Friday, November 12, 2010

Sterilizations of HIV+ Women May Not Be the Worst Thing Health Services Do

When HIV and AIDS started to hit the headlines in the 1980s, there was a lot of scaremongering that did little to help assess the extent of the pandemic and figure out what could be done to prevent its spread. Sadly, this has not changed completely. Headlines are often about revenge, punishment, criminalization and the like.

Even some of the so called prevention strategies sound a bit like a kind of punishment, aiming to place severe limits on sexual and other sorts of behavior. It's hard not to see mass circumcision campaigns, ardently championed by the HIV movers and shakers despite little evidence of their potential effectiveness, as being a kind of punishment.

Such attitudes towards a disease do little to stem its spread, as we have seen in the 25 or more years that have passed since HIV became universally acknowledged. Beatings, persecutions, murders and other travesties have occurred, and continue to occur. But states seem more anxious to create laws that risk punishing those who are HIV positive or who are at risk of being infected, rather than protecting them.

Pregnant women in many countries seem to be at exceptionally high risk and astonishing figures of rates among pregnant women in South Africa were the subject of yesterday's blog post. But I asked, and I ask again, how can we go on believing that HIV is almost always transmitted sexually? We appear to be accusing women of knowingly taking risks while pregnant, without regard for their own health, that of their babies and that of other family members.

Some countries, Namibia being only one, have taken the extreme step of forced and coerced sterilization of HIV positive women. This should not be tolerated and women should be protected from such treatment by law. Of course, it's far easier to identify women as the 'culprit'. Being pregnant means they are evidently sexually active. They are in need of medical care, often vital medical care. And they are unlikely to be able to escape if anyone, or any body, decides to 'punish' them for being infected with HIV.

The authors of the above article, Jennifer Gatsi Mallet and Aziza Ahmed, go on "Life is not that straightforward when it comes to reproduction, not for an HIV positive women, and not for many other women.  Women frequently face a lack of access to contraceptives, inability to access safe abortion services, lack of education and information about preventing pregnancy.  Further, social factors including sexual violence, pressure to bear children, and a woman’s fears around child survival can influence when and how a woman becomes pregnant."

These things may all be true and if so, they all need to be remedied. So, are we then going to blame men? Of course, many men may have views that are inimical to preventing HIV transmission; perhaps the actions of many even cause a good deal of HIV transmission. And if men are violent or if their behavior causes harm, this certainly needs to be addressed. But that's true regardless of whether it has anything to do with HIV transmission.

Rather than looking at individual sexual and social behavior, which may be very much in need of scrutiny, it would be a good idea to look at the weighty but relatively unexamined body of data suggesting that people face serious risks of HIV infection through unsafe medical procedures. Pregnant women are especially at risk because they can receive numerous injections, often unnecessary, usually in health facilities where there is a concentration of HIV positive people and far too few overworked, undertrained, badly supplied health professionals.

The ultimate danger of this blinkered view of HIV transmission is not that innocent people will continue to be punished, though that is bad enough. The worst aspect of clinging to the behavioral paradigm, the assumption that almost all HIV is transmitted sexually, is that the virus will be allowed to continue to spread.

If people are being infected in health facilities, HIV 'prevention' work could be doing more to spread the virus than any other mode of transmission. We don't know if that's true yet; but it's just the sort of thing that we should know after almost three decades of HIV.


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