Monday, June 13, 2011

Are UNAIDS Getting Off On Their Own Sexual Fantasies?

If paying for sex commoditizes it, does paying people not to have sex also commoditize it? Would anyone bribe their daughter with money to wait till they are married before they have sex? Or would they bribe them with money not to have sex for money? Somehow, I can't imagine parents thinking this way.

I don't know if paying girls not to have sex commoditizes it but I know it's one of the stories that does the rounds because it seems to appeal to journalists. And I know that UNAIDS sees it as worth a try in South Africa. I just can't see them trying it out in Washington DC (which might have the highest HIV rates in the Western world).

The article informs us that young South African girls are "one of the highest risk groups, because poverty drives them to have sex in exchange for gifts." What, all young girls? Or is it just all 'poor' young girls? "Researchers now want to see whether using cash payments as a reward for getting good grades and having annual HIV tests could curb the girls' risky sexual behaviour." So if the grades are not good and/or they don't have annual tests for some reason, no money for them?

Maybe things have changed radically in SA but only a few years ago "Startling new evidence from a three-year survey [showed] that HIV is now growing fastest among those who are wealthier and educated." This phenomenon is quite familiar in Kenya and even more so in Tanzania. In fact, the phenomenon is most marked among female Tanzanians: HIV rates are higher among well educated, well off Tanzanian women.

The Nature article is not too clear but I think it is saying that money is being given to boys and girls. Apparently boys are being involved because "Men are driving the epidemic — through their sexual behaviours, drug-taking, risk-taking and the fact that they often hold the balance of power in decision-making in intimate relationships."

Maybe the epidemic is being driven by men, but people could be forgiven for not being entirely convinced of that. HIV prevalence among females at age 15-19 is 6.7% and among males it is only 2.5%. We are informed, frequently, that young women sleep with older men. But how much older? And do all young women sleep with older men? Because in the 20-24 age group, female prevalence is 21.1% and male only 5.1.

Some estimates suggest that some (but by no means all) females sleep with men who are between five and ten years older than them. So if 15-19 year old females were sleeping with 20-24 year old men, it looks like a lot of the males are actually being infected by females, not the other way around. 6.7% of 15-19 year old females are infected, compared to 5.1% of 20-24 year old males. Sorry for being repetitive but these figures don't suggest that HIV transmission is being 'driven by men'.

Even if some young women have sex with much older men, there is no evidence that they all do. And while female prevalence peaks at 32.7% in the 25-29 year age group, it peaks at only 25.8% among 30-34 year old males, never reaching female prevalence rates in any age group. The figures could even suggest that the number of promiscuous females, if you go for the promiscuity theory of HIV transmission, radically outnumbers that of promiscuous males.

This doesn't really give credence to the idea that the epidemic is being driven by men. In fact, it might make you question the assumption that the epidemic is entirely driven by sex. You have huge numbers of females being infected at a very young age and far smaller numbers of men who could be infecting them. The whole principle behind making money from sex is that there are relatively few women being paid by a relatively large number of men.

If the number of women selling sex outnumbers the men buying it, the bottom falls out of the market. But, interestingly, if fewer women are willing to sell sex, the value will go up. If lots of these young females, said to be selling sex because they are so impoverished, suddenly disappear off the market, those left selling sex will be able to command a far higher price. The scheme may have some benefit, but probably not the one intended by UNAIDS!

But the two main claims in the article about paying young women not to have sex are that HIV is driven by large numbers of poor young women having sex for money and that HIV transmission is driven by (smaller numbers of) promiscuous men. Neither of these claims seems very plausible. What is plausible is that small numbers of poor young women have sex for money and that small numbers of promiscuous men pay for sex.

And this still doesn't explain extraordinarily high HIV prevalence figures found in South Africa, therefore it can not justify paying young girls (or boys) to not have sex. HIV prevention interventions need to be based on reality, rather than on the fantasies of a bunch of bureaucrats desperate to have something to show for the billions that have been poured into their institution.

Enabling girls to stay in school has been shown to reduce 'unsafe' sex, unplanned pregnancies and possibly sexually transmitted infections and HIV. But if HIV prevalence is usually higher among better educated girls, perhaps this needs to be investigated before spending money and precious time with interventions that may not work and that may make things worse. There is no substitute for establishing exactly how HIV is being transmitted in high prevalence contexts. Because we clearly don't know that yet.


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