Tuesday, February 1, 2011

Sexual Behavior: Myth Supports the Assumption, Evidence Does Not

IRIN has a recent article entitled "Fidelity campaigns could take years to see results". This is not news. Campaigns advocating abstinence, limiting sex to one partner and using condoms have been around for years and it is well known that they take years to show any results. It is also well known that they don't have very much effect on HIV prevalence.

Despite this, much of the money spent on HIV prevention, a very small amount compared to that spent on treatment and care, is used for fidelity campaigns of one kind or another. They usually result people in being able to trot out the right answers to questions, which keeps the market researchers happy. And, in the end, these campaigns are a good way of spending lots of money.

Various institutions that have bought into these empty campaigns are very well funded and can afford good marketing. They are hardly going to produce reports showing that their campaigns were pretty pointless. Rather, they will put a gloss on everything so that they can continue to receive funding. That's often what the funders want, too.

Institutions such as PSI, that were set up to interfere in the sexual and reproductive health of people in developing countries, can be expected to spend their enormous budgets on their traditional interests of population control (or 'eugenics', as it used to be called). But they really don't need to react with such surprise when their campaigns continue to fail to make much impression on HIV transmission rates.

Whatever the claims of PSI and similar institutions, fidelity and other behavior change approaches to HIV prevention are constantly referred to as 'evidence-based', as if that vouched for their effectiveness. But the notion that "over 90% of adult HIV infections in sub-Saharan Africa are acquired through sexual contact" is an article of faith in the HIV industry, even though the dubious claim dates back almost 20 years.

An article published in BioMed Central, by Marshall Munjoma, et al, simply assumes the truth of this 'behavioral paradigm', assumes that Africans lead incredibly active sex lives, care little about their health, the health of their children or the health of their partners, and takes things from there. And yet, the article strongly suggests that not all HIV is transmitted sexually.

These researchers start by pointing out that HIV incidence, the yearly rate of new infections, peaked in the late 1980s and declined thereafter. They don't explain the initial spread of HIV, the peak in incidence, nor its subsequent decline. And they certainly don't relate these phenomena to sexual behavior.

Yet, if the sexual behavior theory of HIV transmission is true, the major changes in behavior must have begun in the 1980s. By the end of the 1990s, most people who were infected in the 80s would have died and those infected in the 90s would have continuted to die into the 2000s. Once incidence peaked and declined, little further behavior change is required to explain what happened since the late 1990s.

Not only do the researchers fail to explain the sexual behavior changes that must have begun in the 80s and continued through the 90s but they attribute the rapid declines in prevalence in the late 1990s and early 2000s to changes in sexual behavior! The decline in prevalence is due to high death rates. High death rates continue to reduce prevalence in Zimbabwe and new infections also continue, just at far lower rates than in the 1980s.

The researchers note that new infections among women attending ante-natal clinics women are very high over a 6 year period in the 2000s. But many of these infections probably occurred during the women's third trimester or not long after giving birth. Why is it assumed that they must have been infected sexually? Some of these women were probably not having sex very much at these times. Were their partners tested?

The study also found that half those infected were 20 years or younger and nearly 100% of married women reported having sex with their spouses only. The researchers seem content to ignore the possibility of non-sexual transmission in at least some of the people they spent so long tracking. What is the point of research that ignores such vital clues as to how HIV may be transmitted?

To tie in with the IRIN article and the blind faith in behavior change interventions, the authors conclude that the decline in prevalence is due to behavior change, even though 90% of the study participants, both those who seroconverted and those who didn't, do not believe that abstinence protects against HIV. If people don't believe abstinence will protect them, why would they abstain?


1 comment:

Simon said...

The following article shows that these late term infections, or even infections that may have occurred just after delivery, are giving rise to the majority of mother to child infections:


[Mother to child transmission of HIV among Zimbabwean women who seroconverted postnatally: prospective cohort study, by Humphrey, Marinda, Mutasa, etc.]

Therefore, reducing the chances of non-sexual transmission is far more likely to be of benefit than targeting sexual transmission alone.