Sunday, September 4, 2011

HIV: If All your Questions are About Sex, All your Answers will be About Sex

A paper published in the Journal of Adolescent Health in February alludes to the need to rethink sexual risk for HIV among young people in South Africa and the US in its title. But the significance of the results of the study seems to be completely lost to the researchers involved.

The research finds that "Young people in the US report riskier sexual behaviors than young people in SA, despite the much higher prevalence of HIV infection in SA." From this they conclude that "Factors above and beyond sexual behavior likely play a key role in the ongoing transmission of HIV in South African youth, and thus should be urgently uncovered to develop maximally effective prevention strategies."

That's great to know, but the research doesn't shed much light on what other factors could give rise to HIV prevalence hundreds of times higher than that found in most Western countries. They vaguely suggest that "Unique biological forces must be playing a role as well." The research doesn't probe such forces, presumably that's way outside its scope. But nor does it make any attempt to go beyond sexual risks.

In fact, the authors nail their colors to the mast in the first paragraph: "Considering that most of the infections in sub-Saharan Africa are the result of heterosexual transmission, popular opinion has continued to foster the belief that the HIV epidemic in Africa is fueled by promiscuous sexual behavior, or unique sexual mixing patterns. I would suggest that the researchers question the antecedent of that sentence. Where is the evidence that most infections anywhere are the result of heterosexual transmission?

However, much of this 'popular opinion' emanates from some very prominent HIV academics. And it's hardly surprising that the populace associates high HIV prevalence, particularly in African countries, with promiscuity and 'unique sexual mixing patterns'. The entire HIV industry, led by UNAIDS, is built on the assumption that almost all HIV transmission in African countries (though not elsewhere) is a result of heterosexual sex.

In other words, sexual behavior that is not particularly risky is still very likely to result in HIV transmission, but only in African countries. If people are at high risk of infection as a result of low risk behavior, that is tantamount to saying we don't really understand why some people are being infected in huge numbers, all of them Africans, while other people are infected in very small numbers. The researchers don't appear to have a clue.

They say "This high prevalence of infection in the general South African population means that young people do not have to engage in high-risk behaviors (i.e., multiple partners, lots of unprotected sex) to be at risk for HIV infection. Certainly sexual behavior is an essential element of HIV risk; nevertheless, high-risk behavior may not be a prerequisite for HIV transmission."

Yes, people are at higher risk of being infected in a country where prevalence is out of control. But what gave rise to such high prevalence of HIV when the virus is difficult to transmit sexually? If the researchers want to explain current transmission patterns, they need to have some basic grasp of the patterns that gave rise to the epidemic in the first place. They appear to lack this basic grasp.

The authors graciously list some limitations, but one they don't list is the fact that non-sexual risks were not examined: for all the people who were infected with HIV and all those who could have been exposed to the virus without being infected, the researchers don't know anything about their non-sexual risks. They don't appear to have considered non-sexual risks worth the effort.

They didn't even ask about anal sex, same sex partners or intravenous drug use. In the US, anal sex is the number one risk factor, with intravenous drug use being number two. When it comes to extremely high rates of HIV transmission, there needs to be an investigation of all risks, especially the most serious. This piece of research appears to have examined some of the least serious risks and decided that they must be serious despite all appearances, particularly in South Africa.

We don't just need to rethink sexual risk, as the authors claim: we need to rethink all risk. We urgently need to establish why one in ten South Africans are infected with this virus, which is so much easier to spread through contaminated blood that through sex, while only one in 1000 Americans are infected. Research that fails to address non-sexual risks for HIV transmission is a pointless waste of time and money and it allows millions to continue to be infected needlessly with HIV.


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