Sunday, February 27, 2011

Paid to Fail: the Politics of HIV Research

I recently commented on a much hyped but relatively vacuous paper by Halperin, Mugurungi, Hallett, Muchini, Campbell, Magure, Benedikt and Gregson, entitled 'A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?'

But there was one item in the paper I didn't comment on that has stuck in my mind since. They write: "Many men in focus groups and interviews reported that having less disposable income has increasingly led to reduced ability to purchase sex or maintain multiple sexual relationships".

The sentence sounds reasonable enough if you accept the overall conclusion of the paper, that changes in sexual behavior driven by fear of HIV infection resulted in massive reductions in HIV transmission. But the data used by the paper only shows minor changes in sexual behavior. In truth, correlations between sexual behavior and HIV transmission are as unconvincing as they always have been, in Zimbabwe and elsewhere.

But even thinking about this sentence from an economic point of view and the little we know about commercial sex, does having less disposable income necessarily result in a reduced likelihood of purchasing sex? I think the real worry when money becomes scarce is that those who depend on providing sexual services for money have to settle for less money or provide more and/or riskier services.

Of course, such hypotheses need to be tested and many HIV researchers are reluctant to carry out rigorous research into sexual behavior. If sex turned out to be less relevant to HIV it's likely that funding would dry up. And if HIV prevention turned out to be a matter of providing decent health care, those currently selling drugs would also quickly lose interest.

There must be a lot of money in providing safe health care but it doesn't seem to attract the donors. But then, it's important to sell HIV drugs to developing countries because that's where the bulk of the market is. The same can't be said for other health care goods and services; not yet, anyhow.

Another problem with the idea that commercial sex becomes less common when money is scarce is that you'd think the trend for wealthier people to be infected in greater numbers than poorer people would reverse. This trend has reversed in some countries, but not noticeably as a result of economic changes.

The authors of the paper in question put a lot of credence in focus group discussions and that seems unwise. But it's their analysis of those findings that seem most disingenuous. The analysis appears to be independent of the data on sexual behavior, probably because the data is the same in high prevalence countries as it is in low prevalence countries. It's almost as if they are saying "here's the data, it contradicts our conclusions but everyone knows our conclusions are true anyway".

Because this paper doesn't even give a convincing pretense of having any substance, I'm still wondering what is behind it. The authors are very well established so the only reason I can think of that they would put their names to such rubbish is that they know no one really cares how they come to their conclusion as long as they come to the approved conclusion. But it seems like an expensive and circuitous way of failing to reduce HIV transmission.


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