Sunday, May 30, 2010

Why is HIV Policy in Africa Written By Racists?

Kenya appears to have yet another 'campaign' to reduce HIV transmission. This one purports to target HIV positive people, whom, some 'senior government officials' claim, have been ignored so far. This is an odd claim, considering the largest part of the vast sums of money being spent on HIV for many hears now has gone into treatment for HIV positive people. HIV prevention has received a very small amount of money and much of that has been frittered away on 'behaviour change programmes' widely acknowledged to be useless in Western countries.

Of course, HIV positive people must be part of the equation when trying to reduce HIV transmission. But so must HIV negative people. Concentrating on one group and ignoring the other has been counterproductive. One of the reasons that big funders are questioning the continuation of ever increasing funding for HIV drugs is that this approach hasn't yet had much effect on HIV prevalence. As HIV drugs are rolled out, more and more people continue to become infected. If there was an end in sight, perhaps in the form of significant reductions in transmission in high prevalence countries, funders might be persuaded to hang in for a bit longer.

The article is, in fact, very misleading:

"We have focused so much on empowering HIV-negative people to avoid infection. We now need to focus on people who are already infected and empower them to prevent new infections, re-infection, and maintain their own and their partners' good health," said Dr Nicholas Muraguri, head of the National AIDS and Sexually Transmitted Infections Control Programme.

I haven't seen much evidence of empowerment of HIV negative people, though I've seen many references to it. Whether the focus of most of the money and attention for the last several years on drugs and treatment has also included any empowerment for HIV positive people is another matter. It probably hasn't because pharmaceutical companies don't make money out of 'empowerment', they make money out of drug sales.

I have searched high and low for the guidelines in question without finding a copy but the article goes on:

One of the main aims of the guidelines is to ensure that all HIV-positive Kenyans are aware of their status; government statistics show that 84 percent of HIV-positive people do not know they are infected.

I hope this figure is out of date because it is the same as it was back in the 2008 Aids Indicator Survey, the data for which was collected in 2007. Since then, articles have claimed that several million more Kenyans have been tested, one even claiming that about 1.5 million were tested in a six week period near the end of last year.

The more people tested the better, but will any effort ever be made to figure out how people became infected? The assumption is still, despite plenty of evidence to the contrary, that most transmission in Kenya and other high prevalence African countries is due to unsafe sex.

Despite finding medical facilities to be too dangerous for UN employees, UNAIDS claims that medical transmission of HIV in Kenya is around 0.6%. There are children who are HIV positive whose mothers are not and nearly half the married women who are HIV positive are married to men who are HIV negative. Are we supposed to believe that all these women are becoming sexually infected with HIV through some relatively small number of men, to whom they are not married? Well, if you pander to the stereotype of the oversexed African, you may be happy with this explanation. But if you're an economist, no matter how bigoted, you may wonder how a large number women can have anything to gain by having sex with a small number of men to whom they are not married.

Dr Muraguri goes on to say "We want to de-stigmatise the HIV test so that HIV testing becomes a 'kawaida' [usual] thing". What better way could there be to stigmatise HIV than to assume that it is mainly sexually transmitted? Even the possibility that some HIV is transmitted non-sexually is not considered in most of the literature, perhaps from unsafe medical procedures, perhaps from unsafe cosmetic procedures or some other likely candidates. In what way, I wonder, is Dr Muraguri suggesting that this de-stigmatises anything? I see the sexual behavioural paradigm as the very source of HIV related stigma.

The article continues:

"At one point, every adult with sexually transmitted HIV was the HIV-negative partner in a discordant relationship," Muraguri said. "Over 44 percent of married HIV infected partners have an HIV-negative partner - if they are aware of their status, they can take steps to protect their partners from infection.

Yes, over 44% of married HIV positive people have a HIV-negative partner, and haven't people like the doctor ever wondered why this is? And if they were infected by some route other than sexually, their partners could also be infected non-sexually. Isn't it strange that HIV transmission in concordant relationships is so slow? Doesn't it suggest that sexual transmission of HIV alone may not be enough to explain the very high prevalence of HIV in Kenya and other African countries?

People who are aware of their status can protect their partners or protect themselves, but only if they know what the risks are. People can not protect themselves from medical, cosmetic or other non-sexual transmission by wearing a condom or even by abstaining from sex, especially if they don’t even know about these risks.

Anyone worried about reduced funding for HIV, as many claim to be at the moment, should be wondering why the various campaigns that were mere variations on Abstain, Be faithful and use a Condom (ABC), or even worse, abstinence only, have been so unsuccessful. As well as being intuitively unappealing, perhaps they were just barking up the wrong tree. Africans don't have more sex or more unsafe sex than non-Africans, so why should HIV prevalence be higher in many African countries than in many non-African countries?

In case there is any doubt remaining that the campaign excludes all but sexually transmitted HIV:

Prevention with Positives includes encouraging partner disclosure, scaling up prevention of mother-to-child transmission, increased condom use, large-scale male circumcision, and ensuring adherence to antiretroviral (ARV) drugs, which have been shown to significantly reduce the risk of mother-to-child as well as sexual HIV transmission.

This is all good advice, especially for sexually transmitted HIV. But for non-sexually transmitted HIV it offers nothing. People must know how they are becoming infected in order to protect themselves. The racist view that Africans are all having unsafe sex at such high rates that non-sexual transmission is almost irrelevant will not help to cut HIV transmission. But this latest Kenyan programme is being funded by some arch racists, it appears. The American President's Emergency Plan for Aids Relief, the Elizabeth Glaser Paediatric AIDS Foundation, and the US Centres for Disease Control are mentioned but apparently there are others.

Yet another stigamatising attitude is expressed by Nelson Otuoma, chairperson of the Network Empowerment of People Living with AIDS in Kenya (NEPHAK). This seems surprising, but he claims that the 18,000 or so members of NEPHAK have a "have a common message - they must not be generous with the virus, giving it away; they want to be mean with it, keeping it to themselves." There may have been rare (but very media friendly) exceptions of people deliberately or carelessly transmitting HIV but most people don't want their friends, partners, family or anyone else to become infected. Do people seriously believe otherwise?

Even nurses and other healthcare workers have been denied the knowledge that many people in Kenya probably became infected with HIV through a non-sexual route. Many people will list non-sexual ways of transmitting the disease, but it is clear that the assumption is that HIV is usually transmitted sexually. There is no reason for healthcare workers to assume that people face other risks because, regardless of how much money has been spent on improving healthcare (and I've seen little evidence of much of that in Kenya), they are bombarded with courses, publicity and literature on sexual transmission.

If I get to see the guidelines I'll link to them here. But I am very disappointed to hear that, yet again, non-sexual transmission of HIV has been ignored and the old stigma has been given more fuel, as if it needed any more. I have spoken to many people (laypeople and professionals) in Kenya, Uganda and Tanzania and most of them are willing to admit that things in health facilities are slack and must be giving rise to a lot of risks, whether for HIV or any other blood-borne diseases.

In addition to being able to access treatment when they are HIV positive, HIV negative Kenyans and other Africans need to be able to ensure that they stay negative. This means being made aware of the risks they face, not just sexual risks but risks they face when receiving medical treatment, cosmetic treatment, traditional medicine and other practices and the like. If they are not made aware of these risks, no matter how embarrassing it is to those in UNAIDS, CDC and other institutions that steadfastly deny that such risks exist, people will continue to become infected.

Unsafe medical practices are known to be common in some African countries, which means that everyone who receives medical treatment is at risk of becoming infected with HIV and other diseases. Continuing to maintain that sexual behavior is responsible for most HIV transmission among Africans, while warning non-Africans about these risks, is not the way to reduce HIV transmission. The belief that Africans have a lot of unsafe sex, and that’s why HIV prevalence is high in some African countries, is a prejudice: it arises despite evidence to the contrary, not because of evidence for the belief. But these two claims are what HIV policy in Africa tends to be based on.


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