Wednesday, May 12, 2010

Health Minister Takes Aim at Own Foot

In addition to proposing a draconian law to make certain sex related crimes capital offences, the Ugandan government is also considering a law to criminalize ‘deliberate’ transmission of HIV. The ‘State Minister for Health in charge of General Duties’ (is that the same as ‘Minister of Health’?), Richard Nduhura says he is now behind the law, having previously had some reservations. President Museveni also supports the law, which never bodes well.

Naturally, human rights activists and people who have some feelings of humanity are opposed to these laws. Some of them have spent three decades trying to reduce stigma against HIV positive people, whereas laws like these will increase it. People will think twice before having a HIV test, or even going to hospital, if they think they may be HIV positive. Uganda needs more people to test for HIV, not fewer. With these laws, anyone who is at risk of being HIV positive, or even anyone who may be suspected of being at risk, also risks discrimination by neighbours, police and other professionals.

This is particularly serious in a country like Uganda because UNAIDS maintains the contested claim that most HIV is transmitted by heterosexual sex. That means that all pregnant women, their partners and those suspected of having had sex in the past could be HIV positive. After all, the majority of new infections are occurring inside marriages and steady relationships. Therefore, these are the people, along with men who have sex with men, intravenous drug users and commercial sex workers (or anyone believed to belong to these groups) who are most likely to become infected and to be spreading HIV.

But there is a rather more troubling aspect to making ‘deliberate’ transmission an offence. The law is clearly aimed at people who are already discriminated against, along with a lot of other people who will soon be discriminated against. But will it also apply to providers working in medical facilities and those working places where people receive cosmetic treatment? It has long been established that medical and cosmetic transmission of HIV is far more common than the mainstream HIV industry people will admit. But if it ever gets out that people working in these sectors are ‘deliberately’ transmitting HIV, they too will become victims of the law.
What about the esteemed State Minister for Health in charge of General Duties, himself? Healthcare personnel, I am sure, are not ‘deliberately’ infecting people. But what about the ones who reuse a needle or a syringe or fail to sterilize equipment properly? They would be well aware that this carries a big risk of transmitting HIV and other diseases. Perhaps there is a shortage of equipment, perhaps people haven’t received adequate training or perhaps someone is making money on the side by selling reused medical equipment or stealing it and selling it on the black market (I’m not necessarily talking about frontline healthcare personnel, by the way). Isn’t the State Minister for Health in charge of General Duties responsible for the conditions of medical facilities currently extant in Uganda?

Ok, the word ‘deliberately’ is in inverted commas for a reason. How can you tell that transmission is deliberate? I think the answer is simple enough: in many cases, you can’t. Some people may transmit HIV because they didn’t take adequate precautions, others may just be unlucky. Others still may not know they are HIV positive. But this applies to non-sexual transmission as much as it applies to sexual transmission. Healthcare personnel and people providing cosmetic services may not know that the last person on which a piece of equipment was used was HIV positive, before going on to use it on someone else without ensuring that it is properly sterilized.

Will people who use razors and other sharp instruments for hairdressing or other cosmetic treatments be liable for ‘deliberate’ transmission of HIV, if they and their clients happen to be so unlucky? Right now, the word on the street about HIV is that medical transmission is so low as to be almost irrelevant and cosmetic transmission is pretty much irrelevant. But once the hunt is on for people to blame, there will surely be questions about the most efficient means of transmitting HIV, that is, through blood contact.

The aim of HIV prevention policies should be to identify the people who are at risk and to deal with the sources of risk. The aim should not be to group people according to how likely they are to transmit HIV or to be infected with HIV and then to create a law which will end up discriminating against them. But by threatening to punish all ‘deliberate’ transmission of HIV, this law could also punish those who are not currently thought of as transmitting the disease at all, health professionals and those in other service sectors where blood transmission may occur.

In a country where most health spending comes out of the pockets of poor Ugandans and from donors, and very little comes from the government, things are not as neat and tidy as this proposed law may assume. If the aim is to identify all the ways in which people are becoming infected and prevent further infections and also to treat those who are already infected, the health minister and his colleagues are going the wrong way about it. They have, rather predictably, failed to control people’s behaviour as a means of reducing transmission of HIV. They will also fail to reduce transmission by threatening people in ways that result in them being very unlikely to get tested or to declare their status if they are HIV positive. The last thing Uganda needs now is more failure.


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