Friday, April 20, 2012

HIV Conjunctivitis: a Serious Problem for Drivers

This is not about eye inflammation but rather the use of conjuncts in the field of HIV. The virus has been linked with various things that are indisputably undesirable, such as national security threats (mainly against the US, it seems), drug use (often conflated with intravenous drug use or IDU), sex work (often conflated with sex trafficking), sex (often conflated with 'unsafe' sex), female genital mutilation (or FGM, as opposed to male genital mutilation), poverty, lack of education, migration, war and conflict, gender based violence, gender inequalities, unemployment and alcohol abuse (which is conflated with alcohol use), etc. Many of these phenomena are claimed (or assumed) to be 'drivers' of HIV epidemics.

So a paper about alcohol-related HIV risk in Namibia begins "A growing body of epidemiological and social science research links alcohol consumption with the sexual behaviors that put people at risk for HIV and other sexually transmitted infections." Ireland, Finland, the UK and various other countries have serious problems with alcohol abuse, but low HIV prevalence. Indeed, Kenya, Tanzania and Uganda have serious problems with alcohol abuse, yet HIV prevalence is less than half that found in Namibia.

Each of the items associated with HIV listed above may well be linked with the virus, but not always in the ways you might be led to believe. HIV infected people from developing countries have not flocked to the US; IDU is the second biggest risk for HIV in many Western countries, but other types of drug use may not be such serious risk factors; sex work in Western countries is often only a high risk for HIV if IDU is also involved; FGM may be a risk factor, but HIV prevalence in tribes where it is common often have lower prevalence than in those where it is not practiced; poverty and lack of education are often associated with lower prevalence, as are war and conflict; gender inequalities are found in many countries with low HIV prevalence; unemployment is often associated with low prevalence in African countries, etc.

An article about gender based violence in a region in Tanzania makes the common jump from rates of violence to HIV rates. But there is no clear correlation in Tanzania showing that areas with high levels of gender based violence are also areas where HIV prevalence is high. Of course, the intervention should go ahead if it is likely to be successful in reducing levels of violence and changing people's attitudes towards any form of violence. It's just unlikely to have much impact on HIV transmission. In fact, whatever is driving HIV transmission in the region, it may fail to receive the attention it deserves because of the belief that it is driven by violence, perhaps fuelled by alcohol and drug abuse, gender inequalities, poverty and various other, unarguably, undesirable circumstances.

Alcohol abuse is a terrible social problem and can have even worse consequences for those who don't drink at all, or drink little. But the paper argues that alcohol abuse is linked to certain sexual behaviors; it doesn't make a convincing case that all or most HIV transmission is sexual, nor that alcoholics and their sexual partners are a lot more likely to be HIV positive because of their sexual behavior. In fact, levels of alcohol abuse in the study area may not even seem that shocking to people who have worked in 'informal settlements' or slums. And levels of 'unsafe' sexual behavior are hardly earth shattering either.

Notably, the people surveyed have a much higher income than most people in Kenya, Tanzania, Uganda or several other countries where HIV prevalence is not so high. Educational levels are also higher and there is almost no gender inequality in education in the study population. If anything, the paper fails to get to the bottom of what, exactly, could be driving the epidemic. Prevalence in Namibia ranges from less than 5% to 25% or more, and the study area is by no means the highest prevalence area.

What is particularly unconvincing though, is the idea that the sexual behaviors said to be linked to alcohol use actually increase the risks for HIV transmission, simply because the claim also mentions 'other sexually transmitted infections'. Syphilis, being another sexually transmitted infection, is nowhere near as common as HIV in most areas of Namibia; but also, the 2008 HIV sentinel survey shows that syphilis prevalence figures do not correlate with HIV figures, neither by area nor by age group.

The 'conjunctivitis' may partly stem from the (now rapidly declining) availability of funding for HIV, which can drive fundraisers to make connections that don't exist, or don't really have the significance attributed to them. But the consequences can be serious for both HIV and the chosen conjunct. Most development areas have received a fraction of the funding made available for HIV; but HIV programming has often failed to put a finger on, and adequately address, what is really driving HIV in high prevalence countries. Sexual behavior, alcohol abuse and the like cannot explain high rates of transmission, so their possible role in HIV transmission, and the extent of any putative factors, need to be exaggerated to mythical proportions.

At times, programs addressing non-HIV issues can lose their chances of increased funding because their connection with HIV transmission is not considered to be close enough. Examples are nutrition, food security, intestinal parasites, sexually transmitted infections aside from HIV, and various other diseases that have been shown to be serious co-factors in HIV transmission. The fact that these co-factor conditions are so widespread mitigates against their funding because the effects of an intervention would dwarf any possible effect on HIV, which infects far fewer people than the most common diseases in high HIV prevalence countries. Eradicating co-factor diseases is generally dismissed as a mere externality.

Alcohol, drugs, sex and many other factors can be involved to a greater or lesser extent in HIV transmission in various parts of the world. And there is no doubt that these issues are deserving of funding. But the donor-friendly moral aspects of these factors should not blind us to ones that may be in far greater need of attention. After all, HIV has been shown, over and over again, to cluster in ways that can not always be associated purely with sexual behavior. It is a virus that is spread by bodily fluids, including blood. On top of the many co-factor diseases that facilitate HIV transmission, there are not that many ways in which people exchange bodily fluids with others that could explain epidemics such as the ones in Namibia and other sub-Saharan African countries.

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]


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