Thursday, April 23, 2009

Immediate Needs Sidelined by HIV

Wildly exaggerated estimations of how many lives could be saved by mass male circumcision or universal HIV testing and treatment grab the headlines. But stories about being able to save two million children a year who are dying from diarrhoea don't seem to attract so much attention. The treatment for the acute diarrhoea that kills children, an oral rehydration solution of a pinch of salt and a handful of clean water (CLEAN water!), just doesn't jingle the way expensive programmes and drugs do.

Another thing that doesn't grab headlines is something like a nutrition programme that targets starving children. Free meals in a school in Tanzania has had the effect of increasing attendance and allowing almost all children to graduate from primary to secondary school. Before the programme started, pupils who made it to school were too tired and undernourished to concentrate and most failed to finish primary school. Mainstream media has a taste for good news sometimes, but this seems to lack the high sugar content that appeals to them.

If children just turned up at school to be fed and then left or didn't bother to do any work, this programme would be disappointing. But the fact that they were enabled to go on to secondary school means that the programme could have many benefits aside from nutritional and educational. According to the most recent figures, fewer children go to secondary school in Tanzania than in Kenya or Uganda. And only around 1% go to tertiary level education.

One of the problems with current HIV prevention programmes, the ones that are implemented in schools, anyhow, is that the general level of education in the country is low. I have met people who, at the age of 15, started having sex, usually with an older partner. That's not the surprising bit; the surprising bit is that they didn't know what sex was or if they did, they didn't know that that's what they were indulging in.

I came across a paper about reproductive awareness among adolescent girls (10-19 years) in Bangladesh and many had incorrect knowledge or misperceptions about reproduction, the fertile period, STIs and HIV. This is often connected with the educational status of girls or that of their mother. 18 out of 20 married adolescents who had recently given birth didn't understand why they had become pregnant. Most had never heard of STIs and while 40% had heard of HIV, only 20% had knowledge about how HIV is transmitted.

Many girls experience sex of some kind in their teens, whether they chose it or not. Most of them know so little about sex that they don't know how to avoid doing what someone is coercing them into doing, they don't know how to negotiate precautions, such as using a condom, they may not even know what condoms are, where to buy them or how to use them. To understand what safe sex is, children need to understand what sex is. There is no evidence that teaching children about sex encourages them to try it, all the evidence is to the contrary.

Many school based programmes have had little effect except to give people a superficial ability to answer questionnaires about sex in the required manner. Well educated young people are ones who can make decisions, negotiate, relate to other people at a level other than a reflex level, where they simply say things like 'sex is bad' or 'abstinence is the safest sex' or whatever brainless platitude is the current favourite. People need to learn to think, not just repeat what they are told to think.

Even adults are confused about the 'ABC' strategy, Abstain, Be faithful, use a Condom. The word ‘abstain’ is widely misunderstood, or ignored where it is understood (I certainly ignore it); being faithful is sometimes understood as meaning that it is ok to have other partners as long as your main partner doesn't know; and condoms are a somewhat exotic commodity that used to be really common a few years ago. You can still get condoms free of charge sometimes but, apparently, the free ones are not as common as they used to be. (A packet of three condoms made in Tanzania costs the price of a small bottle of soda. A packet of three produced in rich countries cost about four times that much. Some splash out for the local brands but others spend the money on soda.)

Children (and adults) have rights, that are enshrined in the Universal Declaration of Human Rights, to a good level of nutrition, water and sanitation, health and education. There is nothing in the declaration that says they only have the right to remain HIV negative and to other rights only insofar as they maintain a HIV negative status. HIV is just one aspect of development and underdevelopment. To many, it doesn't even matter that much compared to the urgent need for something that the lack of will kill them very quickly.

HIV has deflected attention from vital areas of development. In fact, many HIV prevention and care programmes have poor results because most areas of development, such as health, education, social services, infrastructure, governance, human rights and equality, have been ignored.


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