Sunday, August 8, 2010

In the Absence of Evidence, Use a Shoehorn

According to an article entitled ‘Moulding Men You Can Count On’, “Research shows that men are the main drivers of the HIV epidemic. Men transmit HIV to women, who, in turn, can infect their babies if they fall pregnant.” But this is not something demonstrated by research. It is an interpretation of research that often purports to be well supported. While some men transmit HIV to women, the majority of HIV positive people in African countries are women. There is no evidence that there is a relatively small group of men who sleep with a relatively large group of women.

Of course, there are some men who sleep with a lot of women and some women who sleep with a lot of men. But that’s also the case in non-African countries, where HIV rates are very low. And women also transmit HIV to men. And men transmit HIV to men. The majority of new HIV infections in a country like Uganda are among monogamous and often married people. Also, many HIV positive people have a HIV negative partner.

Various shoehorning arguments have been advanced about men who have sex with men (MSM) also having sex with women. But the percentage of MSM in African countries is unlikely to be much larger than in non-African countries. And women are said to be more vulnerable for structural reasons, such as their relative inequality in society and in marriage. This may be true, but again, most new infections are in monogamous couples and the male partner is often not infected. Women do not become infected by having sex with uninfected men.

The shoehorning becomes more obtuse, racist and sexist. But in the end, the sort of rapid transmission of a virus that is difficult to transmit sexually, found in some African countries, is not explained unless unbelievable levels of unsafe sexual practices are hypothesized. Such levels are not borne out by evidence, but they seem to be believed by the HIV industry. As a result, sexual behaviour in African countries is targeted by almost all HIV ‘prevention’ programs. This has not worked, but the industry is wealthy and powerful enough to continue its deceit. And most academics in the field seem happy to go along with that.

So, not only would this assumed small group of men, who drive HIV epidemics, have to have sex with a lot of women to explain the number of women who are HIV positive, those men must also have had sex with an even greater number of women who were not infected. After all, the probability of infecting someone is lower than 1, thankfully. This is not to deny that there are many social problems, some of which may increase the transmission of HIV. All social problems should be targeted. But let’s not pretend that some of them are driving HIV epidemics when this is clearly not true.

The article correctly points out that no one, male or female, can assume that their partner’s status is the same as their own. But similar remarks apply to children. The mother’s status is not a reliable indicator of their children’s status. Nor is the children’s status a reliable indicator of their mother’s. There have been enough instances identified of discordant couples (where one member is HIV positive and the other is HIV negative). And there have been enough instances of infants and children being found to be HIV positive when their mothers are not.

There’s no great mystery about this. People can be infected with HIV through sexual intercourse with someone who is HIV positive; infants can be infected by their mother. But people can also be infected by unsafe medical, cosmetic or certain traditional rituals. People of all ages can undergo any of these, perhaps all of them. And, while sexual transmission of HIV is not very efficient, transmission through contaminated blood or through other bodily fluids can be very efficient.

The article is about targeting men, because many HIV programs don’t do this, or don’t do it very well. It is very worthwhile targeting men, but it would be far better if they were being supplied with correct and complete information. Men may react a lot better if they are not being accused or implicated in ‘driving HIV epidemics’. Some men engage in unsafe sexual behaviour, as do some women, all over the world. But these same people are entitled to know about other unsafe practices in order to be able to avoid both infection and transmission of HIV and other blood borne diseases. Equally, those who do not engage in unsafe sexual behaviour are entitled to know how to protect themselves, if they are HIV negative. And they are entitled to know how they may have become infected if they are HIV positive.

This program targeting men, and any other program that aims to reduce HIV transmission, needs to make it clear how HIV can be transmitted. People need to know how to protect themselves, completely. There is no point in telling them to reduce their number of sexual partners, have sex less, be faithful to their partner, use condoms and take any other precautions, while neglecting to tell them about non-sexual modes of transmission. Even people whose sexual behaviour is deemed to be risky also face non-sexual risks. Men who have sex with men and commercial sex workers, often thought to be at highest risk of sexual transmission of HIV, also risk being infected and infecting others non-sexually.

There is a lot of talk about ‘knowing your status’ but that’s not enough on its own. You also need to know how you became infected. Especially if your partner is not infected, because then you might have some explaining to do. The assumption that most HIV is transmitted sexually in African countries is one of the main sources of stigma. Men who are being targeted for HIV awareness training also need to know that being HIV positive does not mean you have been engaging in unsafe sex. Then, if their partner is found to be HIV positive, it is less likely that they will react violently. If people don’t know about non-sexual risks and hear about nothing but sexual risks, it’s hard to change the message later. It’s not surprising that people think all sorts of terrible things about a partner who has just been diagnosed as HIV positive when they themselves are HIV negative.

People need and are entitled to correct information, but also, complete information. Allowing them to assume that they are safe from HIV by taking all the recommended measures to avoid sexual transmission does not protect them from non-sexual modes of transmission. Failing to inform people about non-sexual risks is, effectively, luring them into a false sense of security. People will not take precautions against risks they don’t know about. Involving men is vital and the program in question must be applauded for that, but it must include information about non-sexual HIV transmission for two main reasons; to reduce transmission and to reduce stigma. Otherwise the program is as pointless as most of the others approved of by UNAIDS and the HIV industry.


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