Tuesday, June 2, 2009

Why HIV Is Not Just About Sex

I am not denying that HIV is a sexually transmitted infection and that most infections in developing countries such as Kenya occur through heterosexual sex. I am denying that abstinence or even abstinence, faithfulness and condom use programmes (ABC) on their own will reduce HIV transmission to the extent that the virus will one day cease to be endemic.

ABC programmes on their own are not enough. They are not enough because some people do not get to choose whether to have sex or not, when, how often, with whom and under what circumstances. Even if they have some choices, they probably don’t have any say in the sexual behaviour of their sexual partner or partners.

As for using condoms, they are probably the most important factor in reducing HIV transmission. But people who don’t have a choice about the abstinence or faithfulness options are unlikely to have a choice about the use of condoms either.

My scepticism about the effectiveness of ABC programmes does not mean that I think nothing can be done to reduce HIV transmission. On the contrary, many things can be done and many things can improve the effectiveness of ABC programmes, too.

In no particular order, here are some things that are involved in the transmission of HIV that have little to do with sex:

A number of people I talked to in Nairobi said that they have applied for jobs but when it comes to the selection process, they either need to give money to the prospective employer or they need to have sex with them. Those already in jobs are sometimes expected to have sex with their boss in order to get promotion or even to get paid. The rights of the employed and the unemployed are being compromised here.

Marriage is often seen as a protection against HIV but many women don’t have much say in who they marry, nor do they have much influence over their husband’s sexual behaviour. In many instances in Kenya, the man is significantly older than the woman. Therefore he probably has more sexual experience, more power in the relationship and is more likely to be employed than the woman and consequently have more control over finances.

Where women are forced to have sex for some benefit, whether it is for money, gifts, security or anything else, they risk being treated as a criminal by the police. Men who expect sex in return for some benefit are not usually treated as criminals. Therefore, women are often unable to report cases of forced or coerced sex. Victims of sexual abuse are being treated as criminals.

HIV rates are often high in certain contexts, such as in border towns, around big industries and in slums. Border areas and industrial areas often have demographic imbalances, with huge numbers of single men. Slums grow (partly) as a result of people coming to urban areas to work but only finding very low paid jobs. Transactional sex also grows in such areas and, as a result of poverty and lack of social services, people are extremely vulnerable.

HIV prevention programmes that aim to influence sexual behaviour have not been very successful in reducing HIV transmission. But that’s because these programmes have not always addressed the contexts in which sexual behaviour occurs, the contexts that so often result in sex being unchosen and/or unsafe.

Kenyan law can’t guarantee everyone a job but it should be able to guarantee that people will not have to bribe someone with money or sex to get a job, to keep a job or to get promotion or better conditions. Women need better educational opportunities, their rights need to be protected, their dependents need support, they need to be able to inherit their husband’s property, they need to be able to refuse sex with a partner who has been having sex with other women; and the list goes on.

If the country can’t provide people, especially women, with adequate employment or social benefits, it has no right to criminalise what is for so many people a last resort; commercial sex work. Women and girls are forced into some kind of commercial sex work because of extreme poverty and desperation. This exposes them to numerous dangers, HIV being just one of them.

In order to protect people from HIV, other sexually transmitted infections, unplanned pregnancies, violence and exploitation, commercial sex work needs to be decriminalised. This is one of the most urgent steps that needs to be taken in Kenya and other countries with high HIV prevalence.

So reducing HIV transmission depends on changing laws, improving education, health and other social services, reducing inequalities, especially those relating to the law, education, employment and many other measures. Once these issues have been addressed the question of influencing people’s sexual behaviour seems relatively unimportant. When people are empowered and, where necessary, protected, they will take care of their own sexual behaviour.

So far, little has been achieved in the field of HIV prevention. A relatively small percentage of money spent on HIV goes towards prevention (as opposed to treatment and support for those infected and affected) but most of that has been wasted on programmes that don’t have any effect. And they will never have any effect until these several far more important issues are addressed.

In order to reduce sexual transmission of HIV it is not necessary to influence people’s sexual behaviour; they need to be empowered to the extent that they can choose the conditions under which they have sex, how often and with whom; they need adequate laws, education, health, infrastructure and social services. In other words, people need their basic human rights to be assured. If basic rights are assured, people will be better able to look after their own less basic rights.


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