You Can't Reduce Stigma By Replacing One Lie With Another

I have just spent the last couple of weeks in Ireland and the UK visiting relatives and friends. I'm always struck by how distorted a picture of HIV people there have. Most people in Western countries have an education beyond anything that most Africans will ever receive. But what the public get to hear about massive industrial interests is as skewed there as it is here in Africa.

There are different distortions involved, though. Low prevalence, Western countries are usually said to have 'concentrated' epidemics; most of those infected belong to subgroups in the population, such as men who have sex with men (MSM) and injection drug users (IDU). Because the majority of people in these groups happen to be men, far more men than women are infected.

High prevalence epidemics in African (and a few other) countries are called 'generalized', because the majority of people infected do not belong to any specific 'risk groups'. In fact, in generalized epidemics, the majority of people are heterosexual and more women, often far more women, are infected.

There are two other ways of categorizing HIV epidemics. There are also those referred to as low, though still generalized, and those referred to as hyperendemic. But in reality these are just a matter of degree. The most significant difference between epidemics is between those where the main risk factor is said to be penile-vaginal sex and those where there are clearly other risk factors.

That makes it sound as if there are really two different viruses. People are often rightly puzzled about how a virus that is difficult to transmit via penile-vaginal sex is almost always transmitted in that way in certain, high (and even some medium and low) prevalence countries. UNAIDS deals with that puzzlement by building up a picture of a highly aggressive and totally unrealistic level of sexual behavior that is said only to exist in Africa.

And many are happy to accept that Africans have extraordinary amounts of sex with eye-watering numbers of partners, and probably even that they do all sorts of things that non-Africans wouldn't do.

Such a racist and sexist view of HIV transmission is endorsed by academic, religious and political institutions and a whole industry has built up around it. Media participation in the distortion has also been vital and media organizations have been falling over themselves to bellow out the latest 'discovery' in the field.

There are those who ask questions about certain aspects of the orthodox account of HIV transmission. If they are laypeople, they are usually ignored or, at best, patted on the head and told the 'facts of life' about HIV. If they are professionals they are branded as denialists and publicly humiliated.

I happened to meet a journalist last week who has questioned the orthodox view, at least as it relates to one small Western country. He has worked with injection drug users, men who have sex with men and commercial sex workers. He has long been aware that the risk of being infected with HIV is small unless you belong to one of these groups. He is even aware that the risk to commercial sex workers is low unless they are also IDUs.

He hasn't been publicly disgraced, but he has been told to be more careful what he says. The reason he has been told to be careful may be valid enough: it upsets the gay community. But gay communities in every country need to be aware that unprotected anal sex and injecting drug use are the two most common means of transmitting HIV in most Western countries.

And heterosexuals in every country need to be able to evaluate their risk. They can not do this if it is stated or implied that the risk they face is as high as that of anyone else; it isn't. If HIV was mainly transmitted by heterosexual sex there would be no pandemic. In fact, the virus might never have gone beyond a few isolated cases in a small area in Africa.

If the HIV pandemic can not be explained by penile-vaginal sex, how can it be explained? Well, we know that HIV can be transmitted far more efficiently by contaminated blood and other bodily fluids than by sex. Most forms of health care transmission may have been eliminated in Western countries, but some may still be common in poorer countries.

There are really only two kinds of HIV epidemic; those where most people infected are users of health (and possibly cosmetic) facilities and those where most people infected are MSM and IDUs. People are not infected because they are in some way less innocent or less worthy individuals. Such a view is sinister and pervasive, but without foundation of any kind.

HIV is difficult to transmit via penile-vaginal sex, but it is easy to transmit via contaminated bodily fluids, including blood. That blood and anal mucus are involved in anal sex, and often in HIV transmission, is not to say that HIV a 'gay disease'. It is not tantamount to saying that gay people are bad or that gay sex is bad. After all, heterosexuals have anal sex too and the risk is just as high for them.

But if HIV transmission is to be reduced and eventually eradicated, people need to be clear about exactly what risks they face. And when those risks are health care related risks they don't need lectures about safe sex, condoms, number of partners, etc. If gay people are worried about prejudice, this is completely understandable.

But making out that HIV is commonly transmitted through penile-vaginal sex when that is not the case leads to prejudice too. As a consequence of this distortion, many people are infected non-sexually because most are unaware that such risks exist. These millions of people who are avoidably infected are also stigmatized because non-sexual transmission is said to be so unlikely. Let's not replace one distortion with another.