Friday, October 29, 2010

HIV Institutions Need to be Frank About How Discordance Occurs

Some time back, a Ugandan woman who found out she was HIV positive shot dead her husband, who was HIV negative. This incident introduces an article about the urgent need to focus on HIV discordance, where one partner is positive and the other is negative. Sadly, the article doesn't shed any light on how discordance could occur.

There has been some research into discordance but much of it has gone no further than estimating numbers. Discordance occurs in about half of the couples where at least one partner is infected. And even among non-discordant couples where both partners are infected, there are quite a number where partners did not infect each other. This data is not collected very much, but it should be. How could it occur?

For a start, someone needs to be HIV positive to infect someone else through sexual intercourse. This may sound obvious, but I wonder if the woman who murdered her HIV negative partner knew. In Kenya, half of all married HIV positive women have a partner who is HIV negative. Far more women than men are infected with HIV and in Western Kenya there are more than five HIV positive women for every HIV positive man.

If you go along with the oft repeated orthodoxy, that most (some say 90%) HIV infection is sexually transmitted, you may wonder why women are so much more likely to be infected than men when plenty of data shows that men are far more likely to engage in 'unsafe' sex than women. Or you may simply dismiss this by saying that women are more 'susceptible' to infection through sexual intercourse.

This doesn't really explain differences between genders, especially in Western Kenya, where a large number of women must be having sex with a small number of HIV positive men. After all, as I've just said, 'unsafe' sexual behavior is higher among men. But you could, along with the orthodoxy, dismiss that with some other, equally unconvincing, argument.

Currently, guided by the orthodox wisdom, people who find out that they are HIV positive and their partner is not tend to be told that they must have had unsafe sex with someone other than their partner. There isn't really any other possibility, given the orthodox view. They could object that they have only ever had sex with their partner but the assumption is still made that they are probably mistaken or lying. Very often, that's the end of the partnership. Some people remain with their HIV positive partner, many don't.

It would be so much easier to admit that the figures suggest that a lot of HIV infections are probably not caused by 'unsafe' sex. Most women are not promiscuous. Nor are most men, despite all the spoken and written attestations to the sexual behavior of Africans, especially African men. Some men and some women are promiscuous, but that's true in every country in the world.

The assumption that high HIV rates can be put down to sexual behavior at levels that are not possible for human beings is institutional racism, because it informs most HIV policy and programing. The assumption is only made of Africans. In non-African countries, it is not assumped that most HIV transmission is sexual. There is more scope for actually believing what people say about their own sex lives.

It is also institutional sexism. The attested behavior of women, which makes up data collected by HIV institutions, is not used to inform policy and programing. On the contrary, the data is assumed to be lies because it does not accord with the current orthodoxy.

Bizarrely, the article concludes without mentioning non-sexual HIV transmission, the one mode of HIV transmission that might explain prevalence patterns but is rarely discussed by UNAIDS or any other HIV institutions. These institutions are tasked with preventing HIV transmission, yet they choose to ignore the possibility that appalling health services in countries like Kenya, Uganda and Tanzania could result in accidental transmission of HIV.

Another article goes through a similar process of describing some of the problems of discordance and also fails to say how such discordance could occur.

It is difficult to explain discordance without mentioning non-sexual transmission. But it is also unethical, for two reasons. Firstly, everyone has a right to know how they were infected, or how they may have been infected. Secondly, everyone has a right to know how to protect themselves and others from infection, whether it's sexual or non-sexual infection.

Africans are being denied their right to know how they were or may have been infected with HIV and they are being denied the knowledge they need to protect themselves. And it's not just adults that are at risk, infants and children are also at risk. Parents need to be aware of risks that their children face in order to mitigate those risks.

Where infants and children are found to be HIV positive, it vital to establish the source of their infection. It needs to be clear that they were not necessarily infected by their mother, who may not even be infected or may be infected with a different strain of the virus. This phenomenon has often been documented but it has yet to be investigated in African countries.

HIV discordance is a lot easier to explain when it is frankly accepted that not all HIV infection is a result of sexual intercourse. The many non-promiscuous people, virgins, infants, children and no longer sexually active people who find they are HIV positive have a right to know this. And we all have a right to know how HIV is transmitted and how to protect ourselves, especially in high prevalence countries with failing health systems.


No comments: