.


Saturday, March 21, 2009

Dogma: a Pope’s Best Friend

HIV prevention experts have an uphill struggle as it is. HIV is mostly spread by sexual intercourse and a large proportion of the world's population engages in sexual intercourse at some time. Quite a number of people claim not to have sex but many of them turn out to be liars.

As one of the most effective ways of reducing the transmission of HIV is by using condoms, HIV experts advocate the use of condoms, unless the aim is to have children. But some religious groups, Catholics in particular, are opposed to the use of condoms.

Now, I hate to point the finger, but some of the more notable liars about their sexual behaviour have been Catholics. Worse still, the Catholic leader, Mr Gregory Pope, seems to assume that everyone chooses whether to have sex, when, where and with whom. This is not the case and some highly publicised instances of people denying other people's right not to have sex involved Catholics, often prominent ones. I'm surprised Mr Pope hasn't heard about this.

But there are a lot of things that have passed Mr Pope by, especially matters relating to sexual behaviour (and misbehaviour). He and some of his followers subscribe to the myth that latex condoms have tiny holes that the HIV virus can pass through. No, Mr Pope, there is just one hole in a condom, and it's supposed to be there.

Of course, this is not to say that things can never go wrong. For example, people can carelessly rip a condom when opening the package, perhaps by doing so with their teeth. They can damage the condom in various ways and there is a need to be careful. But this indicates that they need sex education that includes instructions on how to use condoms, preferably from people who have had experience of using them.

You say that promotion of condom use and sex education give rise to greater promiscuity; there is plenty of evidence to demonstrate that this is not the case. There is also plenty of evidence to demonstrate what happens when people don't receive any sex education or only receive half baked rubbish, such as 'abstinence only' claptrap. The result of not educating people about sex is very high rates of HIV and other sexually transmitted infections (also unwanted pregnancies).

You see, Mr Pope, people who get abstinence only education, people who take vows of abstinence, perhaps even Catholic priests and brothers, still have sex; they just don't bother to use condoms, perhaps because they have never heard of them or because they have been given incorrect information about them.

You call for a responsible attitude toward sex? People need education, discussion, information, enlightenment, not the lies that anti condom campaigners have been spewing out. How do you expect people to develop a responsible attitude towards sex when you are not even responsible enough to tell the truth? Is lying no longer a sin? Or does it depend on who tells the lie or what the consequences are? Perhaps things have changed since I was a Catholic.

Look, Mr Pope, you don't know what you are talking about. Please consult the World Health Organisation, the UNFPA and UNAIDS. These organisations are experts in public health. They will tell you that "[t]he male latex condom is the single, most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections." They will also confirm that "[y]oung girls and women are regularly and repeatedly denied information about, and access to, condoms. Often they do not have the power to negotiate the use of condoms. In many social contexts, men are resistant to the use of condoms."

I suggest you read this position statement carefully. It has just been revised and it contradicts many of the things you say. There's no excuse for being so badly informed and your attitude toward these matters is grossly irresponsible. I think it could justly be called culpable ignorance, if it really is ignorance.

It's interesting that one of the people who defended Mr Pope works for a Catholic NGO in Senegal. He says that his NGO doesn't promote condoms. I recently blogged about Senegal because the country has the lowest HIV prevalence in all of Africa. But one thing that has long been very common in Senegal is the use of condoms. Thankfully, this particular NGO wasn't the only one working there.

In contrast to Senegal, Rwanda and Burundi, considered to be very Catholic countries, have high rates of HIV and low rates of condom use. Also, because sex before marriage is frowned upon, for religious reasons, many men have their first sexual experience with a commercial sex worker. I know, spotting contradictions in Catholicism is like shooting fish in a barrel!

But sadly, some people will grasp at any excuse to justify their behaviour. Many people are already reluctant to use a condom to prevent unwanted pregnancy or sexually transmitted infections. There are myths surrounding most aspects of HIV, how it's transmitted, how to avoid it, how to cure it, etc. But with myths, people can accept the bits they like and ignore the bits they don't like. People who don't like condoms still enjoy sex and they are not going to see Mr Pope's solution as desirable or even viable.

So Mr Pope's pronouncements about condoms not working very well and promoting promiscuity will certainly appeal to people who just don't want to use condoms. He is, effectively, preaching to the converted, telling people who don't like condoms that it is wrong to use them and that it won't help them, anyway.

No doubt, a Catholic who becomes infected with HIV, despite following Mr Pope's thoughtful advice, will have their just reward in heaven. How comforting. But let's not deceive ourselves; preaching against the use of condoms is promoting the transmission of HIV.


Thursday, March 19, 2009

Abstinence: the Immaculate Contraception

Why is abstinence not proposed as a strategy to reduce alcohol or drug dependency? How about obesity as a result of overeating? Perhaps it’s because if those with a dependency could abstain, they wouldn’t have a dependency. Ok, some people manage to give up drugs, alcohol or overeating. That takes a lot of work and a lot of help and support. Some succeed and some don’t.

Why is abstinence not proposed as a strategy to reduce crime? Instead of having laws, why not just have a campaign to get potential criminals to vow to abstain from crime? They should know that crime is wrong and that they will be punished if they are caught. I think the answer is obvious.

But a certain Mr Pope, a man without an electoral mandate or, indeed, without any experience of sexual intercourse or sexual relationships, thinks that abstinence is the only way to avoid HIV. Well, Mr Pope, you’re quite wrong. In Nyanza province in Kenya, women are more likely to contract HIV from their husbands. Husbands also contract HIV from their wives.

Yes, both parties should abstain, of course. Everyone ‘should’ abstain, but abstinence does not protect anyone from sexual desire. One party in a relationship abstaining does not ensure that the other party also abstains.

Abstinence is an individual decision but most sexual relationships require more than one person. The issue is not about individual duties and responsibilities but rather the duties and responsibilities of people who live in close contact with other people. Each person’s life is to a large extent determined by external influences. Human behaviour and sexual desire do not arise in individuals in isolation, they arise in individuals living with other individuals.

Those external (or non individual) influences determine many things, including when, where, how often and with whom people have sexual relationships. An individual’s decision to abstain doesn’t protect them from HIV because their HIV status is also influenced by factors external to them.

As for the individual decision to abstain, well, I certainly don’t decide to do things that would put me in danger. I am fairly risk averse, I don’t enjoy pain or dangerous activities. But just as the absence of safe water and food supply would not make me any less thirsty or hungry, the relative dangers of sleeping with another person would not decrease the sexual desire I may feel.

If a person doesn’t feel much sexual desire or their desire is outweighed by other considerations, there may be no problem. If they get to decide whether to have sex and with whom, great, they are lucky. But there are many people who are not in that position, for one reason or another. Even in the Catholic Church, people are often in positions where they will have sex, whether they choose to or not.

Abstinence does not guarantee against harm because an individual decision to abstain from sex does not preclude something arising to override that decision. Nor does it guarantee that others will respect the individual decision to abstain.

But, quite frankly, I don’t want to abstain. I think that I have a right to have consensual sex with another adult. I don’t think Mr Pope agrees, but I just don’t subscribe to his views. I don’t feel the need to repress my sexual desire in order to follow his blind dogma. And I know that the absence of the opportunity to engage in sexual activity does not result in sexual desire just disappearing.

So if abstinence is not always going to work, what other options for harm reduction are there? Condoms sound like an obvious harm reduction strategy against sexually transmitted infections. Mr Pope advocates against using condoms because it is ‘wrong’. But Mr Pope and his adherents have defended many things that would also be considered wrong, so I don’t really see where his authority comes from.

Actually, that’s where my argument becomes seriously unstuck. Millions of Africans (and other people around the world) invest authority in Mr Pope and his acolytes. In Kenya and Tanzania, people constantly talk about Jesus, God, their religion, the bible, various quotations and proverbs and titbits of ‘knowledge’ from religious sources.

Mr Pope speaks for millions of people because they pay millions of pounds to support him and his religious prognostications. But beware, Mr Pope, you have many followers who go to your churches and contribute towards the obscene amounts of money you receive, but they don’t abstain. HIV rates are usually higher among those claiming to be Christian than among other religious groups.

I don’t see why Mr Pope’s religious teachings should have such a profound bearing on public health. He clearly knows nothing about public health, but that’s understandable. What I find difficult to understand is his lack of understanding about human behaviour. Even if he doesn’t feel sexual desire or if he feels it’s something he should deal with in other ways than sexual behaviour, why does he think that everyone else should feel the same way. Why does he think that others are able to behave as he does?

Mr Pope, whether you want to hear it or not; abstinence as a strategy does not work. Even if you are not interested in the many studies carried out that show that abstinence as a strategy does not work, you must be able to see that millions of your followers are infected with HIV and millions more will become infected.

I stand to be corrected on this but I think suicide is also considered wrong in the Catholic faith? Is a strategy that is known to fail to protect against HIV not suicidal? By preaching against the use of condoms and advocating abstinence, are you not in danger of increasing what is effectively suicidal behaviour, Mr Pope?


Tuesday, March 17, 2009

Happy to be Wrong

I have spent the last two days on the train from Kigoma to Dar es Salaam, so between electricity supply and internet connection problems in Kigoma and then travelling, I haven't had much opportunity for blogging.

But I did get some time to read a large part of Jared Diamond's Guns, Germs, and Steel, a history of the world that argues for the prominent role played by technology, agriculture, transport, environments and movements of people in the eventual dominance of some nations over others. Diamond has many good ideas and I was especially interested in the chapter on diseases (Chapter 11).

Diamond suggests that old world countries had many diseases that people there had some resistance to and they brought these diseases with them to new world countries. Inhabitants of the new world countries had no resistance to these diseases, so huge numbers of them died.

Most of these new world diseases started as diseases of domestic animals (measles, smallpox, flu, TB, etc). The new world continents had few domestic animals, thus fewer epidemic diseases had developed to infect humans. Therefore, old world invaders did not die in such huge numbers.

HIV (also yellow fever, malaria, etc) is an exception in that it developed from a virus infecting monkeys in the African wild and mutated into a deadly human virus via contact through hunting, eating bushmeat, etc.

Diamond mentions that myxomatosis evolved from a virus that quickly killed most rabbits into a more slow acting virus that infected many rabbits but killed fewer of them. This meant that the virus could establish itself in a large number or rabbits and would have time to infect more rabbits rather than potentially wiping out its host.

Similarly, when syphilis hit Europe in the fifteenth century, it killed people very quickly, in just a few months. But syphilis also evolved into a disease that can be virtually symptomless for a long period, so it can silently infect larger numbers of people. People witnessing the horrors of open pustules and flesh falling off faces, followed by death, would probably act quite quickly to avoid those infected and the virus would be in danger of wiping out its supply of host humans.

This reminded me of something a doctor that I met in Nairobi said. He worked with AIDS patients even before HIV had been identified. He suggested that in the early days, when they still didn't quite know what was happening, patients who turned up seriously ill sometimes died quite shortly after. He said that these were people who had recently been infected with HIV.

HIV has three phases, the first phase immediately follows infection and lasts two or three months. The infected person has no symptoms during this phase but they can suffer a so-called seroconverting illness before entering the second phase. This illness has symptoms similar to other conditions (flu, malaria, etc) and so is treated as such. During this first phase, the infected person is highly infectious, so if they are going through a period of high sexual activity they can infect many other people.

The second phase lasts for up to ten years and, while those infected are not very infectious, they may be sexually active during this period. This would mean that many more people are exposed to the virus. Whether they are infected or not may depend on the presence of other sexually transmitted infections and other factors.

The third phase is where the HIV virus overwhelms the immune system and this phase only lasts a year or so. The patient now has full blown AIDS and they are very infectious but they may not be as sexually active as at previous times.

So if, as this doctor suggested, people were dying of the seroconverting illness, HIV would have very little time to spread beyond the initial host and anyone else they came into contact with in the space of two or three months. A population faced with an incurable sexually transmitted disease that kills in months may well take every precaution to avoid any risks. But this doctor suggested that HIV became less virulent and people do not now die of a seroconverting illness.

But, following Diamond, the fact that HIV does not kill people quickly surely makes it a greater threat. Those who are infected will probably not know that they have been infected until they start to experience the opportunistic infections that characterise the third phase of HIV. They could have infected many more people by that time. A disease that kills the host only after ten or more years is not as likely to give rise to immediate behaviour changes and HIV becomes harder to eradicate.

Nowadays, there are drugs to control HIV progression so that people don't go into the third phase, they are effectively suspended in the second phase. Indeed, the drugs also lower their infectiousness considerably. Uninfected partners of HIV positive people who are on antiretroviral treatment (ART) can remain uninfected indefinitely.

HIV continues to evolve and those on ART need to be monitored regularly to ensure that the virus has not developed resistance to the treatment. But there are alternative drugs they can take if and when resistance arises and HIV positive people receiving ART have a good chance of surviving for many years.

The doctor in Nairobi is optimistic about HIV becoming less and less common and perhaps even dying out, eventually. I don't share his view, for reasons expressed elsewhere on this blog. I don't think we understand many of the most important factors involved in HIV transmission and the countries with the worst epidemics are also worst placed to fight the epidemic spread. But I would be very happy to be wrong in my analysis.


Thursday, March 12, 2009

When is Development Development?

The issue of foreign aid crops up frequently in the development literature. People ask why aid doesn’t seem to be working even after large amounts of money have been donated over long periods of time. These are difficult questions to answer, there’s no denying that.

But there are other questions that may be less difficult. For example, in Tanzania, there doesn’t seem to be much evidence that aid money has been spent on setting up manufacturing outlets. Almost all manufactured goods seem to come from other, very expensive, countries.

Things around the house are either manufactured elsewhere or manufactured by companies that are foreign owned. In Kenya, tea and sugar are among the top products. But even when they are processed in Kenya, they are often processed by foreign companies. The cut flower industru has become one of the countries main exporters. But the outlets producing flowers pay little or no tax, either in Kenya or in their own (developed) country.

Those ‘investing’ in Tanzanian gold mines get years of tax breaks, they can import what they want without restriction and all under the understanding that they are bringing much needed investment to the country. But they don’t leave much behind. Employment conditions are terrible, pay is low, huge social problems develop around the mining industry and when the incentives cease, the mining companies go home. That is, unless they can find other ways of extracting the commodity without having to pay very much in return.

Actually, it’s not fair to say mining companies leave little behind when they have got as much as they can out of a country. They leave behind unhealthy former employees, ghost towns and environmental degradation. The mercury, cyanide and other poisons that they leave behind will slowly kill people, animals and other forms of life, it will poison the water and the soil for the foreseeable future.

When such foreign companies arrive they are given the rights to do whatever they deem necessary to fulfil their objectives. Tanzanians, who struggle to get enough water for their daily needs, find their supply further curtailed. The companies who have come to ‘invest’ in their future have brought their inaccessibly expensive technology to gather water and people already living in the area have to compete for the dwindling supply.

There have been articles in the papers recently about nasty Tanzanians tapping into water pipes belonging to various manufacturers and other commercial interests. Such activities are referred to as acts of vandalism and are entirely unanalysed by commentators. The commercial interests have been assured by the government that they will have unrestricted access to whatever they want. The fact that there are Tanzanians who need water to survive and that the commercial interests are preventing them from getting this water is rarely mentioned.

A large amount of aid money seems to be spent on the continuation of what is already a serious development problem in countries like Kenya and Tanzania: the production of raw materials for rich countries. As long as earnings from the main exports from these countries are dwarfed by what they have to spend on basic (but manufactured) goods that come from rich countries, it’s hard to see aid money having much effect.

For a start, anyhow, much of what is called ‘aid’ comes in the form of loans, loans that must be paid back with interest. The fact that the loans very often can’t be paid back doesn’t mean that the interest doesn’t continue to mount up. But generally, the money that creates unrepayable debts in developing countries never leaves the ‘donor’ country. The money is spent on goods produced in the donor country, transported using the donor country’s transportation networks, handled by the donor country’s employees or it pays for the donor country’s technical expertise.

As a result, the ‘recipient’ country is merely building up a debt in order to buy up the donor country’s surpluses, give business to their service industries and employ their people, often people working in big, foreign NGOs. Vast amounts of money go to NGOs that are based in and administrated by the donor countries. It is in the interest of donor countries that they continue to ‘donate’ aid money, they themselves benefit, they are stimulating the growth and prosperity of their own country.

I’m sure there are lots of reasons why billions of dollars of aid money seem to go to developing countries without having much effect. Worse, many developing countries are regressing. But it could be asked if donors really spend money on developing countries or if donations, to a large extent, fit in with their own commercial interests. To what extent are donations even intended to benefit the recipient?

Countries like Zambia and Botswana depend heavily on their mining industries. When times are good they do relatively well, but doing relatively well is not development. They are always dependent on conditions being favourable in the developed countries who buy the raw materials they produce. Now, conditions are not favourable, and Zambia and Botswana are beginning to suffer. Now that things are difficult, it is apparent that during the ‘good times’ aid money was not used to increase sustainability or self-reliance.

So neither country has developed much in the last couple of decades, despite their great mineral wealth. How much aid money has gone towards developing their ability to produce something other than raw materials? And I’m not talking about money and technology to achieve greater yields from marginal mining outlets. I mean, to what extent has ‘development’ ever meant reducing the extent to which developing countries are completely dependent on developed countries to reach a position that really only constitutes just getting by?


Monday, March 9, 2009

Facts that do not Speak for Themselves

It's very tempting to blame the spread of a sexually transmitted infection (STI) such as HIV on promiscuity. It would be useful to have a criterion for 'promiscuity' as opposed to reasonably normal levels of sexual activity, of course. But the fact is that there is no evidence that Africans, as opposed to people from other continents, are more promiscuous. The evidence suggests that in Africa, as in other continents, some people have a lot of sex and some don't.

It would be very easy to dismiss the last paragraph on the grounds that so many articles state or imply that Africans are more promiscuous than the rest of the world. However, I have yet to come across any evidence for the belief, unless the constant reassertion of something counts as evidence. We don't need an explicit definition of promiscuity, we understand what it means. It's just that the term is being applied indiscriminately.

An interesting study of sexual behaviour was carried out in four African countries with very different rates of HIV; Benin and Cameroon, which both have low HIV prevalence and Kenya and Zambia, which both have high prevalence. The highest rates of partner change were found in Cameroon, especially among men. Even among women, partner change was higher in Cameroon.

In Kenya and Zambia, the age of sexual initiation was slightly lower. There were also lower rates of circumcision and higher rates of other STIs, such as herpes simplex virus (HSV). But there was simply no correlation between HIV prevalence and indicators of sexual behaviour, such as concurrent sexual partners.

Another study found that there were more people in African countries than in countries in other continents who reported having had no sex in the month preceding the survey. And most men in all countries surveyed had no extramarital sex or no sex outside of a long term relationship. Overall, the views of Africans surveyed were more enlightened than the views of those from other continents.

Yet another survey found that age of sexual initiation for females was increasing in most countries surveyed in Africa between the 1960s and the 1990s. But it's interesting to compare age of sexual initiation in developed and developing countries. The country with the highest percentage of 15-19 year olds who are not married and have already had sexual intercourse is the UK, and this stands for both males and females. Also high on the list are Brazil, the US and the Dominican Republic. All these countries have low HIV prevalence, less than 1% in the UK, the US and Brazil.

When it comes to lack of knowledge about sex, contraception and safe sex, levels of unwanted and teenage pregnancies and other matters, the US and the UK are usually very high on the list. It is interesting that these two countries have so many worrying indicators, yet they both have relatively low HIV prevalence.

And so on. Eileen Stillwaggon in AIDS and the Ecology of Poverty lists a number of studies that show that the evidence does not bear out the assumptions about HIV transmission being explained wholly by sexual behaviour. In every country, people have sex. In every country some people have more sex than others. But there is no country where HIV rates can be correlated with high levels of unsafe sexual behaviour, partner change, concurrent relationships and the rest.

This is not to say that there is not a lot of evidence of unsafe sex in developing countries. There is a lot of unsafe sex taking place all over the world. But not all countries have high HIV prevalence. That is the question that researchers have been trying to find the answer to for so many years. It hasn't escaped their notice that STIs are spread by people having sex. They are asking why there are extremely high levels of HIV transmission in some countries and low levels in other countries.

Some have suggested that poverty is a key factor in the spread of HIV. Indeed, people probably don't engage in commercial sex work when they have money coming in from other activities. So poverty must play a part. Others have gone on to show that poverty alone doesn't explain HIV prevalence rates because some poor countries don't have high rates of HIV. One response to this is that economic inequality may be a better way of looking at wealth and poverty, some people are dependent and others have the opportunity to buy sex as and when they want it, they can afford concurrent partnerships.

There are many counter examples to poverty and even inequality driving HIV epidemics and it has been clear for a long time that HIV has many drivers. It is futile to expect to find one factor that drives all epidemics and pointless to argue that poverty or inequality or whatever have no part to play. Epidemics involve many different people with different lives and circumstances interacting with each other.

This blog already covered Senegal
, where education, health and other social indicators are probably not that different from those in Kenya, certainly not different enough to explain the low levels of HIV in Senegal. The histories of HIV transmission are many and various, between and within different countries.

A recent literature review listed the top factors contributing to HIV transmission as: "poverty, famine, low status of women in society, corruption, naive risk taking perception, resistance to sexual behaviour change, high prevalence of sexually transmitted infections (STI), internal conflicts and refugee status, antiquated beliefs, lack of recreational facilities, ignorance of individual's HIV status, child and adult prostitution, uncertainty of safety of blood intended for transfusion, widow inheritance, circumcision, illiteracy and female genital cutting and polygamy."

The article also finds these factors to be "interrelated and complementary". There is no one factor that is the most significant. Even poverty, which is by far the most significant, is closely related to many of the other factors. For example, people who are poor are also more likely to have lower levels of heath and therefore be more susceptible to HIV. They have worse living conditions, they have fewer opportunities, less education, they are more vulnerable to the effects of corruption, crime, global financial crises, food prices and global environmental degradation, and the list goes on.

The issue of connections between poverty and HIV transmission keeps coming up, as if examples of HIV transmission that are not related to poverty suggest that poverty is not a problem. Even if HIV were to disappear tomorrow, poverty is a problem. Poverty needs to be eradicated because it denies people many of their human rights. But also, in countries where wealthy people are more likely to be HIV positive, poverty is not in any way less relevant.

If there are some people who can afford to pay to have wide sexual networks and there are some people who need to be part of a sexual network because they are poor, then 'poverty' doesn't describe the problem. The level of economic inequality more accurately describes it. And before anyone starts throwing counterexamples at me, this is not to say that there are not many other factors involved. The very point is that there are many factors in the transmission of HIV. Poverty and inequality are important but they relate to numerous areas of underdevelopment that are also important factors.

It has been recognised for some time that in Kenya and Tanzania, for example, HIV prevalence is higher in wealthier quintiles. Clearly, there are different circumstances surrounding each instance of HIV transmission. But the problem is to explain what circumstances give rise to, say, the fact that women in the wealthiest quintile in Tanzania have four times the level of HIV positive people than the poorest quintile.

If your causal story is that rich men pay to have sex with poor women, would you add to this that rich women are even more likely to pay to have sex with poor men? I'm not saying that this never happens but I have seen no evidence that this is common. I don't know where all these transactions could take place because I haven't seen young men in bars looking for rich women. There are many young men in bars looking for women to have sex with but they tend to target foreigners, so this doesn't explain the level of HIV among wealthy Tanzanian women.

There is clearly a lot about HIV transmission that we don't yet know. I took a quick look at the occupations of women who are in the wealthiest quintile and was surprised to find that 10% say they do subsistence work and 25% say they do stall and market work. The highest percentage say they have no occupation. Those in the wealthiest quintile may well be dependent on their husbands, but this does not explain why the correlation between wealth and HIV prevalence is stronger for women than for men.

There is more to wealth than occupation and those surveyed are also asked about property, household income as a whole, amenities, etc. But it is remarkable that more than 75% of women in the bottom three quintiles give their occupation as subsistence work. Even in the second wealthiest quintile, more than 50% list their occupation as subsistence work. The bottom three quintiles have a lot in common on the basis of occupation type, the top quintile is quite different. No doubt, these differences in occupation type are related to many other differences in factors that relate to HIV transmission.

But this is only speculation, there is too little data available and it is not finely grained enough to work out or evaluate all the important drivers of HIV epidemics. There are many factors and therefore there are many facts. But the ‘facts’ often appear counterintuitive and there are probably many that we, as yet, know nothing about. What is clear is that a lot of interpretation and clarification is needed and that the facts do not in any sense speak for themselves.


Friday, March 6, 2009

Senegal: an Exception Among HIV Epidemics in Africa?

After spending a lot of time studying as much HIV literature as I could find, I decided to chart the history of HIV in one country, Kenya. This decision stemmed from the belief that the conditions in a country prior to the arrival of HIV are as important as what a country does subsequently to deal with the epidemic. In fact, those conditions may be far more important than the subsequent measures taken to reduce the spread of HIV and certainly would determine a country’s ability to reduce the spread of HIV.

Many of the HIV prevention interventions carried out to date, throughout Africa, have had limited success. In Kenya, very little was done until early in the 2000s, by which time HIV prevalence was declining quickly as a result of a high death rate. Now that HIV prevention programmes have been around for long enough to carry out significant evaluations, it seems that a lot are not performing very well.

Since a lot of HIV funding was motivated by political, religious, moral and commercial considerations, it is not very surprising that so many of the programmes have been a failure. Of course, not all have been so motivated and not all have been a failure, but much of the money has clearly been wasted. 

The politics, the religion and the moral posturing continues. The commercial considerations, on the other hand, have changed radically. HIV is a massive opportunity for pharmaceutical companies. It has also been a godsend for suppliers of other goods and services, consultancies, private health and large, prominent NGOs such as Family Health International, Population Services International and others.

Senegal is often cited as an exception among African countries. HIV prevalence there remained at a very low rate for the whole of the nineties and, though it has been steadily increasing since, has probably never gone far above 1%.

It must be made clear, West Africa is quite different from East Africa (and, indeed North, South and Western Equatorial Africa, which all have identifiable 'regional' pandemics). The majority of countries in West Africa never had prevalence of above 2%. This compares with a high of 14% in Uganda and 11% in Kenya. In fact, the majority of East African countries currently have HIV prevalence rates of over 4%.

This is a relatively quick and dirty comparison of Senegal and Kenya as I am not in a position at the moment to do more detailed work on Senegal; but here goes!

Kenya made some advances in health, education, the economy and other social areas in the 1970s, the decade following independence. Their success began to level off in the 1980s, in part as a result of conditionalities and structural adjustment policies emanating from the International Monetary Fund (IMF) and the World Bank. By the 1990s, Kenya was on a downward trend that continues today. This downward trend is sometimes blamed on the effects of HIV but it started before HIV would have had much influence.

Senegal seems to have had a steady upward trend in social indicators from 1975 to 2005 and is on target to exceed Kenya's position. Senegal is still behind Kenya in some areas, such as education, but this may yet change. And Senegal is ahead in life expectancy, a significant health indicator.

The Human Development Index (HDI), produced by the United Nations Development Programme, is a composite measure of the level of development in a country. It combines measures "of life expectancy at birth, adult literacy and combined gross enrolment in primary, secondary and tertiary level education, and gross domestic product (GDP) per capita in Purchasing Power Parity US dollars (PPP US$)".

The graph, below, shows how Kenya and Senegal compare in their Gender Development Index (GDI), Life Expectancy (LE) Index, Education Index, Human Development Index (HDI) and Gross Domestic Product (GDP) Index.

The second graph shows Kenya's rise and fall and Senegal's steady rise in the Human Development Index.

With regard to the HDI, it is to be hoped that developing countries are doing just that, developing. That is not the case in Kenya. It has experienced retrogressive development since the 1980s and this trend, presumably, has roots in the 1970s and earlier. Senegal seems to be going in the right direction.

But the difference between Senegal and Kenya going by these five social indicators does not explain, on its own, why Kenya has had a serious and generalised epidemic and Senegal has not.

Senegal is said to have a concentrated epidemic, meaning that most of the people infected belong to high risk groups, such as commercial sex workers (CSW), men who have sex with men, intravenous drug users, haemophiliacs and perhaps others. Kenya's epidemic is classified as generalised because the majority of those infected now are not members of identifiably high risk groups. Members of high risk groups are infected but they are increasingly outnumbered by people who are not members of such groups.

My suspicion is that there is something about the conditions that existed in Senegal when HIV arrived that resulted in the epidemic not spreading beyond high risk groups. I think it was inevitable that Senegal would only experience a concentrated epidemic and equally, it was inevitable that Kenya would experience a generalised epidemic.

I have already discussed on this blog why I think it was inevitable that HIV would become generalised in Kenya. But, although I haven't had the chance to study Senegal in detail, there are several telling factors that could shed light on the matter.

John Iliffe, in The African AIDS Epidemic: a History, notes that commercial sex workers are licensed and inspected, following a French model. This contrasts sharply with the situation in Kenya, where sex workers are not an easily identifiable group, with some people resorting to transactional sex as and when they need to. But also, sex workers, and even those suspected of being sex workers, are treated as barely human. They are victims of abuse from the public, their clients and the police. Few, if any, of their rights are recognised by the law and they are obliged to accept this.

In Kenya, unlike in Senegal, there are few health services, health is not particularly accessible and it is especially inaccessible for those known to be or thought to be involved in commercial sex work. Iliffe notes that Senegal already had a successful programme to reduce sexually transmitted diseases, started in 1978, and their health services were able to control the blood supply, something Kenya and other countries are still struggling with.

There were other factors in Senegal that worked to its favour; male circumcision is almost universal; many Senegalese are Muslims and, consequently, have very different lifestyles from the predominantly Christian Kenyans (although the positive and negative effects of any religion can be mixed); HIV-2, a less virulent form of HIV (more correctly called HIV-1) was already common when HIV-1 arrived; condom use during casual sex was already very common in urban areas; and the country was quick to mobilise leadership, education, NGOs and various social services in reaction to the epidemic.

Travelling around Kenya and talking to people, it is clear that the government has done very little and will probably continue to do very little. Educators often know as much about sex as anyone else (and that's not much); they often shy from talking about sex and especially about condoms because of their religious or moral beliefs or because of those of their peers and those of parents; male attitudes towards females seem to have changed little; a lot of NGOs are carrying out pointless HIV 'prevention' activities because their donors would remove funding if they did anything else; other NGOs are doing a good job but are hampered by lack of money and support.

From what I have seen and read in Kenya, it is hard to believe that billions of dollars have been pumped into the country to contribute to the fight against HIV. At least since the 1980s, health, education, infrastructure and other social services have been run down, despite all the talk about achieving millennium development goals (MDGs) and fighting HIV. Most development indicators have been declining for thirty years.

Conditions in Kenya, I think, made it inevitable that HIV would spread rapidly and become generalised, almost from the beginning. The positive feedback from the epidemic would also fuel the already declining social trends. If Iliffe is right, conditions in Senegal were never such that HIV would spread beyond high risk groups and the country was in a position, and continues to be in a position, to protect people from dangers like HIV.

Kenya is not in this position and this explains their continuing predicament. It also explains why I think universal male circumcision, universal testing and treatment (UTT) pre-exposure prophylaxis (PrEP) or any other technical solution will have limited success. The country is weak and vulnerable. Thirty years of retrogressive development need to be reversed. Money needs to be spent on basic needs such as primary health, education, infrastructure, water supply and food security.

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


Wednesday, March 4, 2009

The Wisdom of Hacks

When a journalist goes 'in search' of a story, would it be more correct to say that they know what they want to write about but that they need a bit of scenery? Elizabeth Pisani seems to want to find stigma everywhere that she 'researched' her article (or is it a review?), so she just adds the word in at every opportunity. But had she bothered to read through her own article, she would have found stigma aplenty.

Pisani doesn't just write about stigma, she also stigmatises people with HIV, people she considers to be prostitutes and whores, gay men, anyone who has or may one day be infected with HIV. In her time as a journalist, has she never heard that people who have sex with other people are human beings, not whores or prostitutes? Did she never come across human beings in her career as a human being, journalist or epidemiologist?

Yes, she claims to have studied and worked in epidemiology. But don't worry, there is barely a hint of data or scientific reasoning in this article. It's all prejudice and gutter press cant. Where she didn't find the stigma she craved, she certainly left some behind on her way out. And brought some back home with her as well.

But did Pisani ask the woman she was talking to if she was a 'prostitute'? Well, we don't know, but she was in a bar. Certainly in bars in Kenya and Tanzania it is often assumed that women there must be prostitutes. Like any good journalist, she didn't feel the need to leave anything traceable, checkable or testable in her article. And this journalist is not afraid to exploit human misery and, in the process, contribute to that misery.

There are many reasons for not wanting to take a HIV test, aside from fear of stigma. People don't want to find out they are ill, whether it is with something easily treatable, something that will disappear in time or something that is death threatening. It's not pleasant to find you have a virus, cancer or any other condition, regardless of the effects it may have. There's the dependence on others and on unreliable health services to consider, as well.

But people are also afraid of medical professionals, afraid of giving a blood sample or being manhandled by professionals of any kind. This is true in any country, developing or developed. But in developing countries, where most people rarely or ever see a health professional, testing for HIV can be even more traumatic.

There may be some people who don't care whether they are HIV positive or not, they may think it is inevitable that they and others around them will eventually become infected. Maybe it's all the same whether they are infected with HIV or something else, because other diseases could kill them much more quickly. People become very fatalistic when they are in desperate situations.

There are people who believe myths about testing, such as that it is harmful, that it doesn't work for certain blood types, that it always means you will be positive, etc. Where do they get these myths? Well, many of them have been well propagated by newspapers since the epidemic was first recognised. The myth about condoms having holes in them came from some priests and other religious people. The one about condoms not working very well came from American politicians. The myth about using beetroot or having a cold shower came from some South African politicians, the list is endless. If you want to research them, just look through some newspaper archives.

People may not want to take a test because it is too expensive. Ok, the test itself is free but transport to the clinic is not. If a person is found to be HIV positive the drugs are free but the transport to and from the clinic every month, or every few months, is not free. Nor are the foods, food supplements and drugs people need during the course of their treatment, which is for the rest of their lives.

I have spoken to people who were prevented from testing by circumstances they could do nothing about, such as distance from the facility, lack of funding or opportunity, etc. I have also spoken to people who have become infected through circumstances they had no control over and people who are presently in great danger of becoming infected but can't do anything about it. I find it hard to believe that Pisani never came across such people.

And what do people do about protecting themselves, testing and treatment when there is a civil disturbance, a famine, a global financial crisis or all three in the same year? Well, they just about get by. People are used to getting by or dying in the attempt.

But HIV, like malaria, TB, various cancers, intestinal parasites, malnutrition and other endemic conditions, is not pleasant, even if it is treatable. I'm sure Pisani could come up with additional reasons for not wishing to take a HIV test, aside from stigma.

She goes on to ask "Why don't people ask casual sex partners if they have HIV before they strip off?" Just imagine the scene, last thing before taking off your clothes, the person you were considering sleeping with saying, "yes, I am HIV positive". If I was facing my first chance to make a few dollars in days and had no other source of income, I don't think I would ask, nor would I answer honestly if I was HIV positive and the question arose.

Pisani (and I, for that matter) have other options, we have a source of funding for our next meals and other comforts, we are not in a desperate situation. We are probably both HIV negative as well, so the need to lie about our status is not an issue either.

A 'quality' newspaper like the Guardian (and its readers) should realise a few things that they may not learn from their journalists: people who have sex with other people are not prostitutes and whores. Most people have sex with other people, Pisani's parents had sex, even if she doesn't. All over the world people have sex, yes, even unprotected sex.

But there is not a serious HIV epidemic in every country in the world. The Western country where Pisani lives doesn't have a problem with shortages of fuel or basic food (to the extent that people's health and lives are threatened on a daily basis), there just aren't as many desperate people there. Not yet, anyhow. So there will not be such huge numbers of people coming to Western cities to find work and, not finding it, turning to transactional sex. But that is the case in Nairobi and many other African cities.

There is not the same problem of having to move to a country like Botswana to work in terrible conditions in mines for very little money, away from home and family, where men are forced to live with other men, with no entertainment or comforts for long periods of time. But these problems exist in Tanzania, South Africa, DRC and other countries.

There were no serious episodes of post election violence in Western countries recently and there were certainly no conflicts like the ones in DRC, Sudan and Somalia. Not that Western governments didn't have a part to play in those conflicts, but the disturbances didn't occur in those Western countries. There are only serious HIV epidemics in some countries in the world, yet in all countries people have sex, even (the horror!) unprotected sex.

Don't the Guardian and their readers want to know about some of the many reasons for this?

Despite her alleged background in epidemiology, Pisani seems to adhere to the Victorian prudishness about HIV that assumes and sometimes even states that it is all a matter of people having sex and behaving stupidly. So all they have to do is to behave smartly and things will be ok, right?

But people in Western countries waste more food than people in developing countries eat, that's stupid. What they can't eat, they now want to burn in their cars, that's stupid. There are enough armaments produced in the West to wipe out everyone several times over, that's stupid. Contributions to global warming by Western countries (or in developing countries on behalf of Western countries) threaten the future of humanity, that's stupid. But HIV in Western countries is not the major threat that it is in developing countries.

Pisani is right about one thing, there is a lot of stigma. But her article merely adds to this. And as long as HIV is seen as just a matter of sex and stupidity (or any other simplistic explanation), we will make little progress in preventing the spread of the virus or providing treatment for those who are infected.

There are high rates of HIV in developing countries because people there are extremely vulnerable, whether it is through poverty, poor health, lack of education, labour practices, inequality or exploitation. Vulnerable people are more directly and more immediately affected by disease, global warming, financial crises, famine, water insecurity and anything else that's going around, whether these originated among vulnerable people or not.


Monday, March 2, 2009

Wishful Thinking And Wilful Lobbying

Further to my last posting, which was about universal HIV testing and treatment (UTT), I would like to point out that the advocates of this strategy make it clear that UTT would be combined with currently used prevention approaches. The authors are not suggesting that all the current approaches can be discontinued. They are idealistic but they do have one foot in the real world.

Some of those who have jumped on the UTT bandwaggon, on the other hand, seem to think that current approaches will cease to have much relevance. Similar remarks apply to another technical solution that was fashionable for a while and still is in some circles: mass circumcision. It was feared, even when mass circumcision was first mooted as a strategy for HIV prevention, that people would experience 'disinhibition', that they would think being circumcised meant they didn't have to bother with other precautions.

But that's the problem with bandwaggons, every new toy is seen as the future until it is replaced by the next toy. Using every strategy possible to prevent transmission of HIV is rarely discussed. In fact, strategies that don't relate fairly directly to sexual behaviour are rarely discussed even though they are numerous and would have benefits beyond HIV prevention.

Perhaps there is a feeling of unease developing among some of the loudest proponents of UTT. Maybe they are beginning to feel that many of the prevention strategies that have been employed so far have been a complete failure. Perhaps they wish to bury most of the failed strategies that emanated from dogmatic, right wing moralising rather than from any evidence, scientific, social or otherwise.

But UTT makes very good commercial sense for the makers of pharmaceutical products that are so expensive that most people can’t afford them. Given that the majority of people with HIV live in the developing world, pharmaceutical companies wouldn’t have much of a market for their products unless they could persuade governments and international institutions to pay for them with aid money. And they seem to have been very successful in this endeavour.

Much HIV policy thus far has depended on the assumption that a sexually transmitted infection can be prevented by targeting sexual behaviour and by aiming to regulate the forms sexual behaviour should take. But firstly, it was never reasonable to assume that these could be achieved. Secondly, these policies failed to take into account the determinants of people's behaviour, sexual and otherwise. These policy makers were not really interested in the effect their policies were having, they were just interested in seeming to say the right thing in front of their electorate and/or their funders.

Very early on in the HIV epidemic, HIV was handled by doctors and other technical and medical personnel and this was a period of rapid learning and adaptation. Doctors and others were quick to warn about what steps should be taken to contain what could become a serious epidemic. On the whole, they did a good job, especially considering they were working in the dark.

But HIV quickly became a football for politicians, religious leaders, journalists, pundits of all kinds and, of course, NGOs. There was little that medical practitioners could do anyway and the field was soon full of people jostling for attention. HIV attracted enormous amounts of money and at the same time deflected money, attention and personnel from other issues. These processes continue today.

Prejudices were fed by the same political and religious leaders, journalists and anyone else who felt they should have a say. We saw, and still see, moral outrage, blame (on women, sex workers, immigrants, gay men, Africans, whoever), finger wagging, posturing and anything but effective prevention strategies or the money to pay for them.

Now that this potential technical solution has come along, are we going to see a quiet retreat from these long held dogmas? And if so, will the issues of cross generational marriage, female genital mutilation, the low status of women, labour rights denied, lack of health, education and other services no longer be considered important?

The rush to embrace UTT sounds like a tacit admission that prevention strategies up to now have been a failure and that it is not possible to legislate for people's sexual behaviour. These are both true, of course, but this doesn't mean that UTT will work, whether on its own or in conjunction with existing strategies. If UTT is to work, many other conditions need to be fulfilled first.

HIV has been decontextualised and ahistoricized. Every epidemic has a history and a context. The epidemic in Kenya is different from those in Uganda and Tanzania. In fact, the epidemic in Nairobi is different from that in Mombasa. There are few sex tourists in Nairobi, for a start. But the commercial sex work that takes place in the central business district is quite different from the problems faced by the 70% of Nairobians who live in slums. The epidemic around the Mumias Sugar Company is different from the ones in the towns bordering Uganda. The problems of tea plantation workers in Kericho differ from those of the nomadic people of Northern Kenya, and so on. The determinants of HIV transmission are many and various, requiring many and various solutions.

UTT is yet another solution that is blind to such distinctions as epidemics that are driven by economic need, lifestyle, labour conditions, abuse and exploitation, poverty and whatever else. UTT assumes that HIV is primarily a medical problem and, as such, that it is the same in every country in the world.

UTT could work well in countries with good health, education and social services, buoyant countries with low levels of inequality and good legal and governance structures that protect people's rights. Kenya is not such a country, neither are any developing countries. That's why they are called developing countries.