Wednesday, November 17, 2010

UNAIDS' Secret Weapon: Bait-and-Switch

On first hearing about self-testing HIV kits you might think that it's a brilliant idea. The result would be that more people know their status, their status information would be up to date and it could be kept up to date. Also, people might find out their status far earlier than otherwise, which would hopefully mean they are less likely to transmit the infection.

But then it might strike you that those who know their status need not tell anyone. They would be especially unlikely to tell anyone if they lived in a country where there is a law against having sex without revealing your HIV status, transmitting HIV despite knowing your status, etc. People might even be reluctant to reveal their status in countries where HIV is deeply stigmatized, which is most countries, especially in Africa.

Stigma is especially deep in Africa because the HIV industry, UNAIDS and others, insist that HIV is almost always sexually transmitted. Speculation about what people would or wouldn't do if self-testing kits were available are all influenced by the assumption that transmission is almost always sexual.

Therefore, people may test when they suspect they were infected sexually, but they may not do so if they have no reason to suspect this. If they are infected through medical treatment, or some other non-sexual mode, they are unlikely to think of getting tested.

However, if person A tells person B that person A has just tested positive, person B is very likely to assume that person A was infected sexually. If person B is HIV negative, and married to person A, they will then accuse person A of infidelity. If person B is positive, they will accuse person A of infecting them.

Whether there will ever be any reliable way of telling which party was infected first suddenly becomes a lot more interesting. That's if one party doesn't beat up the other party, drive them out of the family home or even kill them.

The behavioral paradigm, the assumption that almost all HIV transmission in African countries is sexual, is not supported by evidence. On the contrary, it is controverted by a large body of evidence. But it is so widely held that HIV is almost universally associated with something illicit, drugs and men having sex with men in non-African countries, heterosexual sex in African countries.

Before a self-test kit for HIV becomes widely available, shouldn't we deal with the problem of the behavioral paradigm? Unless we deal with this assumption, stigma will not just disappear of its own accord. Simply repeating a mantra about non-stigmatization will not make it disappear.

These questions are not raised because of any objection to technical solutions, where those technical innovations really are solutions and where they are appropriate. But HIV testing has always been controversial. The HIV industry has stoked this controversy, it's not completely clear why, and as a result, HIV testing is 'opt-in' rather than 'opt-out', unlike other medical tests.

If finding out people's HIV status is carried out in order to treat them and prevent further transmission, self-test kits may be very useful. But HIV has been characterized as a threat and a punishment for some kind of imagined transgression by various political and religious interests; the claim that the test would be purely diagnostic does not stand up to scrutiny. Many people are far more worried about being stigmatized than they are about knowing their status, to the extent that many don't wish to know their status.

The worry is mainly about HIV in African countries because the behavioral paradigm is only believed to hold true there. Despite the claims of UNAIDS and others, HIV is not only transmitted sexually, it may not even be mainly transmitted sexually. But as long as the orthodoxy is maintained, the resulting stigma will ensure that wider HIV testing will not address the problem of understanding what is driving the epidemic.

There is little justification for wider levels of HIV testing if no effort is made to find out how people were infected (which includes finding out when they were infected as accurately as possible). Making self-test kits widely available may even do a lot of damage if current assumptions about African sexuality are not re-examined.

The most absurd thing about purely technical solutions is that they don't have any impact on sexual behavior, the very behavior which has for so long been blamed for spreading HIV. Absurd because of the incorrect association of HIV infection with illicit sex. But also because this has created the stigma which resulted in almost all programs to reduce HIV transmission being total failures.

In the end, all this stigma could have been avoided by establishing exactly how HIV is transmitted. Now it looks as if these technical 'solutions', microbicides, pre-exposure prophylaxis, test and treat policies, etc, will also have to fail before anything is done that is likely to reduce HIV transmission. UNAIDS' latest HIV strategy appears to be good old bait-and-switch, widely considered to be fraudulent in the broader commercial world.

[There is a brief note about HIV self-testing and it's relationship with pre-exposure prophylaxis on my other blog.]


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