Give those Women a Pat on the Head

Those in the Aids industry often talk about gender and empowerment in relation to reducing HIV transmission. But what do they mean? Do they mean that women would be able to protect themselves from HIV if only their rights were recognised, such as the right to decide when, where, with whom and under which circumstances to have sex? Well, gender inequality is repulsive in many ways and it has numerous negative consequences. Gender equality is a human right and we should strive for full gender equality everywhere and remove barriers to equality.

But in developing countries like Kenya, people face all sorts of risks that make them vulnerable to diseases, not just HIV. And the risk of sexually transmitted HIV is higher where women don't have rights to negotiate or determine their sexual or reproductive life. The Aids industry seems anxious to inform women about these rights but they don't seem to regard women's rights to safe healthcare as being important, or as having any relevance to their sexual or reproductive life. These issues only merit brief mention every now and again. I read or scan through hundreds of articles every week and rarely come across one that even mentions the non-sexual risks of HIV.

To repeat myself, gender inequality is repulsive and such inequalities are probably involved in transmission of all sorts of disease and exposure to many risk factors, such as lack of access to clean water and sanitation, adequate housing and a clean environment. But gender inequality itself does not transmit HIV. HIV is a virus transmitted from person to person, through sexual intercourse, by HIV mothers giving birth or breastfeeding or through unsafe medical or cosmetic procedures.

It may sound like hair splitting, but people will continue to have sex (I presume) even if gender inequalities are reduced, they will continue to have children and they will continue to avail of medical and cosmetic procedures. Ensuring that women have the right to choose the circumstances under which they do these things is all very well, but what sort of choices are women going to make when, firstly, they don't know anything about unsafe medical and cosmetic practices and secondly, they have no influence on how those practices are carried out or how to make them less risky?

The truth is that the Aids industry is very much in the dark about how HIV is transmitted in most countries. They know that medical and cosmetic transmission occurs but they have not investigated instances of these kinds of transmission. They have chosen to concentrate on sexual risk to the exclusion of all other risks. They have made a choice about the health and welfare of people, especially women (who are exposed to far more healthcare and cosmetic risks than men), that disempowers women in developing countries. By deciding what risks women need to avoid and ignoring others, the Aids industry is doing the opposite to what it says: it is beating the empowerment drum while silently spreading disempowerment.

Incidentally, the HIV 'gender imbalance' in Kenya is quite curious in many ways. North Eastern province has the worst Gender Development Index (GDI) but also the lowest HIV prevalence. This province also has the highest percentage of girls married by the age of 18. The province with the lowest percentage of girls married by age 18 and one of the best GDI figures, Nairobi, has the second highest HIV prevalence.

Looking at it another way, in Central and Eastern provinces there are four HIV positive women for every one HIV positive man. These two provinces have little in common, with Central having the best set of development indicators and Eastern having one of the worst. Central province has only half the HIV prevalence rate of the country as a whole but Eastern has only a third, in other words, very low HIV prevalence. According to the received Aids industry view, somehow, a small group of men manage to infect a very large group of women. What, exactly, is the Aids industry saying about the sexual behaviour of people in these provinces?

Compared to that, there are only two HIV positive women for every one HIV positive man in North Eastern and Rift Valley provinces. As you move to the provinces with 'more equal' HIV epidemics, where there are only 1.5 HIV positive women for every HIV positive man, you find that these three provinces all have relatively good GDI scores but they account for half of the HIV positive people in Kenya. The Aids industry may interpret this as showing that sexual behaviour in these provinces is not as risky as that in some other provinces. Yet this lower level of risk seems to give rise to much higher rates of HIV transmission.

The oddest ratio of all is found in Coast province, where there are only 1.3 HIV positive women for every one HIV positive man. This looks more like a truly sexually transmitted disease, where male and female prevalences are similar enough. But this is also the province where there is likely to be the highest rates of intravenous drug use (mostly men) and sex tourism (which doesn’t seem to result in large numbers of HIV positive tourists). Even men having sex with men is said to be high here but I don't think that is borne out by the evidence. But is this infection ratio really a reflection of sexual practices here being quite different from those in other provinces? It would be difficult to say without investigating, not just sexual practices, but also any other ways in which HIV could be transmitted.

HIV transmission patterns are very complex and vary a lot, even within a country like Kenya. Gender is, of course, relevant. But perhaps it's not relevant for the reasons the Aids industry wants us to believe. There is little to be gained by patronising campaigns that tell women how hard their lives are but that also ignore the very risks that could most easily be avoided. Gender inequalities don’t just relate to people’s sexual behaviour, they relate to people’s access to healthcare, education and other social goods. Gender inequalities also relate to the sorts of information that people have access to. The Aids industry currently ensures that women don’t have access to adequate information that would allow them to protect themselves and their children from HIV and other diseases.

Women can be empowered and stigma can be reduced at the same time by accepting that HIV is not just transmitted sexually. To work out what proportion of HIV is transmitted sexually and non-sexually, the Aids industry needs to stop obsessing with people's sex lives and further humiliating them. The industry needs to investigate the numerous women who are HIV positive when their partners are HIV negative and the numerous children who are HIV positive but who were probably not infected by their mothers. Simply telling people that being HIV positive is not their fault while making it clear that you think it probably is their fault is not going to help people to avoid HIV risks or to reduce stigma.

Bandying about words like 'gender', 'empowerment' and 'stigma' is not going to reduce HIV transmission as long as non-sexual HIV transmission is left out of the picture. At present, the strategy of the Aids industry simply disempowers people and increases stigma. Don't just pat people on the head and tell them it's not their fault, show them how HIV is being transmitted and how they can protect themselves and others.