Friday, April 13, 2012

Some Ignorance Kills, Some Sells Newspapers

It's easy enough to associate HIV with 'ignorance' and poverty, which may be why journalists have such a strong tendency to do so, as in this article on HIV in Swaziland. Communicable diseases often infect people in poorer and less well educated communities in greater numbers, though high HIV prevalence is not common to all poor countries with low levels of education. But HIV has often gone in the opposite direction, with higher prevalence among wealthier and better educated quintiles.

Swaziland is not just the country with the highest HIV prevalence in the world, it is also a country where the virus appears to infect people regardless of their wealth and education level, which is another counterexample to the 'ignorance and poverty' reflex. But the subtitle should also raise questions that the author leaves unasked: "Despite improving healthcare and information campaigns, country still has world's highest infection rate". Could there be something about the healthcare and education people receive in some countries that lies behind high transmission rates?

We are told that neighbouring countries have seen HIV prevalence fall, but not Swaziland, because of "cultural norms around sexuality being exacerbated by a financial crisis". But such a vague comment could be applied to any country, with or without high HIV prevalence. Show me the country without any 'cultural norms around sexuality', or even one that is not suffering the effects of the financial crisis. There are lots of countries where sexual behavior remains relatively uninfluenced by public health programs and other attempts to change things.

If "research has found that, despite government information campaigns, understanding of HIV/Aids is poor", it's about time the information campaigns themselves were given some thought. There is a lot of finger-wagging about using condoms, yet condom use is often associated with higher HIV prevalence. Other finger-wagging exercises are about numbers of sexual partners and 'high-risk' sexual partners; while HIV prevalence does appear to be higher among people with more partners, the numbers of people with more sexual partners is far smaller than numbers with one partner, or even zero partners.

For all the sexual risks researchers have thought of for HIV, the majority of new infections occur among people who probably face extremely low levels of sexual risk. Yet, HIV and sex education tends to concentrate almost entirely on sexual risk, to the exclusion of non-sexual risk. The article also notes that attempts to persuade men to be circumcised have not been very successful in Swaziland. And some of those who were circumcised ended up thinking they didn't need to use condoms any more, which is hardly a surprise, given the breathless evangelism that seems to accompany circumcision campaigns.

Oddly enough, newborns are being circumcised in higher numbers; perhaps they take less persuasion. But various randomised clinical trials claiming that circumcision reduces HIV transmission have not shown that circumcision of newborns also reduces transmission. People are receiving what is called information, but how often is it disseminated in the form of disinformation?

Apparently 78% of people in need of antiretroviral drugs are currently receiving them, which is a very high figure if it's true. In the long run this should significantly reduce sexual transmission of HIV; whether it will also reduce non-sexual transmission is not clear yet as too little research has been carried out. We need to wait for the HIV industry to admit that non-sexual transmission occurs enough for it to be in need of research, and that could take a long time. But instead of the old slogan 'don't die of ignorance', people could be advised not to live in ignorance of how they became infected. Because knowing how people became infected can result in a lot of transmissions avoided.

We are told that some of the gains in the fight against HIV in Swaziland have been jeopardized by the financial crisis because some maternal health services were interrupted. In fact, this could reduce the risk of transmission in health facilities, if conditions in health facilities are not safe. Of course, reduced access to health facilities has other negative health consequences. But several African countries with low access to health facilities have far lower HIV prevalence than Swaziland, for example, Kenya, Uganda and Tanzania. And countries with almost no access to health facilities have even lower HIV prevalence than those three; examples are the Democratic Republic of Congo, Ethiopia and Somalia. In many countries, it is those who attend health facilities who are most likely to be HIV positive.

Far from being an argument for reduced health services, this is an argument for ensuring that health services are safe. It is also an argument for investigating the relative contribution of non-sexual, as well as sexual transmission in high and medium HIV prevalence countries. It is also an argument for a bit of analysis when spending money on HIV. It's all very well to be able to provide drugs for everyone who needs them but treatment goes beyond the provision of drugs; health goes beyond the absence of disease; and disease goes beyond HIV; there are many diseases, some of which cause a lot more suffering and death than HIV.

The entire article swallows the assumptions about African HIV epidemics being almost entirely due to sex, without even having to dwell much on sex. There's even the claim that a Swazi MP "had encountered impoverished patients mixing cow dung with water to fill their stomachs in order to be able to take ARVs", a rather dubious story that nevertheless was echoed by the vast echo chamber that is Big Media. Does widespread poverty and starvation really need this kind of nonsense in order to be read?

Improved information campaigns are useless if much of the information is untrue, or if only part of the story is given. This can result in people disbelieving what they are told, whether it's true or not, and remaining ignorant of matters that may save their lives. It's not surprising many are reluctant to test for HIV if they know they will be told it was a result of their sexual behavior. Yet, there's a very good chance that many people were not infected sexually.

It's a lot easier to avoid non-sexual infection than sexual infection, but people need to know it exists and how to avoid it. Countries like Swaziland need better healthcare, but it must be safe healthcare. Information campaigns need to include advice about non-sexual risks as well as sexual risks.

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



David Gisselquist said...

Among adults in 16 African countries (information from Demographic and Health Surveys), Swazis are the most likely to say that condoms stop HIV, but are the least aware of bloodborne risks. Across the 16 countries, the percentage of adults with HIV falls as more people are aware of bloodborne risks. From these data, one reason behind Swaziland's terrible AIDS epidemic may be that people have not been adequately warned about HIV from blood-to-blood contact through skin-piercing procedures. See graphs, data, and discussion at: and

Simon said...

Thank you for this comment, I discussed Brewer's paper some time back but forgot to include it here!

Anonymous said...

Every time you go to a VCT, you're asked a series of questions about your sexual history but none about blood-born procedures.

Anonymous said...


Simon said...

Hi Anonymous, I think it's often left to counselors to decide what to prioritize and what to leave out. So some may mention non-sexual risks or ask about them, but people seem to think they are less important, perhaps even almost irrelevant. What country are you speaking of?