Sunday, July 8, 2012
The 'no sex for a month' idea was big news for the usual period that these fads can hold the media's attention. But now that it has been 'tested' by a mathematical model and found to be no better than other HIV prevention strategies, the press is not quite so interested. However, measuring its possible effectiveness against other strategies and finding it to be no better is sneaky because it doesn't emphasize quite how ineffective the other strategies really are, nor why they are all ineffective. As the authors say "Despite significant investment in programmes for the treatment and prevention of human immunodeficiency virus (HIV) infection, the prevalence of such infection in sub-Saharan Africa remains stubbornly high."
Before anyone rushes to point out that prevalence figures in some countries remain higher because widespread treatment keeps more HIV positive people alive, they should also bear in mind that "for every two individuals starting treatment, five become infected with HIV": incidence is also still high. Which is even worse for the 'treatment is prevention' brigade, because it isn't, especially in high prevalence countries. The percentage of HIV positive people on treatment may not be high enough to test the 'treatment is prevention' hypothesis, but the strategy is clearly not enough on its own.
Parkhurst and Whiteside are good at milking the publicity machine and are aware of the benefits of toeing the HIV industry party line. As well as attracting press attention, a 'no sex month' assumes that most HIV transmission is a result of heterosexual sex. Some probably is, perhaps most is, but we don't know the relative contribution of sexual an non-sexual transmission. Where non-sexual transmission, such as through unsafe healthcare or cosmetic practices, is common, a no-sex month will have very little impact. Worse, it will deflect attention from practices that risk transmitting all sorts of blood-borne pathogens, such as hepatitis, bacterial infections, scabies and whatever else.
Sadly, Kenya is said to be considering such a campaign; they wouldn't want to miss the opportunity to get more funding for yet another useless strategy, and there's also the publicity. Worse still, Swaziland, with one of the worst HIV epidemics in the world, is also said to be considering a no sex month campaign. So I hope they read the article that shows that the strategy is like all the others: media-friendly hype.
People who give up something (or try to) for Ramadan, Lent or any other period will know how hard it is to break a habit or deny themselves a pleasure, even for just a month. But where an addiction or compulsion is involved, even reducing ones indulgence is difficult, and may not happen at all. Alcoholics and people with certain eating disorders, for example, may be able to release themselves completely from something that blights their lives if it were possible for them to stop for just one month. But sex, for most people, is neither a habit, an addition nor a compulsion. It's an appetite, a normal, healthy appetite at that. It's also a human right.
Many people can and do exercise self control as and when they need to. But what is the status of an imperative such as a 'no sex for a month'? It's irrelevant for most people, even in relatively high HIV prevalence countries; most people are not HIV positive, many who are are not sexually active, many don't have HIV positive sexual partners. A blanket, self-imposed ban on sex for a month is nothing like a similar ban on smoking, drinking, overeating, sugar consumption, drunk driving, texting while driving or anything else that results in high levels of injury or bad health. And banning any of those addictions, compulsions and anti-social habits has rarely had much impact. A no sex month wouldn't even have the arguable advantage of a religious motivation.
The mathematical modelling exercise is useful because it finds that none of the interventions show much benefit; it's not just the no sex month idea that is unlikely to give benefit, even if everyone were to magically abstain from sex for a month. But there are also interesting thought experiments around a no sex month. During Lent, chocolate eating, alcohol consumption, smoking and whatever else is probably more concentrated in high-user groups, those most likely to benefit from abstaining from their addiction, habit or compulsion. Heterosexual HIV transmission should end up being confined to those most likely to transmit heterosexually in the normal course of events!
If a no sex month didn't look like a non-starter before you thought about it for a few minutes, you would quickly dismiss it after a few minutes. It just shows you how much time, resources and effort could be avoided with the employment of a bit of thought. But where money and careers, even egos are involved, there's no accounting for the conclusions people will arrive at. The authors "do not conclude that an intervention based on a yearly no-sex or safe-sex month would be ineffective, merely that it would be as effective as an alternative policy that spreads out the reduction in transmission across the whole year".
However, money, careers and egos probably are involved and the silly idea, the sort that the media like the most, may result in more wastage and increased morbidity and mortality, or at least a continued failure to reduce these. The authors recommend comparing a no sex month strategy with male circumcision, concurrency reduction messages and condom promotion. But these, while possibly not so silly, have been shown to be wrong headed and/or ineffective. Different things need to be considered, not more of the same. As a non-scientist, I would suggest that a reduction in anti-African and anti-female prejudice among HIV researchers and the HIV industry could do more than the combined benefits of all the clever and stupid ideas that have been discussed over the last 30 years.
[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]