Underlying Factors in HIV Transmission Are Not Causes

When I was researching for a grant proposal to address gender based violence (GBV) and female genital mutilation (FGM) in the Mara region of Tanzania, I was unsurprised to find that HIV rates there are relatively low. High levels of violence, even GBV and FGM, do not necessarily lead to high levels of HIV. On the contrary, high rates of FGM are often correlated with low HIV prevalence.

This does not, as far as I am concerned, make GBV or FGM any less repulsive. But low prevalence of HIV in an area can sometimes make it difficult to attract funding. Low levels of nutrition, food security, education and other basic human rights are often ignored until it can be shown that HIV rates are high, or that rates are connected with other developmental problems.

Any claim that something is the 'main' driver of HIV is suspect, including an article on AllAfrica.com today entitled 'Women's inequality Main Driver of HIV'. Like GBV and FGM, all inequalities need to be addressed, because they are symptoms of underdevelopment, not because they are more or less related to HIV transmission.

Of course the "relentless cycle of vulnerability affecting girls and young women" needs to be addressed. But the attitude of UNAIDS and other institutions contributes to that relentless cycle. Telling whole populations that HIV is almost always transmitted through heterosexual sex gives rise to the sort of disempowering social and cultural norms and attitudes that such institutions claim to find so abhorrent.

The article correctly refers to staggering infection rates among women between 15 and 24 years but it does not refer to the fact that many of these women have only one partner who is HIV negative. Fewer men than women are infected in many countries and in some regions, rates among women are several times higher than those among men. It doesn't take people long to work out that something about what they are being told is not true.

Apparently 80 per cent "of young people, aged between 15 and 24 years, living with HIV are female". But most men are not infected until they are a lot older, well into their 20s, perhaps even their 30s. Why wouldn't some people think that HIV is introduced to populations by women? People know more about their own sexual behavior than they are sometimes given credit for, and if they or their partner become infected, they have a right to question the HIV orthodoxy.

All the HIV industry has succeeded in doing is in disempowering women further and undermining their efforts to change their situation. The industry has also further alienated men from wanting to bring about any kind of change. They have been branded as the main culprits in HIV transmission, in addition to all the other things they are accused of. They may not be innocent, but that's no reason to condemn them for something they are not all guilty of. And condemning them, rightly or wrongly, will not help bring about change, either.

Apparently men will be targeted in HIV campaigns that have so far mainly targeted women. But if this means further accusations of promiscuity, strange sexual practices and widespread antisocial behavior, it will prove as fruitless as most prevention work that has taken place so far. It will not be a new strategy, just another way of beating people over the head with the old strategy.

Another 'leading cause' of HIV often mentioned is illiteracy. Again, continuing high levels of illiteracy and profound inequalities in education are disgraceful after so many decades of development work. But HIV transmission has usually been found to be higher among the better educated (and richer) people in high prevalence countries. That wouldn't justify the claim that education 'causes' HIV, but nor should it justify the claim that illiteracy is a cause.

If UNAIDS are interested in what causes HIV, they should re-examine data about sexual practices and sexual transmission. They will find that some of the data is anomalous if it is assumed that almost all HIV is sexually transmitted but the anomalies disappear once they allow that some HIV is transmitted non-sexually.

Reliance on mathematical models is unwise when it comes to estimating the contribution of various modes of transmission because this can lead to circularity. But HIV prevention will be a whole lot easier when it begins to target genuine causes, rather than mere underlying factors.