Tuesday, May 4, 2010

HIV Stigma and Institutional Racism

The received view about HIV these days is that unless you are a gay man, a sex worker or an injecting drug user, you are unlikely to be infected. At least, that’s the received view in rich countries. In fact, in their 2009 Aids Epidemic Update, UNAIDS don’t even mention sex workers for North America and Western and Central Europe. They say “[i]n North America and in Western and Central Europe, national epidemics are concentrated among key populations at higher risk, especially men who have sex with men, injecting drug users and immigrants”. Despite this though, heterosexual sex appears to account for about 30% of transmission.

But in poorer countries, especially in Africa, the received view is somewhat different. Here, it is claimed that the most common way of spreading HIV is through heterosexual (vaginal) sex. UNAIDS say “[h]eterosexual intercourse remains the primary mode of HIV transmission in sub-Saharan Africa, with extensive ongoing transmission to newborns and breastfed babies.” They even claim that 94% of transmission is by heterosexual sex in Swaziland.

But the report goes on to suggest, effectively, that low risk sex is high risk sex in Lesotho and Kenya because it accounts for most transmission. “In Lesotho, between 35% and 62% of incident HIV infections in 2008 occurred among people who had a single sexual partner. Heterosexual sex within a union or regular partnership accounted for an estimated 44% of incident HIV infections in Kenya in 2006, while casual heterosexual sex accounted for an additional 20% of new infections”. However, if low risk sex is high risk, this just begs the question of how sexual behaviour could account for so much transmission in some countries but not others. Most people in every country have low risk sex but most countries don't have high HIV prevalence. UNAIDS accept that gay men and drug users are also at high risk, but that they contribute far less to the epidemic.

According to this received view, sex workers in African countries would be particularly at risk, along with their clients and their clients’ other sexual partners. So it’s easy to see how stigma creeps in. If you become infected with HIV, you are probably a prostitute, someone who frequents prostitutes or, even worse, a gay man or an injecting drug user. Because of the stigma attaching to HIV, people are often less quick to see that there are many who could have been infected unwittingly. And the issue of infants being infected by their mother can also be an inconvenience when painting a picture of rampant illicit sex and drug taking.

A former UNAIDS employee, Elizabeth Pisani, says “HIV is mostly about people doing stupid things in the pursuit of pleasure or money”. She also says “In Africa, people are contracting the virus through heterosexual, non-commercial sex”. Pisani is someone who certainly knows how to reinforce stigmatizing views. I’m surprised she ever left UNAIDS.

Of course, heterosexual sex would account for a substantial proportion of HIV transmission. But how substantial is anyone’s guess. Because, holders of the received view claim that HIV infection through accidental blood exposure in poor countries is low or negligible. Back to UNAIDS again: “A small percentage of prevalent HIV infections in sub-Saharan Africa is estimated to stem from unsafe injections in medical settings.” Also: “In an analysis of data from Kenya, medical injections were estimated to be the source of 0.6% of all HIV infections”. Though strangely enough, they admit that medical transmission is far more significant in Uganda.

They even find that in Eastern Europe and Central Asia “[i]n addition to new infections associated with injecting drug use and unprotected sex, key informants and scattered media reports suggest that a notable number of new infections may be occurring as a result of unsafe injections in health-care settings.” However, what they mean by ‘key informants’ etc., actually refers to a whole body of evidence about unsafe injections that UNAIDS are unwilling to countenance, so they ignore it.

In hospitals and clinics in developing countries, instruments that are contaminated with blood and various blood-borne diseases may be reused or inadequately sterilized. Health services are underfunded, understaffed and short of resources. There is no lack of evidence that they are risky places. So how can UNAIDS come up with these figures for medical transmission of HIV? Well, by being selective about what evidence they cite and by ignoring anything they don’t like the look of. High rates of medical transmission, and consequently, lower rates of sexual transmission, doesn’t fit with the view that, in Africa, people have a lot of unsafe sex. And institutions, politicians, churches and funders are interested in supporting sexual behaviour change programmes.

These same people are probably not interested in accepting that some of the problem may arise from unhygienic practices in the very health facilities where they are urging people to go for testing and treatment. The mainstream doesn’t want to see itself as being a significant part of the problem. So UN and WHO personnel, diplomats and other high ranking officers are issued with their own needles and syringes when they are visiting African countries. They are also given instructions to avoid treatment if at all possible.

But Africans themselves are supposed to visit whatever health facility is available to them without even a warning about the risks they face or the precautions they can take. And if they are infected with HIV, they will probably unknowingly go on to infect others.

It seems to me that racist attitudes allow members of institutions such as UNAIDS to assume that Africans have lots of unsafe sex, but that most non-Africans don’t. And racist attitudes allow these institutions to recommend that their employees avoid medical facilities in developing countries, without doing the same for people who have to live in those countries.

In Western countries, people travelling to African countries are likely to be made aware of some of the potential risks of visiting medical facilities there. They can buy information about medical safety and even kits containing syringes, needles and the like, so they can reduce the risks they face further. If it is so important for Westerners visiting African countries to take care when visiting medical facilities, or even to avoid visiting them altogether, why is it not equally important to protect Africans from being infected in these facilities?


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