Monday, February 7, 2011

Global HIV Policy: Blame, Stigma and Finger-Wagging

With HIV/AIDS, it's always been easier to blame individuals for their reckless behavior than to examine the conditions people live in and figure out which of these conditions may explain why HIV prevalence varies from a fraction of a percent in some populations to 25% in others and even 40% in some demographic groups.

The idea that whole populations have hundreds of times less sexual experience than other groups is not credible, especially where birth rates may be very high in some countries with low HIV prevalence. India is an example of a country with high birth rates and HIV prevalence lower than 1%. There is no reason to think that Indians in general shy away from sex.

While prevalence is a lot lower than 1% in most demographic groups in India, it is 30-40% in some demographic groups in several African countries. In fact, prevalence among Indian sex workers is only 7%, which is about the same prevalence as found in Kenya, Tanzania and Uganda. Yet sex workers in India face terrible risks, far worse than most sexually active people in African countries.

That HIV prevalence is not correlated with individual sexual behavior is nothing new. But some researchers have shown that HIV prevalence is correlated with malaria prevalence, something that is clearly not just a matter of individual behavior. Whether it makes HIV positive people more likely to transmit the virus, HIV negative people more likely to be infected or both is not clear. I have only seen the abstract. But it is one more nail in the coffin for the 'individual responsibility' theory of HIV prevention.

People in high malaria prevalence areas are more than twice as likely to be HIV positive as those in low prevalence areas. Some people have been calling for research into cofactors in HIV transmission for years but such research is still relatively uncommon. But similar research was recently carried out on schistosomiasis (bilharzia) as a co-factor and it was found to be associated with higher HIV prevalence. Tuberculosis also makes people more likely to transmit and to be infected with HIV.

Further loosening the connection between HIV and individual sexual behavior, it has also been shown that "a number of biological factors are critical in determining whether an unprotected sexual exposure to HIV results in productive infection". Mentioned are "viral factors, host genetics, and the impact of co-infections and host immunology" but again, I only have access to the abstract.

These researchers even have the effrontery to claim that "HIV sexual transmission is very inefficient". That's true, but it's not something that the sex obsessed HIV industry likes to dwell on. Global HIV prevention policies are based on blame, stigma, finger-pointing and finger-wagging, not research. But these upstarts go on to mention destigmatizing the issue, leading to new and more effective strategies for prevention. Whatever next?

Another batch of researchers conclude that because new HIV infections among discordant couples (where only one partner is infected) are twice as likely to occur among those trying to have a baby, this must be a result of higher levels of 'risky' sexual behavior. Having sex with your partner is not risky, or shouldn't be. But having a baby seems to be, especially for the female partner. Perhaps the researchers would like to assess the non-sexual risks that pregnant women face, such as unsafe health care.

The researchers may well be right and their research is certainly very interesting. But any research into HIV transmission among discordant couples, especially where pregnancy is involved, is incomplete without some clarification about how the women are being infected. Sure, they must be having sex if they are trying to have children, but this does not mean that transmission is always sexual.

The 'concurrency' card is still frequently played by those in the know (about how to receive copious amounts of funding) but it is still unsupported by clear evidence that it is common or that it really does explain high rates of HIV transmission. This research from Kenya pours cold water on the concurrency theory, finding that only 3.5% of females and 4% of males were engaged in concurrent partnerships in the previous six months.

The authors claim their findings suggest that: "concurrency expands individuals' sexual networks and bridges additional networks involving partners' other sexual partners". Perhaps, but with such low rates of concurrence, it's unlikely to do so to any great extent.

We need credible explanations for high rates of HIV transmission and viable prevention interventions, not the institutional racism and sexism that we have come to expect from UNAIDS and their ilk. UNAIDS have spent long enough showing that they are not capable of acting on research, especially research that exposes their prejudice for what it is. It's time for them to stand aside and let an unbiased institution take over.


No comments: