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.


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