Tuesday, January 12, 2010

How Long Can We Continue to Ignore Those Who Are Still HIV Negative?

I was back in Mogotio with Ribbon of Hope today, weeding the watermelon beds in our latest shamba (smallholding). There were eight of us there today, three who were getting paid for the work. Others will get payment in kind. I have to be honest, I managed to do a few hard hours under the hot equatorial sun but I had to give up at lunchtime and I'm now stiff and sore. And there was at least two thirds of the field left to weed when I left!

But it's good to see the project get off the ground because it will provide some casual employment in an area that sees little work and it will provide some good food crops at low prices at a time when food prices are particularly high. In the next few months the shamba will require a lot of looking after, weeding, irrigating and security. There will be plenty of people willing to do some of that work.

Mogotio is only about 30 kilometers out of Nakuru, so it is by no means the most isolated place you'll find. But it feels isolated. There are very few NGOs that ever visit the place and I haven't been able to find out about anything they do. I saw a World Vision four wheel drive but none of the community leaders I asked could say what the organisation does there. UNHCR has been active in the area recently because hundreds were displaced by the heavy El Nino rains. There are over one hundred white UNHCR tents just outside the village, but that's an exception.

The area is almost entirely dominated by the sisal industry. There are a few factories, most of which don't operate very much. There is little money to be made by growing sisal and people who live in these areas don't make much of that money anyway, it's mostly made by the estate owner, who lives in Nairobi and rarely visits the area. Some of the people who work for or have worked for the factories are owed wages going back many years. Every now and again they get some money, but just a fraction of what they are owed.

Like a lot of parts of Kenya, HIV is widespread here but it receives little attention. Most NGOs are based in the cities and bigger towns. They work in or close to wealthy suburbs and rarely leave those areas for long. When they do, it's like a state visit, a convoy of huge, air conditioned, white, oversized vehicles, stirring up the dust and little else. HIV spreads more slowly in rural areas and that may be one of the reasons that less attention is paid to them than to urban areas. However, the majority of Kenyans, over 80%, live in rural areas.

And many more people in rural areas don't go to school or don't go to school very much, many don't have access to mainstream media, they don't have access to health or other social services and they have little or no connection with the benefits of the cities and towns. They are more isolated than their distance can explain. Every now and again something comes their way, probably not much, then the project or organisation leaves and loses touch.

But even some of these isolated areas have access to some HIV testing and counseling facilities and even the HIV drugs that most people are supposed to receive for free. They usually don't have access to any other kind of drugs and they are lucky if they can stay healthy, but it's a start. But treating more and more HIV positive people every year has little impact on reducing HIV transmission. Many more people become infected for every one person who gets treatment.

And HIV prevention really is a strange animal. In all the time HIV has been around, few methods of HIV prevention have been developed. A fraction of the money that goes into HIV goes towards prevention, less than 25% in Kenya. About half of that goes on prevention of mother to child transmission and the 12% that's left is spent on rather dubious projects that are known to be of little or no benefit.

A series of findings were presented at the 2006 Aids Conference that demonstrated that most kinds of HIV prevention programmes have a very small effect, some have a negative effect and the majority don't do anything. Consider the list: Voluntary Counseling and Testing, Condom Social Marketing, Mass Media, Abstinence-Based Interventions, Peer Education, Family Planning Counseling for HIV-Infected Women, Needle Exchange Programs, and the Effect of HIV Treatment on Risk Behavior.

The only one in the above list that has proved itself is needle exchange programmes. These have been known to be effective for a long time but they are strongly disapproved of by many funders, especially US funders, who feel that they increase drug use. They don't increase drug use, they reduce it and they have an impact on HIV transmission. But such programmes are of little relevance in Kenya as a whole and of virtually no relevance in a place like Mogotio.

The majority of HIV infections in Kenya come from heterosexual intercourse. A sizeable percentage comes from male to male intercourse. A debatable, possibly high percentage, comes from medical treatment, such as injections. But in rural areas, like Mogotio, people are in need of good education, health services, ordinary health services, not vertical interventions that treat HIV (or something else) alone, basic social services, infrastructure and things like that. There is no mystery about HIV transmission that makes its reduction intractable. People need a reasonable standard of living, they need security in their lives, especially food security, they need work, for which they get paid; just basic things that people in developed countries take for granted.

Yet more and more money continues to be poured into programmes that are unlikely to work or even ones that have been demonstrated not to work. In the case of Mogotio, of course, they don't even get these programmes most of the time. Money intended for the constituency appears to get stuck elsewhere and people are forced to plod along without even the most basic of their rights being realized. As long as people have so many problems in their lives and so little to aspire to, HIV will continue to be low on their list of priorities. If HIV is low on their list of priorities, even effective prevention programmes, if effective programmes exist, are destined to fail.


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