Saturday, June 26, 2010

Promoting HIV Transmission

A recent survey in Chad has shown that a third of sex workers think that mosquito bites or sharing a meal can spread Aids. National HIV prevalence in Chad is 3.3%, only half the prevalence in countries like Kenya, Uganda and Tanzania. But among sex workers in Chad, HIV prevalence is 20%. In Mombasa, it is estimated to be about 31%. Yet in Mombasa, and throughout Kenya, the vast majority of people, male and female, know the right answer to the questions they are regularly asked about Aids and how to protect themselves.

Many years of data on HIV prevalence, HIV knowledge and HIV behaviour show that these three are not very closely connected. People may know all the HIV industry want them to know about HIV but their behaviour is relatively uninfluenced by their knowledge. More to the point, their sexual behaviour is not very closely connected with HIV prevalence. Those who do all the things the HIV industry would like them to do often have higher HIV prevalence than those whose levels of unsafe behaviour would be deemed very high by the industry.

Indeed, sex workers in Kenya have been targeted for a long time. But the shockingly high prevalence found among sex workers in the 1980s, which peaked at 81% in 1986, fell continuously thereafter, falling below 50% in 1997 and remaining below this level. The amazing thing is that behaviour change didn't occur till a long time later. HIV and other sexually transmitted infections (STI) fell even though people didn't change their behaviour significantly. It simply became less likely that people in this group, said to be at high risk of becoming infected, would become infected with HIV or other STIs.

I write 'said to be at high risk' because it is only in some countries that sex workers are at much higher risk of being infected with HIV than other groups. In other countries, sex workers are only really at risk of becoming infected with HIV if they are also intravenous drug users (IDU), which only some sex workers in African cities are. But this kind of data seems to suggest that HIV appears to be a sexually transmitted infection in African countries whereas it is mainly transmitted among men who have sex with men and IDUs in rich countries.

This is not to suggest that HIV is not sexually transmitted, just to remind people that it is not entirely sexually transmitted. But there is a surprising lack of clarity about how much HIV is transmitted sexually and how much non-sexually, especially in African countries with high HIV prevalence. It is clear that HIV can be and is transmitted by unsafe medical and cosmetic practices but it is not clear what percentage of HIV transmission is caused by such practices. The only thing that is clear is that the HIV industry doesn't want to admit that non-sexual HIV transmission is something to worry about in African countries.

Note, they are not saying that no one should worry. Those in the industry worry about their own employees and the risks they face when they visit developing countries. They warn their own employees not to visit clinics unless they are approved, because the industry has its own well funded clinics. They just don't worry about the fact that people who have to live in these countries have no option but to use whatever clinics are available. The even deny that there is a significant risk from medical treatment in these countries while, at the same time, warning their own employees about this risk!

So what is the HIV industry going to teach people, especially sex workers, in Chad? If they approach the problem in the same way that they did in Kenya, prevalence is unlikely to drop. It reached a peak of about 10% in Kenya in the late 1990s and even higher in Uganda some time earlier. But over a decade of 'HIV prevention' later, both countries have prevalence of over 6%. That's nothing to boast about. Will people in Chad be told the truth, rather than a little bit of the truth?

The truth is that people there are at risk of being infected with HIV by medical and cosmetic procedures. How high a risk is not really clear, it depends on how good the hospitals are and how many people have easy access to them. If there are few hospitals and few people go to them, they are probably less likely to be infected with HIV, though they could be more likely to suffer from and die from numerous other preventable and curable conditions. But people need to be warned that sexual behaviour is not the only risk.

I was in Nairobi a few days ago and I talked to several sex workers and, in common with many other people I have talked to in East Africa, they have heard a lot about sexual transmission of HIV. They have heard a little about the risk from intravenous drug use and only brief and infrequent remarks about risks from contaminated blood, such as during blood transfusions. But they are not told that they and their children could be at risk when they go to a clinic or to the hairdresser. Sex workers, especially, go to clinics a lot. They usually go to clinics that specifically target sex workers, where the risk of being infected with an STI would be higher than in clinics not targeting sex workers.

If people in Chad and other African countries are only told how to protect themselves from sexually transmitted HIV, they will not be very well protected. They also need to be told about non-sexual risks, unsafe medical and cosmetic practices. If they don't know about these risks they will not what measures to take to reduce the risks they and their families face. It would also be unsurprising if they continue to believe that they are at risk from mosquito bites and from sharing food.

As long as the HIV industry continues to insist that HIV is primarily transmitted by sexual behaviour in African countries and that other risks are not significant, a lot of preventable HIV infection will continue to occur. If medical facilities are risky for UN employees then they are also risky for Africans. It's hard to believe that the UN can have one story for Africans and another for their employees, but that seems to be the case at the moment.


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