Monday, September 3, 2012

HIV Finger-Wagging Exercises Are Bad for the Recipients' Health

The education Millennium Development Goal (MDG), number two, is to achieve 'universal primary education'. The target is to "Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling". School fees have been abolished in many countries, including Tanzania, and this has led to very high levels of enrollment according to the MDG website. But it goes on to say that this has "brought a new set of challenges in providing enough teachers and classrooms."

There are other challenges not mentioned. For example, many teachers don't spend a lot of time in the classroom, many have receive poor training, many of the pupils who have enrolled hardly ever turn up for classes. And worst of all, the majority of children in Tanzania, Kenya and Uganda fail literacy and numeracy tests. In other words, (almost) universal enrolment is not universal education; and even relatively high levels of attendance do not lead, in the cases of Kenya, Uganda and Tanzania, to high levels of attainment.

A report by an initiative called Uwezo shows that enrolment and attendance figures are noticeably lower for people in lower income brackets and in public schools, while those for dropping out are higher; the overall enrolment figure is far lower than that cited in the MDG document, above. Performance was generally very low, especially in Uganda and Tanzania. In fact, Tanzania scored lowest in English (not so surprising, given it's not as widely used as in the other two countries), numeracy and even Kiswahili (Uganda was not scored for Kiswahili).

So, to return to my last blog post, about a paper called "Changes over time in sexual behaviour among young people with different levels of educational attainment in Tanzania", the authors raise questions about the relationship between educational attainment (the three levels of attainment being 'none', 'primary' and 'secondary', so not a very finely grained measure) and sexual behavior, and how these change over time. A number of countries have shown that higher HIV prevalence was often found in those with higher levels of education and lower prevalence in those with lower levels of education, but the correlation has changed over time.

To understand why these and other researchers should go to so much trouble, it's important to look more closely at the highly simplistic, probably rather racist and clearly empirically unfounded theory they have of HIV transmission. They believe that high levels of HIV prevalence mean that there are (or were) high levels of sexual risk taking (or 'unsafe sexual behavior' or 'promiscuity', or whatever you wish to call it). On the contrary, high levels of sexual risk taking exist in many places where HIV prevalence is low; and HIV prevalence has been found to be high where levels of sexual risk taking are not high.

The relationship between sexual behavior and HIV prevalence is not clearly understood. It can be presented as being a fairly direct relationship and it is often concluded that unsafe sexual behavior *causes* HIV transmission, that this is not a mere correlation. As a result, HIV interventions involve wagging fingers at people about whom to have sex with, how often, how many people, what kind of sex to have, etc. Of course, there's nothing wrong with good sex education; there's just no evidence that recipients of these finger-wagging exercises have ever received good sex education (or good education of any kind, if Uwezo's data is to be believed).

To be clear, unprotected sex with people whose status you don't know is risky. There's the risk of sexually transmitted infections, HIV and unplanned pregnancy, for a start. But HIV is not always transmitted sexually; we just don't know the relative contribution of sexual and non-sexual HIV transmission. We have no real idea of how much transmission occurs in health facilities, through unsterile procedures such as injections, in cosmetic facilities, through tattooing, traditional practices and other skin piercing practices.

So what relationship should one expect between education or socio-economic group and sexual behavior? What relationship between sexual behavior and HIV transmission? And what relationship could there be between various HIV educational campaigns and behavior given the current situation in Tanzanian, Kenyan and Ugandan schools? Those are difficult questions to answer. They are also empirical questions which can only be answered by collecting and analysing good data, not by casting aside data that doesn't fit the preconceived views and hypothesizing data that has no basis in reality.

In a report entitled "Integrated biological and behavioral surveillance survey among migrant female sex workers in Nairobi", there are some curious findings. While HIV prevalence is high, at over 23%, STI prevalence is relatively low, the highest being syphilis, at 2%. But HIV prevalence of over 20, 30 and even 40% can be found among women who are not sex workers, for example in Kenya, where overall HIV prevalence is probably less than 7%.

If the women are sex workers, what are their risks? Or, to put it a different way, what are the risks for women who are not sex workers and among whom HIV prevalence is far higher? The immigrant sex workers, who are said to face even higher risks than indigenous sex workers, have an average number of sex partners per month of 21.6. This is nowhere near the kind of figures we have heard in the past for sex workers, with client numbers running to the 20s and 30s per day. Things have changed for the better, you may think, but massive rates of HIV transmission through heterosexual intercourse alone requires numbers of sexual encounters that are probably not achieved, or even achievable, by many.

When it comes to 'knowledge' about HIV transmission among sex workers, "there is a trend of increased prevalence of HIV among participants who know the correct answers to the knowledge questions, the exceptions being participants who know that sharing needles puts one at risk, and that a healthy looking person can have HIV." Those who 'know' the 'correct' answers after all the finger-wagging are often more likely to be HIV positive. In some ways, this is hardly surprising. There is a photo of a flip-chart headed 'Modes of Transmission': "(a) Unprotected intercourse (sexual) with an infected person (80%)", along with all the others, with 20% of transmission to share among them. Perhaps one of the risk factors is attending finger-wagging exercises purporting to teach commercial sex workers and others how to protect themselves from HIV?

Perhaps HIV related education does little to reduce HIV transmission because people are not being told about important non-sexual risks, because they are being told or led to believe untrue things about sexual transmission, because the recipients of the programs are very badly educated, often by badly trained teachers. Besides, there is no clear correlation between good education and low HIV prevalence; the relationship is probably often inverse because those who can afford a good education can also afford healthcare at a facility where they would certainly have faced a high risk of being infected with HIV in the early days, before HIV was recognized and before anyone got around to doing anything about it.

Educational HIV prevention interventions have had limited success because they are one-sided, concentrating on sexual risk and ignoring non-sexual risk; it's not all about sex and it never has been. In addition, they probably don't even constitute good sex-education. But educational standards among the recipients are also low, among adults, high risk or otherwise, or children. This has little to do with HIV and the right to education should not be tied to public health messages, however well meaning. Few public health campaigns will ever succeed in countries where both the health and education sectors are in as deplorable condition as they are in East African countries.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


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