Thursday, August 12, 2010

A Threat to the Behavioral Paradigm

An article entitled 'Could HIV be a matter of biology?' may surprise some people, who would think that all diseases must have some connection with biology. But there is a large group of people, comprising the bulk of the HIV industry, who think biology is of little relevance, perhaps of no relevance at all.

The article says "Africa's HIV epidemic may not be driven by behaviour alone according to a new study suggesting that Kenyan women are more biologically susceptible to the virus." This is not just the claim that women are more susceptible but that women in countries where there is a high disease burden are more susceptible than women in countries where disease burden is low.

The HIV industry, led by UNAIDS and big HIV donors, is quite explicit on the matter: most HIV transmission in African countries is through heterosexual behavior. Most of the industry's 'prevention' programs and resources are aimed at influencing sexual behavior. Little or none of their programs or resources are aimed at influencing the conditions in which people live, even though these may have a lot of impact on sexual behavior and on HIV transmission.

The hypothesis that HIV could be, at least partly, a matter of biology, is not particularly new. There are several researchers who have long objected to the 'behavioral paradigm', the view that massive HIV epidemics in some African countries are mainly a result of African sexual behavior. African sexual behavior, the paradigm says, is substantially different from the sexual behavior of people in other continents, where HIV transmission is mostly related to men having sex with men, intravenous drug use and perhaps commercial sex work.

But the hypothesis that those living in countries with high disease burdens are more susceptible to HIV, for example, endemic malaria, intestinal parasites and various forms of malnutrition, is not new. Eileen Stillwaggon, and possibly others, have been expounding such a hypothesis for many years. Indeed, the knowledge that HIV attacks the very cells that are produced in large quantities when people's immune systems are attacked should alert researchers to the possible role of co-infections in susceptibility to HIV.

Just when people are (biologically) least protected from HIV infection, they are most susceptible. So the authors of this study hope that their findings will 'revolutionize prevention efforts'. Let's hope so. Lecturing people about who to have sex with, how, when and where has not worked. There may be many reasons why this approach has not worked. But approaches to HIV prevention that do not assume the truth of the behavioral paradigm are long overdue.

It would be good if any Damascan convertion that may take place were not limited to a search for non-behavioral responses to HIV. After all, some effort to reduce levels of malaria, intestinal parasite infestation, malnutrition and many other conditions are also long overdue. They seem to have become isolated from funding, except to the extent that they may have something to do with HIV transmission. They are all in need of the sort of effort that has gone into reducing HIV transmission, but hopefully with better results.

It would also be encouraging if those holding the purse were to take note that health is not just a matter of disease or disease reduction. Malaria and parasites are intimately connected with environmental factors. Two of the top killers of infants and children, diarrhoea and respiratory infections, are similarly connected with the environments in which people are forced to live. It would be stupid beyond belief to treat all these diseases without also improving the conditions in which people live. Stupid beyond measure, but sadly, the approach favored by UNAIDS, the HIV industry and healthcare development as a whole up till now.

Towards the end of the article, the issue of stigma is raised. Because of widespread adherence to the behavioral paradigm, those infected by HIV and those thought to be at risk of being infected and of transmitting the disease, are associated with sex, illicit sex, specifically. If the HIV industry could be persuaded to accept that HIV is not just a matter of behavior, they might relax their adherence to the childishly naive paradigm. Instead of blaming people, while at the same time saying they don't blame them, they might come to realise that HIV positive people really are not to blame for becoming infected.

We should not expect the HIV industry to be influenced to any significant extent by scientific research; they have remained almost hermetically sealed from such influence so far. But those who have long opposed the behavioral paradigm and who advocate for genuine improvements in the conditions in which people live may soon be joined by other reasonable people. There would be little point in eradicating one virus and leaving people to die of other, more easily preventable and curable diseases. HIV is not just about sexual behavior and health is not just about disease.



Craig Cohen said...

I appreciate your comment on our recent work, and linking our work with Eileen Stillwaggon. As you know already, our work takes place in Nyanza Province, the region of Kenya hardest hit by the HIV epidemic. It is imperative that we broaden our concept of HIV prevention, and HIV care and treatment for that matter. You can find other links to our work at Regards,

Simon said...

Hi Craig, thank you for your comment. Until I read the article about Faces I wasn't aware that any substantial work was being done in that area. The only thing I'd worry about is that the work would be abandoned if things like schistosomiasis reduction were found to have little effect on HIV. I think intestinal parasites, water and sanitation are some of the most important areas of health and development and viewing HIV in isolation has tended to exclude these and other issues. So it's good to hear that work is being done to show HIV in its broader context.

As a matter of interest, does your research give any insight into why HIV prevalence in Nyanza is only high among the Luo and is low among the Kisii? I was wondering if the Kisii had a less intimate relationship with Lake Victoria, don't use it for commerce, don't fish there, etc? All the best with your work. Regards