Thursday, March 6, 2014

HIV Strategy: Blaming the Victim and their Individual Behavior

[Cross posted from the Don't Get Stuck With HIV website.]

Since the early days of HIV/AIDS, finger pointing has been the main publicity angle. In Western countries the collective finger was pointed at men who have sex with men. Their reaction was to object to the finger being pointed at them and to insist that everyone is equally at risk. Though some still believe that everyone is equally at risk, it is not true. In Western countries the majority of HIV transmissions have always been among men who have sex with men, with a smaller proportion of transmissions through intravenous drug use.
But things are quite different in developing countries, particularly high HIV prevalence African countries. In high HIV prevalence countries men who have sex with men, intravenous drug users and even sex workers contribute a relatively small proportion of HIV transmissions. In fact, the largest contribution still appears to come from those with little or no risk; mainly monogamous heterosexuals. So the process of finger pointing often turns into one of victim blaming. After all, you can't point the finger at everyone around you, nor at someone who is HIV negative; so the clearest 'evidence' of unsafe sexual behavior becomes HIV positive status.
This gives rise to the task of explaining how a virus that is difficult to transmit through heterosexual sex outside of Africa is so frequently transmitted through that route in Africa. The HIV industry needed to show that 'Africans' must be promiscuous, ignorant and unhygienic. This wasn't too difficult because population control advocates (the word 'eugenics' is no longer fashionable), a significant proportion of wealthy NGOs operating in Africa, had had been playing the over-sexed, under-educated slum-dweller cards for decades.
The processes of pointing the finger at a particular group whose behavior was disapproved of, blaming those infected with HIV for their status, and concluding that HIV is all a matter of individual behavior, threw off course any efforts to reduce HIV transmission in developing countries. Although 'prevention' activities only receive a small proportion of HIV funding, that is still a massive amount of money. But prevention activities have rarely gone beyond exhortations to 'behave' in a particular way. The finger-wagging programs perfected by population control NGOs decades before HIV was identified became, and often remain, the state of the art of HIV prevention.
There has been plenty of research showing that these finger-wagging programs are of little or no benefit (except to the NGOs). An example of such research shows that "peer education programs in developing countries are moderately effective at improving behavioral outcomes, but show no significant impact on biological outcomes". There is a voluminous body of literature showing that you can't simply wag your finger at people and expect them to change their behavior, whether the aim is to address substance abuse, dangerous driving, over-eating or anything else.
Sometimes the association of HIV transmission with individual behavior is further connected with conditions that are beyond the control of the victim, for example, poverty. But this has also given rise to confusion: there is plenty of evidence that HIV in African countries is transmitted among wealthier people. This challenges the idea that HIV epidemics are driven by sexual behavior because, even if wealthy people 'can afford to have a lot of sex and a lot of partners', as the HIV industry would have it, there would need to be some poor people involved in this theory. Rich people don't pay other rich people for sex.
Instead of looking beyond sex, or sex and poverty, it seems some researchers are convinced they will eventually find out how sex and economic inequalities 'drive' HIV epidemics. One paper concludes that "Further work is needed to understand the mechanisms explaining the concentration of HIV/AIDS among wealthier individuals and urban residents in [sub-Saharan Africa]". But they don't seem to consider the possibility that their protohypothesis about sex is simply wrong. They don't seem to think that non-sexual transmission may be a very significant factor in the spread of HIV among wealthier people.
HIV can be transmitted through unsafe healthcare and other skin-piercing processes, such as various cosmetic processes. Wealthy people tend to have better access to healthcare. In fact, urban dwellers also tend to have better access to healthcare. Perhaps this is why the above paper found that HIV is "generally concentrated among wealthier men and women". This may also explain why HIV "was concentrated among the poor in urban areas but among wealthier adults in rural areas" in a number of countries.
Instead of trying so hard (and failing, over and over again) to find out what it is about the sexual behavior of wealthy people and urban dwellers, perhaps researchers should look at non-sexual risks, as well as sexual risks. Could the risks that people face be determined by their wealth and environment, precisely because they are not sexual risks, but healthcare and other risks? These risks are clearly not *individual* risks. They relate to health-seeking behavior, but it is not the behavior of wealthy and/or urban-dwelling people that gives rise to infection with HIV in a hospital or salon; the risk of infection depends on whether the facility is safe or not (which might vary considerably over time).
Some historians of HIV, such as Jacques Pepin (The Origins of Aids), admit that HIV was mainly transmitted through unsafe healthcare for many decades, and hardly ever through sexual behavior. But they don't explain how healthcare transmission magically disappeared in the 1980s even though conditions in many African countries remain very unsafe (although how unsafe they are is still a dangerously under-researched field).
Coupled with the magical disappearance of the risk of HIV transmission in under-equipped, under-staffed and badly run health facilities is the magical re-appearance of the promiscuous, ignorant and dirty African, though for many, this had never really gone away. Pepin vaguely mentions things like 'urbanization' as the main explanation for levels of promiscuity for which there has never been any evidence and which do not explain very high rates of heterosexual transmission of HIV anyway.
Ugandans have recently responded to having the finger pointed at them by allowing an 'anti-homosexuality' bill to be passed, effectively saying 'it's not us, it's them'. Various human rights groups, and even some donors, may belatedly object to such disgusting measures, which are being copied by other African countries. But the objection needs to be directed at the approach to HIV that began a long time ago, and began in Western countries, not in African countries. Men who have sex with men are by no means the only group who have been blamed for HIV epidemics. Other groups include long distance drivers, sex workers, house girls, fishermen, miners, and many others. It's this finger-pointing approach that gives rise to the stigma that those pointing the finger claim to abhor.
Thirty years into the HIV epidemic (I'm adopting the view that HIV is not a pandemic because most people don't face any risk of being infected and prevalence is, and will remain, low in most countries) research institutions, NGOs, international bodies and, perhaps most importantly, donors are still obsessing about sexual behavior and pretending that HIV status is up to the individual when it is clear that a large, but as yet unestimated, proportion of infections is a result of unsafe healthcare and other skin-piercing processes.


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