Friday, February 19, 2010

Lack of Logic in the Received View of the HIV Pandemic

Something I have always found mysterious about UNAIDS' view (it's something of a received view) of the course of the HIV epidemic is that they estimate that the number of new infections peaked in Sub-Saharan Africa (SSA) some time in the mid 1990s. And they reckon that the reason new infections began to drop from then on can be put down to the success of HIV prevention and education programmes in changing the sexual behaviour of people, especially men who have sex with men (MSM), commercial sex workers (CSW), intravenous drug users (IDU) and young women.

With few exceptions, most SSA countries were doing very little to treat people with HIV or to prevent the transmission of HIV in the 1990s. Treatment was in its infancy and was inaccessible to the majority of Africans. And where prevention programmes had been implemented, they consisted of little more than mass education campaigns. They had very little influence on people's behaviour in the 1990s. And why would they have much influence? They had only started and only in a few countries, Uganda being one of the countries that started HIV prevention early. But even the nature and effectiveness of Uganda's HIV prevention campaign is still being hotly debated. Prevalence there has changed little in years and sexual behaviour indicators have long been sliding in the wrong direction.

What bothers me is that even if widespread prevention activities started in the mid 1990s, it would take many years for them to have much effect. That's if they actually had any effect at all. Ok, I can't research every country in SSA, but in the case of Kenya, very little was being done in the 1990s. It was only in the early 2000s that some serious work started, say 2002 or 2003. And the Kenya Aids Indicator Survey (KAIS) makes it quite clear that HIV prevalence, which had been dropping before 2003, actually increased and is now higher, after half a decade of HIV prevention work.

What I'm getting at is this: if rates of HIV transmission peaked in the mid nineties, then it did so for some reason other than the fact that every country had implemented widespread prevention programmes. The reason I suggest this is because prevention just wasn't a big thing then, at least, not big enough to explain why the epidemic started to 'decline'. I'm not saying that rates of transmission didn't drop, just that they didn't drop because of prevention programmes.

Another reason for thinking that prevention programmes didn't have much influence on rates of HIV transmission is because even after they did start, there is little evidence that they could have been the cause of the drop. There is plenty of evidence that most current HIV prevention programmes have little or no effect. In Kenya's case, scaling up HIV prevention programmes seem to have resulted in an increase in prevalence, the total number of people living with HIV. This doesn't tell us if transmission rates have decreased, so what about transmission? Are there still lots of people becoming newly infected?

According to the KAIS, transmission patterns are changing. Numbers infected in urban areas have dropped but numbers infected in rural areas have increased, especially among men. The majority of Kenyans, 75% or more, live in rural areas. Poorer and less well educated people are now being infected in greater numbers. The majority of poor and less well educated people live in rural areas and most Kenyans are poor and badly educated. These trends all follow what KAIS refer to as a 'rapid scale up of HIV prevention, care and treatment services'.

A recent article in quotes UNAIDS as claiming that their successful prevention and education programmes have *finally* begun to change the behaviour of those who are most at risk. If this is only happening in recent times, how can they claim that it had anything to do with a decline in incidence that began in the mid 1990s. But Kenya, along with many other SSA countries, have explicitly not targeted some of the groups who are thought to be most at risk, MSM, CSWs, IDUs and young women. The well presented 'Modes of Transmission Survey' for Kenya makes it quite clear that these groups are still being ignored.

There may be isolated signs of people's behaviour changing in some ways. All sorts of movements may have achieved great things, especially relating to HIV treatment and increasing access to treatment. I certainly wouldn't claim that all the billions that have been poured into HIV for over two decades has been wasted. But I have yet to see clear evidence that HIV transmission has declined as a result of prevention efforts. I think the epidemic has its own dynamics, like any epidemic, but I am not convinced that the enormous Aids industry has had much influence on its course. I just hope I'm wrong.


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