Tuesday, November 20, 2012

UNAIDS Adopts Broad Brush Approach to HIV Stigma

In my last blog post I made a statement that I feel is in need of explanation: "People who work with HIV really do distinguish between those who were infected through ways that are thought of as being within their control, and those who are infected in ways that are thought of as not being within their control. An example of the former is sexually transmitted HIV; an example of the latter is mother to child transmission."

This is highly insulting to many people who work with HIV, and that is not my intention. My objection is to the view that HIV is almost always transmitted through heterosexual sex in African countries (and hardly ever in most non-African countries; and that most of infections not transmitted through sex are transmitted from mother to child). This is sometimes referred to as the 'behavioral paradigm', and should be condemned as racist and sexist. However, I accept that many people working with HIV do not explicitly adhere to the behavioral paradigm, and that some don't even do so tacitly.

Suffice to say that I think belief in the behavioral paradigm is highly prevalent. I also think the pandemic will not end until it is acknowledged that there is a lot of evidence that a substantial proportion of transmission of HIV in African countries is not sexual. Once that is acknowledged, the issue can be addressed, and non-sexually transmitted HIV should be a lot easier to prevent than sexually transmitted. For example, a good deal of transmission may be a result of unsafe healthcare, unsafe cosmetic practices and unsafe traditional practices. Of course, such acknowledgement needs to be accompanied by taking appropriate action to address these problems. But blaming it all on people's behavior has got us nowhere.

As things stand, many HIV prevention programs, because they assume that HIV is almost always transmitted through heterosexual sex, are spread over a huge population. There is virtually no possibility of targeting because funding is limited; and if the 'target' population is, effectively, all sexually active people, often including many people who will soon be sexually active, the impact of such programs, at an individual and population level, will be very small. In addition, if the programs exclusively address sexually transmitted HIV, the virus will continue to be spread through other modes, unchecked by any warning, training or intervention.

While heterosexual transmission of HIV is not particularly efficient, male to male transmission is very efficient, especially for the receptive partner. Stigmatizing every sexually active person in high HIV prevalence countries, as the HIV industry has done, does not result in male to male sex being any less stigmatized, on the contrary. But failing to target groups who face exceptionally high risks does not protect anyone. And stigmatizing them can result in the problem not being addressed at all. Most of the billions being thrown at HIV is wasted, and very little indeed goes to those who are most in need of it.

A recent report finds that HIV incidence among men who have sex with men (MSM) in Kenya may be as high as 35%. To put that in perspective, if incidence really is that high, most men practicing receptive anal sex could be infected within three years of sexual debut. The 2009 Kenyan Modes of Transmission Survey claims that HIV prevalence among 'MSM and prison populations' prevalence is estimated at 15.2%. There is no way of guessing how much of that figure is accounted for by men having sex with men because prison populations are likely to face a lot of non-sexual risks, such as through various skin piercing procedures. But the latest figure is considerably higher. The figure for bisexual men is far lower, at 6%.

Another mode of transmission that can be very successfully targeted is mother to child transmission. Of course, it would be a lot better to establish why so many women are being infected, often in the second or third trimester, or even just after giving birth, especially when so many women have partners who are HIV negative. Telling them (or implying that) they must almost definitely have had sex with someone who is HIV positive doesn't help matters, particularly when they are sent home to tell their partner that at least one of them is HIV positive, possibly both, and possibly even one or more of their children. So, an article title goes, "Stigmatisation slows Kenya's efforts to avert mother-to-child HIV transmission". But who wants to know that they are infected with an incurable disease they are told is almost always sexually transmitted?

The article is written by someone who doesn't seem to know very much about HIV. The author writes "women end up seeking services of traditional birth attendants or deliver in poor-equipped health centers thus exposing their children to HIV". Most health facilities are badly equipped and it is in these hospitals and clinics that mothers and their babies may risk being infected with HIV. In many countries, it is women who give birth in health facilities who are most likely to be HIV positive. It would seem to be safer to give birth at home, which is quite counterintuitive when you see the living conditions for the majority of people in some African countries.

Dr William Maina, head of Kenya's National AIDS Control Program (NASCOP) bemoans the fact that "stigmatization remains a great challenge." He goes on "Some people still treat HIV as a 'special' disease. Those who are living with it are frowned upon." Excuse me Dr Maina, NASCOP exists because HIV is seen as 'special', and following the edicts of UNAIDS, WHO and other institutions ensures that belief in the behavioral paradigm is propagated. If people are afraid to use hospitals, they may have a lot to fear, but unfortunately there's no reason why they should know about hospital transmitted HIV, because the HIV industry doesn't talk about it.

Dr Maina continues with his litany of HIV industry approved statements about mothers infecting their babies, never mentioning the fact that in some countries, 15-30% of HIV infected infants have HIV negative mothers. An unknown percentage of infected mothers have uninfected partners. If mother to child transmission can be reduced from approximately 13,000 a year, that's great. But the soundest way to ensure mothers can't transmit HIV to their child is to ensure mothers don't get infected (and it's also good to ensure that babies don't get infected in health facilities). Mother to child transmission should be the exception, as it is in Western countries.

"When a pregnant woman is diagnosed with HIV, discrimination starts, particularly in the family. Her husband sees her as immoral yet many women get the disease from their spouses", according to one woman. It's not surprising that people think any woman infected has been having illicit sex, or that her partner has, since that's what people are told, incessantly, by the HIV industry. There's no point in complaining about 'stigma' and 'discrimination' when the very source of these are the industry itself. Many women do not get HIV from their spouses, but they are all branded as 'promiscuous'. Do they really believe that many pregnant women decide they will have sex with someone other than their partner, who also happens to be HIV positive? Oh yes, I forgot, they have to have sex with all and sundry because they are so poor.

"Many married women are diagnosed with HIV during antenatal clinics visit. Most of them blame their status on their husbands. The women get infected because they have little choice to make when it comes to using contraceptives or telling their men to go for HIV test" said Maina. Please, Dr Maina, UNAIDS, WHO, and all the others, try to exercise your brain a little; do you really think that most people who are infected with HIV are lying sluts? If not, have another bash at targeting HIV prevention interventions. It is a lot easier to target those most at risk when you are in a position to be frank about who those people are, and please, don't brand them as being promiscuous or dishonest or both, because that is not going to encourage them to visit your clinics. And by the way, clean up your clinics a bit, while you're at it.

I apologize to anyone who is offended by my sweeping statement about 'people who work with HIV...', but I include myself among those people. I believe that sexual transmission of HIV can be addressed in part through good education and health systems. Neither sexually transmitted nor non-sexually transmitted HIV can ever be adequately addressed in countries where health, education and various other areas of development continue to be ignored. However, denying the contribution of non-sexual transmission and continuing to disparage Africans, especially HIV positive Africans, isn't working, and it never will. Stigmatizing entire populations is not 'targeting', no matter how convenient it may be to the HIV industry.

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


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