Friday, May 29, 2009

Predictions and Evaluations - HIV in Kenya Today

Sadly, I am now back in the UK. But I will continue to study and blog about HIV and development in Kenya and other places.

About two months ago I wrote a posting entitled A Short History of HIV in Kenya. At the time there was little response but in the last few days someone has responded, at some length. As the respondent raises important issues, I am replying to some of them via a new posting rather than continuing what is now an old thread.

The respondent points out that many people have questioned the HIV predictions of institutions such as UNAIDS, given that they have had to revise their figures downwards on several occasions.

I am not a big fan of UNAIDS but methods of measuring the extent of HIV epidemics and predicting future prevalence are evolving. It is hardly surprising that figures include a lot of somewhat vague modelling and informed guesswork. Over the years, measurements and predictions have become better informed, but they will continue to be rough.

However, estimating the overall severity of a HIV epidemic is not just a matter of surveying the number of people infected and affected and making predictions about future prevalence. It is also necessary to establish who is at risk, why they are at risk, if the level of risk in increasing, if the number of people at risk is rising, etc.

It is also necessary to judge a countrys capacity to prevent new transmissions and to support and care for those infected and affected by HIV. Mere numbers of people infected and affected will not, on their own, be of much help in preventing further infection or helping those who are infected. Nor will they shed light on why people continue to be infected in high numbers, despite large amounts of money supposedly being poured into HIV prevention.

The big worry in Kenya and other developing countries is not whether prevalence is high or low (whatever may count as high or low, whether it is increasing, decreasing or flatlining; the big worry is what countries have been doing so far and what they are able to do in the future.

Are there adequate health services that are accessible to everyone, are all children attending school, are adults well enough educated to raise healthy and well educated children, does the country have the infrastructure to implement health, education and other social programmes to reduce HIV transmission and to keep it low, etc?

The main concern is not whether the HIV pandemic is increasing or decreasing according to some vague figures and guesswork. The main concern is whether the original factors in the spread of HIV in the 80s, 90s and 2000s are still present in developing countries.

And there is a lot to be worried about; health services, education, infrastructure, social services, employment, legal conditions, levels of inequality and human rights suggest that very few improvements have been made in Kenya and other countries. Therefore, there is no reason to assume that HIV will just disappear.

It is true that, at one time, Kenyan HIV prevalence was estimated to be about 15%. Then it was realised that this was incorrect and the figure was revised down to about 10%. Over a period of several years, prevalence continued to fall, mainly because infected people died of Aids. But in the mid 2000s, rates started to increase again.

The respondent in question is right to be sceptical about HIV prevalence figures but wrong to come to any conclusions on the basis of these unreliable figures.

What is a low prevalence figure, anyway? A few years ago, North Eastern Province had an estimated prevalence of below 1%, perhaps well below 1%. But the risk factors there were significant, high unemployment, low education, poor health and health services, rapid urbanisation, increasing mobility, high levels of economic and gender inequality. More recently, prevalence was estimated to be well over 1%. The fact that figures may seem low in some areas now does not mean that they will stay low.

As for the claim that people outside of Sub Saharan Africa (or outside of certain developing countries) are not likely to contract HIV, this is also not borne out by the evidence. Eastern European countries are seeing high rates of HIV transmission, especially among high risk groups, such as intravenous drug users, commercial sex workers and men who have sex with men.

But even developed countries, such as the UK and the US, are also seeing substantial transmission rates and not just among high risk groups. The risk is nowhere near as high as it is in developing countries but it certainly raises questions about the effectiveness of their HIV prevention programmes. After all, these same programmes are being exported to developing countries, where they may have even less success.

Finally, it is still the case that everyone is at risk. It is just that they do not all have the same odds (and they never did). People in developing countries are more at risk, women are at more risk than men, men who have sex with men are at more risk than heterosexuals, etc.

If figures are unreliable, and they often are, take a look at the risk factors. Take a look at the conditions people live in. Cholera, for example, is not a problem in Zimbabwe because 100,000 people have been infected and thousands died. It is a problem because water and sewage services are not adequate and any water borne disease could flare up and become an epidemic in a short period of time. And if this happens, the country will not have the capacity to prevent it from spreading, perhaps to surrounding countries.

Right now, many Kenyans are poor, unemployed, undereducated, malnourished, unhealthy and desperate. There is a good chance that things will get worse before they get better. People are vulnerable to HIV and many other diseases. These are the kinds of things you need to know to judge whether the HIV epidemic is getting worse or not.


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