Tuesday, December 7, 2010

The Dogmatic Sexualization of HIV

The main thrust of this blog has been to challenge the 'behavioral paradigm', the view that HIV is almost entirely transmitted by sexual behavior in African countries (The figure '90%' is often bandied about but there is no evidence for it). Therefore, any articles that either support or challenge the behavioral paradigm are of particular interest. As for the belief that the paradigm only holds for African countries, it is difficult to see that as anything other than racism.

A group of people led by Munyaradzi Mapingure have published a paper suggesting that the behavioral paradigm may need to be reconsidered in the light of their findings. They discuss sexual behavior data for Zimbabwe and Tanzania which clearly does not correlate with HIV prevalence. Zimbabwe has some of the highest HIV rates in the world while Tanzania has relatively low HIV prevalence. Yet levels of 'unsafe' sexual behavior are far higher in Tanzania than they are in Zimbabwe.

This lack of correlation between HIV and sexual behavior considered to be unsafe is not rare. There have been many instances of it over the years, in many countries. But few researchers have used the lack of correlation to question the behavioral paradigm. In 2003, a number of researchers published papers suggesting that HIV may not be as closely connected with sexual behavior as HIV prevention programming would lead one to believe. The HIV orthodoxy has yet to refute the body of evidence.

Mapingure and colleagues find that "women in Tanzania reported more risky sexual behaviour than women in Zimbabwe, which is opposite to what is reflected in the HIV prevalence. Prevalence of risky sexual behaviour characteristics, such as having had a casual sexual partner in the previous 12 months, having had more than one lifetime sexual partner, early sexual debut, being in a polygamous relationship and having siblings by different fathers, were all higher for Tanzania. Alcohol consumption, which increases the tendency to engage in risky sexual behaviour, was also more common in Tanzania than in Zimbabwe."

The authors conclude :"Clearly, sexual behaviour only cannot explain the observed differences in HIV prevalence between the two countries" and ask how this "paradox" can be explained. But there is no paradox. They even discuss other papers which make it quite clear that the behavioral paradigm was never in the least bit tenable. Every few years, detailed data on sexual and other behaviors in African countries are found not to correlate with HIV prevalence (check the Demographic and Health Surveys by country).

This paper suggests a few reasons why their results appear paradoxical but the authors seriously consider the possibility that non-sexual HIV transmission might be playing a part in Zimbabwe (which doesn't rule out the possibility of non-sexual transmission playing a part in Tanzania, also). They qualify this possibility by suggesting that such transmission would have been more likely in the 1980s, before the dangers of unsafe medical procedures were widely recognized.

HIV epidemics such as the ones in Zimbabwe, Swaziland, South Africa and others suggest that rates of transmission were probably still high well into the 1990s and perhaps the 2000s. The dangers of nosocomial transmission of HIV, transmission from unsafe medical procedures, may have been recognized a long time ago. But there is little evidence that this form of transmission was successfully eradicated in any sub-Saharan African country. It is more likely that relatively low HIV prevalence in Tanzania is a result of very low access to health services.

Conversely, higher access to health services in Zimbabwe could go a long way towards explaining the incredibly high rates of transmission seen there. And the rates really are incredible. Given the low transmission probability for sexual transmission of HIV per sex-act, Zimbabweans would need to do little else but have sex to explain national prevalence, which reached almost 30% at one time.

In an article commenting on the above paper, Mapingure says "early in the epidemic, syringes weren’t sterilized properly". WHO has recently accepted that as much as 14% of injections are unsafe. Disposable syringes are being reused, either because they are in short supply or because supplies are not reaching their target. Also, health workers are probably not fully trained in making their practices absolutely safe. Published Health Service Provision Assessments make it clear that many Kenyan and Tanzanian health facilities do not have the capacity to eliminate nosocomial infections.

He concludes “Most HIV prevention programmes are failing because they focus on sexual behaviour. We need to look at the whole sexualization of HIV.” This is not just a challenge to the behavioral paradigm. It is a challenge, a long overdue challenge, to the whole of the HIV orthodoxy. UNAIDS and those tasked with reducing the spread of HIV have failed miserably. To this day, they refuse to accept the possibility that non-sexual transmission of HIV is the only thing that can explain the huge differences in prevalence found between and within different countries.


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