Sunday, April 1, 2012
When I see a title like 'Kenya: War Against HIV/Aids Stepped Up', I expect it to be more of the same, sex, stigma, blame, etc. But this article suggests a genuinely more inclusive HIV strategy and specifically rejects the sex-only, immorality theory of HIV epidemics in Africa. ABC (Abstain, Be faithful, use Condoms), the article points out, has failed to reduce HIV transmission enough to eradicate the virus; it has also done a lot to spread stigma and blame. It is mostly directed at heterosexual sex and ignores other kinds of transmission. It also divided those who chose to oppose condoms and even being faithful to one partner, insisting that abstaining from sex was the only way to prevent transmission.
It seems there are those who would like to stress "the need for urgent comprehensive prevention strategies that tackles all the facets of the epidemic". Of course, those promoting ABC, or even abstinence only, claimed they were tackling all facets. It is proposed that ABC be replaced with another acronym, SAVE, which stands for Safer practices, Access to treatment, Voluntary counselling and testing and Empowerment. All four facets of this strategy could include non-sexually transmitted HIV, such as through unsafe healthcare or cosmetic services. Apparently even religious groups find it less polarizing than ABC.
Those promoting SAVE correctly point out that ABC placed little or no emphasis on testing, care and treatment for infected people. These also play a significant role in reducing HIV transmission, as well. But, despite blaming ABC for leaving out women, effectively disempowering them, or failing to empower them, circumcision is one of the interventions that is advocated for. This intervention does little to reduce transmission from women to men and it probably increases transmission from men to women. It is likely to have an overwhelmingly disempowering effect, as men pretend and women believe that circumcision is connected with lower HIV rates, perhaps with complete protection against HIV.
However, the article goes on to mention things such as "use of sterile injection equipment and ensuring that all blood transfusions are tested for HIV", also "standard hygiene precautions such as gloves and clean needles for all patients". These are issues that WHO, UNAIDS, PEPFAR, the Global Fund and various other big players in the HIV industry have long refused to address, or even discuss. Now that funding is thin on the ground, it would be better for countries like Kenya to decide on their own approaches to HIV, given how badly the big funders have done. The last thing the country needs is to adopt a new strategy but to have all the priorities set by external funders; that's what happened to ABC, which started as a weak idea and became a lot weaker, in the form of abstinence only.
Access to treatment is in serious need of work so that a far hiigher percentage of HIV positive people are able to reduce illness, live longer and even avoid the risk of infecting their partner, either through sexual or non-sexual contact. And it seems as if the prevention of mother to child transmission (PMTCT) program is not doing well at present. If SAVE can get this on track, it would have a huge impact on transmission rates. PMTCT can work very well, reducing transmission to just a few percent. However, it is reported that only 4% of pregnant women started antiretroviral therapy within six months of diagnosis in Kenya. That sort of coverage will make little impression on overall transmission rates and it is disappointing that this opportunity has, so far, been almost entirely missed.
It is also disappointing that women themselves have not received as much attention as their children (although a lot of that turned out to be mere lip service). If more attention was paid to women before, during and after pregnancy, if they had access to safe healthcare, HIV transmission to women might be a lot lower. This would be an even better way of reducing transmission to children, if the mother wasn't infected in the first place. Many countries have notably high rates of HIV infection among mothers who have received professional healthcare. Let's hope SAVE achieves all of its aims, which appear to include safe healthcare.
A spokesperson for the SAVE strategy points out that treatment and care are not just a matter of giving people drugs, which is often the best that many can expect in Kenya; some don't even get the drugs. But there are other disease that are in as much need of prevention and treatment as HIV; it can not be dealt with in isolation. And health is more than just the elimination of diseases; people need good levels of nutrition and access to clean water and sanitary conditions.
Professor Alloys Orago of the National Aids Control Council sounds a bit lukewarm about SAVE and points out that ABC "has had gaps" but can not "be discarded all together". SAVE doesn't appear to want to discard ABC, but to build on it. Orago says "ABC effectiveness has not been felt because many organisations working around HIV/Aids agenda failed to implement it fully and their approach tried to portray HIV fight as a moral question and not looking at it holistically", which could easily be interpreted as meaning that it wasn't up to the job; though I don't think that's the intention.
We don't need more ABC because it was derailed by those who had their own agenda. SAVE could suffer the same fate if those with the big money are attracted to it. The only hope would seem to be if those in Kenya who believe things could be different refuse to give in to those with various axes to grind (and the money to ensure they do the grinding). It's good to hear that some big international NGOs are supporting the initiative, as long as they are free to spend their funding as they see fit. Hopefully we'll hear more about this initiative.
[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]