Tuesday, August 17, 2010

Swaziland Takes Half a Step Towards Eradicating HIV

According to IRIN's PlusNews, Swaziland is to dump its ABC approach HIV prevention (Abstain, Be faithful and use a Condom). Swaziland has the highest prevalence of HIV in the world. The article states: "experts are still at a loss as to why Swazis have resisted all attempts to change the behaviours that put them at risk from the virus." But they needn't be puzzled. ABC hasn't worked anywhere. It's just that Swaziland is the first country to publicly admit it.

Don't be fooled by all the articles about Uganda working magic in the 1990s using ABC to reduce HIV prevalence. The approach didn't exist in Uganda in the 1990s and HIV prevalence was never even as high in Uganda as most of these articles say. Prevalence did reach very high levels in the country and they are low now, that's true. But many strategies were employed to reduce HIV transmission and the main reason why prevalence dropped so quickly in the 1990s is because death rates were very high. A similar pattern occurred in Kenya somewhat later, which took the Kenyan government by surprise as they hadn't even got around to admitting that there was a HIV epidemic in the country.

While recognizing that ABC is not working in Swaziland, Dr Derek von Wissell, director of the National Emergency Response Council on HIV/AIDS is still convinced that "behaviour is what has to change". He then turns his attention to men, pointing out that 70% of men are "free agents", to whom being faithful does not apply. This is supposed to explain why HIV prevalence is 38% among girls in the 20-24 age group?

There is something very unconvincing about this explanation. Unless the majority of sexually active women are having a lot of unprotected sex with a small number of men, we really don't have any idea where all these infections are coming from. In order to infect someone with HIV, a man needs to be HIV positive. In fact, he also needs to have sex with each woman quite a number of times, statistically. If Dr von Wissell is thinking straight, there is a small number of men who need to be identified and given some good advice, quickly. Never mind targeting sexually active women.

But I don't think the man is thinking straight. His thinking, like that of most thinking throughout the HIV industry, is skewed by the 'behavioral paradigm', the belief that almost all HIV is transmitted through heterosexual sex in African countries. To hold this belief, you need to think that, sexually, Africans are different from people from other continents. They have a lot more unsafe sex with far more partners than those in other continents. Also, the women are particularly prone to having unsafe sex, lots of it, with a certain group of highly sexually active, HIV positive men.

Of course, these beliefs are just prejudices, there is no evidence for them. On the contrary, there is plenty of evidence that some people in all countries have lots of sex, even unsafe sex. But most people don't. Yet, in some African countries, HIV prevalence is so high that almost every sexually active woman can be considered lucky to remain uninfected. Swaziland, in particular. If you stick fast to your prejudices, you might wonder who these evil men are, you might even wonder about why the majority of women take such stupid risks. But if your approach to reducing HIV transmission is so influenced by prejudice, you may not be bothered by any glaring irregularities.

The lessons that the HIV industry steadfastly refuse to learn are that, one, you can't just legislate for (or against) certain kinds of sexual behavior, despite decades of evidence of this from the population control brigade. And two, not all HIV is transmitted sexually. If von Wissell wants to "challenge conventional thinking" and to avoid slavishly following what went before, he would want to go a little further than uttering soundbites about needing to find new ways to prevent infections. He could start by looking at how HIV is being transmitted, how it is actually being transmitted, not how the HIV industry says (and really wants to believe) it is being transmitted.

Even allowing a very high probability of HIV transmission per sex act, you would have to believe that Swazi women have a lot of sex with a lot of different partners to explain current prevalence rates. Coupled with that, you would have to believe in that small bunch of HIV positive men, who get to have sex with far more than their fair share of women. In days gone by, all sorts of myths were dreamed up to explain pregnancies that shouldn't have occurred, such as seals appearing as men and then disappearing again. But we don't need to resort to such myths any more. It's time for the HIV industry to wake up. It's time to admit that non-sexual HIV transmission plays a part in hyperendemic countries such as Swaziland and to investigate modes of transmission properly.

ABC doesn't work; it has never worked; it will never work. Good sex education, as opposed to obscure platitudes and moral cant that is completely ungrounded in any reality, would be welcome. Children in African countries are in bad need of any kind of education; but general education is a prerequisite to sex education. Education about and access to condoms would also be helpful, in many ways. But no approach to HIV prevention that assumes the truth of the behavioral paradigm will eradicate HIV. Swaziland has made the first half step. Let's hope the HIV industry doesn't interfere this time.


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