Monday, July 20, 2009

HIV Policy in a Vacuum

For some time it has been claimed that HIV testing plays a big part in reducing transmission of HIV because people who find out that they are HIV positive can take precautions to avoid spreading the virus. More importantly, it has been claimed that people who find out that they are HIV negative take steps to stay that way.

Well, of course it is good for people to be tested, whether they turn out to be positive or negative. Most people in most countries with a serious HIV epidemic don’t know their status. Those found to be positive can be given counselling, advice and, where required, medication. Those found to be negative can also be given counselling and advice.

But in South Africa, it has been noticed that many people who receive a negative result have subsequently increased their risky behaviour []. The goal to test as many people as possible is still perfectly valid but people need to modify their behaviour as a result of going through the testing and counselling process.

This sort of trend is not confined to South Africa. It has been noticed in Uganda that there was a 50% reduction in condom use among people who tested negative for HIV. In Zimbabwe, similar phenomena occurred and people also increased the number of their sexual partners, too.

The story is not all bleak because it is said that the opposite is true of young people testing negative in the US. They, apparently, go on to reduce their sexual activity and take other measures to avoid risky practices. That’s comforting because the US has the highest HIV prevalence in the developed world.

But it doesn’t answer the question of how to resolve the problems in South Africa, Uganda and Zimbabwe. Clearly, testing and counselling can’t be abandoned. And the mere knowledge that a negative test result can sometimes give rise to increased unsafe sexual behaviour should be of great help to policy makers and implementers.

But I think also that this is an important reflection of the fact that HIV is not just about sex. If you like, sex is not just about sex. People have sex for all sorts of reasons, aside from obvious ones, such as having babies, having fun, doing ones duty, etc.

The circumstances in which people live often determine whom they have sex with, how often, what kind of sex they have, how many partners they have, when they have sex and where they have sex. And many people are not in a position to choose or control all of these circumstances.

For example, a man who runs a community based organisation in Kibera slum in Nairobi points out that 66% of girls in slums enter the sex industry at some time, some at a very early age. Their economic and social circumstances play a big part in whether they can avoid becoming involved in the sex industry or not. Knowing that they are HIV positive or HIV negative may not play much part in how they behave after they have been tested.

Married women do not always have the option to demand that their partner uses a condom, even if they know that their husbands have other partners or may already be infected with HIV or other sexually transmitted infections.

Many Kenyans live in poverty, many are short of food all or most of the time, clean water and adequate sanitation are non-existent for most people, electricity and other modern conveniences are just not readily available. Given these circumstances, people face many hazards already. Unsafe sex may just be one hazard of many.

It’s not the sex itself that threatens people but a whole array of circumstances that determine people’s sexual behaviour, their relative risks and vulnerabilities.

It is probably beyond the scope of voluntary counselling and testing services to provide Kenya with the means to develop its health, education, infrastructure and social services. But these matters need to be dealt with in the forthcoming National AIDS Strategic Plan, whenever the government gets around to publishing it. The last one (and the one before) concentrated on a narrow range of HIV prevention programme possibilities.

Let’s hope the next one takes a broader outlook and takes into account the connections between people’s sexual behaviour and the circumstances in which they are forced to live.


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