Monday, June 21, 2010

Institutional Sexism and HIV Transmission

There was a time when HIV was thought to affect men far more than women. That may be partly because it was first recognized in rich countries, where people infected were usually male and had sex with men. But it was soon accepted by the health care profession that both men and women could be infected, sexually and non-sexually. In developing countries, the number of women infected soon outnumbered the men. In Kenya, the ratio of HIV positive females went from 1:2.7 in 1986 to 2:1 in 2006 and it's probably about the same now, in 2010.

That makes HIV much more of a woman's disease than many others, even sexually transmitted diseases. The orthodoxy of UNAIDS, the WHO, CDC and others is that women are more susceptible, for various reasons, than men. But these institutions have been trying for years to say what it is that makes women more likely to be infected with HIV in developing countries than women in rich countries. They have come up with a lot of theories about African sexual behaviour, many of which are not borne out by the evidence. These 'theories' are mere prejudices in the absence of evidence, but they have been used to influence most of the HIV prevention activities carried out in high prevalence countries.

It's no wonder that most of these high prevalence countries have only seen small drops in HIV transmission. If there is no evidence for very high rates of unsafe sexual behaviour in high prevalence countries, and plenty of evidence for higher rates of unsafe sexual behaviour in low prevalence countries, the behavioural paradigm, the belief that most HIV transmission is due to high levels of unsafe heterosexual behaviour, is clearly faulty.

The behavioural paradigm was not so evident in the 1980s or even in the early 1990s. It arrived later, probably on the back of large amounts of donor funding from countries who chose, for political or religious reasons of some kind, to see HIV transmission as a moral issue. They chose to see high HIV prevalence as a sign that people in some countries were the victims of immoral behaviour and they switched their attention from non-sexual transmission modes to sexual modes.

The issue of institutional racism on the part of these institutions, UNAIDS, the WHO, CDC and others, has been raised on this blog before. The belief that Africans have higher levels of unsafe sex than non-Africans, when all the evidence says this is not so, lays the charge of institutional racism on their doorsteps. Never mind their posturing about wanting to reduce stigma or improve the lot of women.

But these institutions are also guilty of institutional sexism. Far from reducing stigma, the orthodoxy that says that HIV is mainly transmitted by heterosexual sex in developing countries stigmatizes women more than it stigmatizes men. How are HIV positive women supposed to see themselves in the light of this kind of orthodoxy? What options do they have to defend themselves from the implication that they are promiscuous? And how do they explain their positive HIV status to their husbands when they find that they are infected when their husband is not?

The orthodox view, the racist and sexist orthodox view, says that the majority of people infected, including the 53% of married HIV positive women, were infected by having unsafe sex of some kind. Some HIV positive women with HIV positive husbands are not even infected by their husbands because they are infected with a different genetic strain of the virus. All these women and men are tarred with the same brush, stigmatized by the very institutions that use public money, ostensibly, to reduce stigma, to reduce HIV transmission, to find out why HIV is being transmitted at such high rates in some countries and not in others.

We can offer HIV positive people in developing countries some hope of not being stigmatized. But only if we accept that the behavioural paradigm is wrong, that we don't yet know why people are being infected in such huge numbers. We can offer then a thorough investigation of the non-sexual modes of transmission, because this is clearly relevant. We just don't know the significance of non-sexual transmission yet and that is because we, or at least UNAIDS, the WHO and CDC, have steadfastly refused to investigate properly why HIV transmission is still so high in some countries. We behave like people who don't know anything about HIV transmission. But, in reality, we know the behavioural paradigm is a piece of racist and sexist nonsense.

Are we going to continue to allow people to become infected with a chronic and life threatening illness, even though we know that our policies are based on prejudice rather than on scientific knowledge? How do we face off the charges of institutional racism and sexism that we are so clearly guilty of? Or do we need to go through a process of truth and reconciliation, where the movers and shakers of the HIV industry are allowed to admit their abject failure and promise to eradicate racism and sexism from their institutions? This is not a time for professional, political or religious pride: until we admit we were wrong, we will continue to allow people to suffer and die.


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