According to IRIN's PlusNews, Swaziland is to dump its ABC approach HIV prevention (Abstain, Be faithful and use a Condom). Swaziland has the highest prevalence of HIV in the world. The article states: "experts are still at a loss as to why Swazis have resisted all attempts to change the behaviours that put them at risk from the virus." But they needn't be puzzled. ABC hasn't worked anywhere. It's just that Swaziland is the first country to publicly admit it.
Don't be fooled by all the articles about Uganda working magic in the 1990s using ABC to reduce HIV prevalence. The approach didn't exist in Uganda in the 1990s and HIV prevalence was never even as high in Uganda as most of these articles say. Prevalence did reach very high levels in the country and they are low now, that's true. But many strategies were employed to reduce HIV transmission and the main reason why prevalence dropped so quickly in the 1990s is because death rates were very high. A similar pattern occurred in Kenya somewhat later, which took the Kenyan government by surprise as they hadn't even got around to admitting that there was a HIV epidemic in the country.
While recognizing that ABC is not working in Swaziland, Dr Derek von Wissell, director of the National Emergency Response Council on HIV/AIDS is still convinced that "behaviour is what has to change". He then turns his attention to men, pointing out that 70% of men are "free agents", to whom being faithful does not apply. This is supposed to explain why HIV prevalence is 38% among girls in the 20-24 age group?
There is something very unconvincing about this explanation. Unless the majority of sexually active women are having a lot of unprotected sex with a small number of men, we really don't have any idea where all these infections are coming from. In order to infect someone with HIV, a man needs to be HIV positive. In fact, he also needs to have sex with each woman quite a number of times, statistically. If Dr von Wissell is thinking straight, there is a small number of men who need to be identified and given some good advice, quickly. Never mind targeting sexually active women.
But I don't think the man is thinking straight. His thinking, like that of most thinking throughout the HIV industry, is skewed by the 'behavioral paradigm', the belief that almost all HIV is transmitted through heterosexual sex in African countries. To hold this belief, you need to think that, sexually, Africans are different from people from other continents. They have a lot more unsafe sex with far more partners than those in other continents. Also, the women are particularly prone to having unsafe sex, lots of it, with a certain group of highly sexually active, HIV positive men.
Of course, these beliefs are just prejudices, there is no evidence for them. On the contrary, there is plenty of evidence that some people in all countries have lots of sex, even unsafe sex. But most people don't. Yet, in some African countries, HIV prevalence is so high that almost every sexually active woman can be considered lucky to remain uninfected. Swaziland, in particular. If you stick fast to your prejudices, you might wonder who these evil men are, you might even wonder about why the majority of women take such stupid risks. But if your approach to reducing HIV transmission is so influenced by prejudice, you may not be bothered by any glaring irregularities.
The lessons that the HIV industry steadfastly refuse to learn are that, one, you can't just legislate for (or against) certain kinds of sexual behavior, despite decades of evidence of this from the population control brigade. And two, not all HIV is transmitted sexually. If von Wissell wants to "challenge conventional thinking" and to avoid slavishly following what went before, he would want to go a little further than uttering soundbites about needing to find new ways to prevent infections. He could start by looking at how HIV is being transmitted, how it is actually being transmitted, not how the HIV industry says (and really wants to believe) it is being transmitted.
Even allowing a very high probability of HIV transmission per sex act, you would have to believe that Swazi women have a lot of sex with a lot of different partners to explain current prevalence rates. Coupled with that, you would have to believe in that small bunch of HIV positive men, who get to have sex with far more than their fair share of women. In days gone by, all sorts of myths were dreamed up to explain pregnancies that shouldn't have occurred, such as seals appearing as men and then disappearing again. But we don't need to resort to such myths any more. It's time for the HIV industry to wake up. It's time to admit that non-sexual HIV transmission plays a part in hyperendemic countries such as Swaziland and to investigate modes of transmission properly.
ABC doesn't work; it has never worked; it will never work. Good sex education, as opposed to obscure platitudes and moral cant that is completely ungrounded in any reality, would be welcome. Children in African countries are in bad need of any kind of education; but general education is a prerequisite to sex education. Education about and access to condoms would also be helpful, in many ways. But no approach to HIV prevention that assumes the truth of the behavioral paradigm will eradicate HIV. Swaziland has made the first half step. Let's hope the HIV industry doesn't interfere this time.
Showing posts with label abc. Show all posts
Showing posts with label abc. Show all posts
Tuesday, August 17, 2010
Wednesday, June 2, 2010
Paying Ugandans to Transmit HIV
For years, we have been blasted with ‘news’ about how successful Uganda was at controlling its HIV epidemic in the early days of the virus. Even articles about HIV in other countries were almost guaranteed to refer to Uganda’s ‘success’ and this was usually put down to the country’s adoption of ABC (Abstain, Be faithful and use a Condom) programmes. This is despite the fact that ABC campaigns didn’t exist anywhere in the late 1980s and early 1990s, at a time that HIV prevalence rates in Uganda were dropping fast. It wasn’t until many years later that Uganda and other countries were sold this rather spurious set of claims, which went so far as to claim that abstinence alone was responsible for falling HIV prevalence.
But it became rather embarrassing in the early 2000s, when Uganda’s prevalence rates appeared to be flatlining and perhaps even rising. Now that it has become too obvious for even the usual suspects at UNAIDS, CDC, WHO and the journalists who spread their wisdom to continue claiming that all is well in Uganda, people are asking what went wrong and how can the country get back on the right track. The UNAIDS Uganda country co-ordinator, Musa Bungudu, is interviewed and his answers show serious lack of understanding about HIV in general and HIV in Uganda in particular.
He emphasises the ‘behavioural change approach that helped Uganda to reduce HIV prevalence in the past’. Among the many who have echoed the praise for Uganda, there have been a few who have questioned the history of HIV there and especially the reasons given for Uganda’s early success and the country’s subsequent failures to eradicate the virus. In an article entitled ‘How Uganda Reversed Its HIV Epidemic’, a number of authors who worked in Uganda in the 1980s and 1990s (Gary Slutkin, Sam Okware, Warren Naamara, Don Sutherland, Donna Flanagan, Michel Carael, Erik Blas, Paul Delay and Daniel Tarantola) remember things very differently.
The story they give is that a campaign was mounted to inform people about all the modes of transmission and ways to avoid infection. Rather than just being a behaviour change campaign aimed at sexual behaviour, people were informed about medical transmission and other non-sexual modes, research and monitoring were carried out to determine who was at risk and why, etc. And these were, we are told, the usual strategies for an early Aids programme. The epidemic in Uganda was one of the first to peak. Therefore, the country would have benefited a lot more from such a campaign than countries where HIV was peaking later, once the ABC and abstinence only adherents managed to wrest most of the money from genuine health professionals.
In contrast, in Kenya, the epidemic peaked 10 years later, by which time politicians, religious leaders and commercial interests had taken the front seat and all reason and sense was stuck in the boot, where it languishes to this day. Interestingly, a completely coincidental sexually transmitted infection (STI) programme had been rolled out in Nairobi, just before HIV had been identified. During the time this programme was going on, HIV prevalence rose from very low rates (determined through stored blood samples) to prevalence rates of over 80%, only to drop dramatically as the STI programme was phased out. Aside from this remarkable coincidence, Kenya as a whole did as little as possible to reduce the spread of HIV and as much as possible to deny that there was even a serious epidemic in the country.
So, Uganda were successful in the early days of the epidemic and people often ask why, what did they do that other countries could have done and what were they doing that they are not doing now. Well, perhaps it was the adoption of the behavioural paradigm, so beloved by politicians, religious leaders and other bigots, the belief that HIV is mostly transmitted by unsafe heterosexual intercourse in African countries because, as the story goes, Africans have inordinately more sex than everyone else. And even Mr Bungudu, a Ugandan, doesn’t seem to feel the need to question the possibility that this behavioural paradigm is wrong.
He mentions that HIV prevalence was perhaps as high as 20% in the 1980s and that it dropped to about 6% by 2000, which would have been, to a large extent, due to very high death rates in the 1990s. He mentions that prevalence is even increasing but, most importantly, he notes that the rate of new infections is increasing. About half the HIV positive people who need antiretroviral treatment (ART), which means that HIV prevalence, the number of people living with HIV, should be rising. But Uganda continued with the programmes said to reduce HIV transmission, so why are they not working now?
One explanation appears to be that the country did, indeed, start off well, approaching every mode of transmission, not just sexual transmission. But once they embraced ABC, abstinence only and anything else that followed from the behavioural paradigm, transmission by all non-sexual routes started to increase. The country, effectively, abandoned a major part of their earlier campaign. In this pursuit, they were amply supported by their major donors, who didn’t want to hear about anything but sexual transmission and ineffective behaviour change campaigns. In fact, most countries are afraid to run any campaign that doesn’t explicitly mention sexual transmission to the exclusion of all other routes of transmission for fear of losing their funding. They are right to worry about losing their funding. But, as a result, they have lost control of the epidemic.
Bungudu then performs the classic UNAIDS trick of attributing most new HIV infections to low risk sex (entailing the contradiction that a virus that is difficult to transmit sexually is frequently transmitted sexually). Most new infections have been found to be among married people. Worse still, most of those infected are women whose husbands are HIV negative. Does Bungudu want to subscribe to the racist view that, not only do most Africans have a lot of sex, but also that many married women are sleeping with people other than their husbands, perhaps for money? To explain such high rates of sexual HIV transmission among married women whose husbands are HIV positive would require that they sleep with an awful lot of other men. HIV negative people married to HIV positive partners can remain HIV negative for years, even if they have regular unprotected sex.
But yes, Bungudu mentions high levels of unfaithfulness and all the other explanations that UNAIDS cling to, even saying that “a poor woman is likely to go out with a rich man for his money. If he is infected, she may get HIV.” What he doesn’t seem to appreciate is that this would take an awful lot of poor women having an awful lot of sex with a lot of rich people (are there many rich people in Uganda?). But we know that, for a long time, HIV prevalence was higher in richer sectors of the population. And this trend was as true for rich women as for rich men. The problem with everything that Bungudu says is that it all presupposes the truth of the behavioural paradigm. And it all ignores the obvious conclusion, that sexual behaviour does not explain why HIV is so high in some African countries and so low in most other countries.
Continuing the official line, which I suppose he has to do if wants funding to continue, Bungudu reflects on the fact that prevention messages are not getting to remote communities. He completely misses the fact that HIV prevalence in remote areas has always been lower than in urban areas. But once ‘messages’ start reaching these areas, in the form of assumptions about people’s sexual behaviour, HIV transmission tends to rise. This is being experienced in Gulu, now that the area is being ‘developed’. Prevalence has doubled in the last few years despite the fact that roads, hospitals, schools and other social services are being built.
It is a good thing that all these amenities are being built and I’m certainly not arguing otherwise. But if the HIV message continues to be about sexual transmission and excludes non-sexual routes, many more people in Gulu and other areas will continue to be infected. People like Bungudu and others need to open their eyes, to question what is happening and not just to repeat the prejudiced rubbish they have been fed by international health institutions.
The only hopeful thing Bungudu mentions is that Uganda’s HIV efforts are about 90% foreign funded. If the Ugandan government can find a way to provide more of the funding, they may be able to find a way to turn the epidemic around. But only if they also reject the simplistic and highly prejudicial maunderings that make up international HIV policy to date. Otherwise, the fact that most Ugandans are not able to access health services could be the only thing that gives them some protection from HIV. But if Ugandans are not prepared to stand up for other Ugandans in the face of such prejudice, no one else will.
But it became rather embarrassing in the early 2000s, when Uganda’s prevalence rates appeared to be flatlining and perhaps even rising. Now that it has become too obvious for even the usual suspects at UNAIDS, CDC, WHO and the journalists who spread their wisdom to continue claiming that all is well in Uganda, people are asking what went wrong and how can the country get back on the right track. The UNAIDS Uganda country co-ordinator, Musa Bungudu, is interviewed and his answers show serious lack of understanding about HIV in general and HIV in Uganda in particular.
He emphasises the ‘behavioural change approach that helped Uganda to reduce HIV prevalence in the past’. Among the many who have echoed the praise for Uganda, there have been a few who have questioned the history of HIV there and especially the reasons given for Uganda’s early success and the country’s subsequent failures to eradicate the virus. In an article entitled ‘How Uganda Reversed Its HIV Epidemic’, a number of authors who worked in Uganda in the 1980s and 1990s (Gary Slutkin, Sam Okware, Warren Naamara, Don Sutherland, Donna Flanagan, Michel Carael, Erik Blas, Paul Delay and Daniel Tarantola) remember things very differently.
The story they give is that a campaign was mounted to inform people about all the modes of transmission and ways to avoid infection. Rather than just being a behaviour change campaign aimed at sexual behaviour, people were informed about medical transmission and other non-sexual modes, research and monitoring were carried out to determine who was at risk and why, etc. And these were, we are told, the usual strategies for an early Aids programme. The epidemic in Uganda was one of the first to peak. Therefore, the country would have benefited a lot more from such a campaign than countries where HIV was peaking later, once the ABC and abstinence only adherents managed to wrest most of the money from genuine health professionals.
In contrast, in Kenya, the epidemic peaked 10 years later, by which time politicians, religious leaders and commercial interests had taken the front seat and all reason and sense was stuck in the boot, where it languishes to this day. Interestingly, a completely coincidental sexually transmitted infection (STI) programme had been rolled out in Nairobi, just before HIV had been identified. During the time this programme was going on, HIV prevalence rose from very low rates (determined through stored blood samples) to prevalence rates of over 80%, only to drop dramatically as the STI programme was phased out. Aside from this remarkable coincidence, Kenya as a whole did as little as possible to reduce the spread of HIV and as much as possible to deny that there was even a serious epidemic in the country.
So, Uganda were successful in the early days of the epidemic and people often ask why, what did they do that other countries could have done and what were they doing that they are not doing now. Well, perhaps it was the adoption of the behavioural paradigm, so beloved by politicians, religious leaders and other bigots, the belief that HIV is mostly transmitted by unsafe heterosexual intercourse in African countries because, as the story goes, Africans have inordinately more sex than everyone else. And even Mr Bungudu, a Ugandan, doesn’t seem to feel the need to question the possibility that this behavioural paradigm is wrong.
He mentions that HIV prevalence was perhaps as high as 20% in the 1980s and that it dropped to about 6% by 2000, which would have been, to a large extent, due to very high death rates in the 1990s. He mentions that prevalence is even increasing but, most importantly, he notes that the rate of new infections is increasing. About half the HIV positive people who need antiretroviral treatment (ART), which means that HIV prevalence, the number of people living with HIV, should be rising. But Uganda continued with the programmes said to reduce HIV transmission, so why are they not working now?
One explanation appears to be that the country did, indeed, start off well, approaching every mode of transmission, not just sexual transmission. But once they embraced ABC, abstinence only and anything else that followed from the behavioural paradigm, transmission by all non-sexual routes started to increase. The country, effectively, abandoned a major part of their earlier campaign. In this pursuit, they were amply supported by their major donors, who didn’t want to hear about anything but sexual transmission and ineffective behaviour change campaigns. In fact, most countries are afraid to run any campaign that doesn’t explicitly mention sexual transmission to the exclusion of all other routes of transmission for fear of losing their funding. They are right to worry about losing their funding. But, as a result, they have lost control of the epidemic.
Bungudu then performs the classic UNAIDS trick of attributing most new HIV infections to low risk sex (entailing the contradiction that a virus that is difficult to transmit sexually is frequently transmitted sexually). Most new infections have been found to be among married people. Worse still, most of those infected are women whose husbands are HIV negative. Does Bungudu want to subscribe to the racist view that, not only do most Africans have a lot of sex, but also that many married women are sleeping with people other than their husbands, perhaps for money? To explain such high rates of sexual HIV transmission among married women whose husbands are HIV positive would require that they sleep with an awful lot of other men. HIV negative people married to HIV positive partners can remain HIV negative for years, even if they have regular unprotected sex.
But yes, Bungudu mentions high levels of unfaithfulness and all the other explanations that UNAIDS cling to, even saying that “a poor woman is likely to go out with a rich man for his money. If he is infected, she may get HIV.” What he doesn’t seem to appreciate is that this would take an awful lot of poor women having an awful lot of sex with a lot of rich people (are there many rich people in Uganda?). But we know that, for a long time, HIV prevalence was higher in richer sectors of the population. And this trend was as true for rich women as for rich men. The problem with everything that Bungudu says is that it all presupposes the truth of the behavioural paradigm. And it all ignores the obvious conclusion, that sexual behaviour does not explain why HIV is so high in some African countries and so low in most other countries.
Continuing the official line, which I suppose he has to do if wants funding to continue, Bungudu reflects on the fact that prevention messages are not getting to remote communities. He completely misses the fact that HIV prevalence in remote areas has always been lower than in urban areas. But once ‘messages’ start reaching these areas, in the form of assumptions about people’s sexual behaviour, HIV transmission tends to rise. This is being experienced in Gulu, now that the area is being ‘developed’. Prevalence has doubled in the last few years despite the fact that roads, hospitals, schools and other social services are being built.
It is a good thing that all these amenities are being built and I’m certainly not arguing otherwise. But if the HIV message continues to be about sexual transmission and excludes non-sexual routes, many more people in Gulu and other areas will continue to be infected. People like Bungudu and others need to open their eyes, to question what is happening and not just to repeat the prejudiced rubbish they have been fed by international health institutions.
The only hopeful thing Bungudu mentions is that Uganda’s HIV efforts are about 90% foreign funded. If the Ugandan government can find a way to provide more of the funding, they may be able to find a way to turn the epidemic around. But only if they also reject the simplistic and highly prejudicial maunderings that make up international HIV policy to date. Otherwise, the fact that most Ugandans are not able to access health services could be the only thing that gives them some protection from HIV. But if Ugandans are not prepared to stand up for other Ugandans in the face of such prejudice, no one else will.
Sunday, September 27, 2009
Some Things Change, Some Stay the Same
The Preliminary Report of the Kenya Aids Indicator Survey (KAIS) was released last July and was based on data collected in 2007. Prevalence was estimated to be 7.8% among 15-49 year olds (7.4% among 15-64 year olds). Many parties expressed surprise that HIV prevalence had increased since 2003, when the Demographic and Health Survey estimated prevalence to be 6.7% among 15-49 year olds.
HIV prevalence in Kenya peaked in the late 1990s and fell rapidly thereafter into the early 2000s. Prevalence fell because death rates were very high. But death rates peaked in the early to mid 2000s. If there had been few new HIV infections in the early to mid 2000s, HIV should have stabilized at a fairly low level. This didn't happen. Instead, prevalence increased.
One possible reason that HIV prevalence has been increasing throughout this decade is that antiretroviral therapy (ART) has been keeping many HIV positive people alive. However, the number of Kenyans on ART by 2005 was very small. Numbers have increased since then, although it's not yet clear what effect this will have on national prevalence figures.
Another possible reason why HIV prevalence has been increasing is that there are many people becoming newly infected every year. While huge sums of money have been poured into treatment and care for HIV positive people and their dependents, very little has been spent on prevention. What has been spent on prevention has been wasted on pointless finger-wagging about how people should and shouldn't lead their sex lives.
The final KAIS report was launched in the last few days. I can't find a copy of it online but there have been many articles about it and they all, like this one, talk about the report as if these figures are new and surprising. It is not surprising that there are more people living in rural areas infected with HIV. The vast majority of Kenyans live in rural areas. Prevalence is lower in rural areas than in urban areas but the absolute numbers are higher. This is not a new trend.
Various commentators in various articles have resolved to deal with trends noted by the KAIS report but many of these trends go back many years. Even the KAIS figures are already two years out of date. And there are likely to be quite different trends now because, in case these commentators haven't noticed, some profound changes have taken place in the lives of all Kenyans. There was a violent election campaign, a violent election and a particularly violent post election period, during which many people were killed, injured and displaced. There have been energy shortages, food shortages, water shortages, a global economic collapse, increasing unemployment and, no doubt, countless other pressures on people's lives.
Some things are not the same now as they were two years ago, when data was collected for KAIS. They are certainly not the same as they were in 2003. But the HIV prevention work that is being carried out by Kenya's health and HIV agencies is pretty much unaffected by anything that has happened in the last ten and perhaps even twenty years.
Consequently, HIV prevention continues to be given low priority and takes forms that continue to have little or no impact. That's why a recent survey of 13-19 year olds shows that, many years and tens of millions of dollars later, less than 50% understand what abstinence means. More importantly, only 20% understand what being faithful means and only 7% fully comprehend condom use. The question is, do the 48% who can say what abstinence means really understand sex and safe sex? I think the answer is clearly 'no'; all they have taken in is a definition. They will not be able to protect themselves adequately, despite being able to parrot definitions of abstinence and the like.
HIV prevention work in Kenya needs to do new things, not continue with the failed, dogmatic activities of the past. Children (and adults) need to know what sex and safe sex are, they need to know how to protect themselves and often, they need protection. There are young people pouring into Nairobi and other cities now, they are desperate for work and until they find work, countless thousands will become involved in some form of transactional sex. People's living conditions need to be changed so that they don't face such dangers.
HIV policy needs to be based on what is happening now, not what was happening, or what someone thought was happening, years ago. And policies that failed years ago need to be changed, not shored up with excuses. HIV trends can change very quickly and all Kenyans are at risk of becoming infected, though some are at higher risk than others. There is no point in just concentrating on high prevalence areas, as one Kenyan WHO representative suggests; low prevalence areas can quickly become high prevalence areas. Also, absolute numbers can be a far better indicator than percentages when it comes to describing how an epidemic is spreading.
But the Kenyan government needs also to concentrate on people's lives, livelihoods, environments and opportunities. People still need the things they have always needed, health, education, social services, infrastructure, good housing, employment and protection from harm. Relevant authorities such as the National Aids Control Council and, indeed UNAIDS, need to be able to distinguish between the things that change and the things that don't change.
HIV prevalence in Kenya peaked in the late 1990s and fell rapidly thereafter into the early 2000s. Prevalence fell because death rates were very high. But death rates peaked in the early to mid 2000s. If there had been few new HIV infections in the early to mid 2000s, HIV should have stabilized at a fairly low level. This didn't happen. Instead, prevalence increased.
One possible reason that HIV prevalence has been increasing throughout this decade is that antiretroviral therapy (ART) has been keeping many HIV positive people alive. However, the number of Kenyans on ART by 2005 was very small. Numbers have increased since then, although it's not yet clear what effect this will have on national prevalence figures.
Another possible reason why HIV prevalence has been increasing is that there are many people becoming newly infected every year. While huge sums of money have been poured into treatment and care for HIV positive people and their dependents, very little has been spent on prevention. What has been spent on prevention has been wasted on pointless finger-wagging about how people should and shouldn't lead their sex lives.
The final KAIS report was launched in the last few days. I can't find a copy of it online but there have been many articles about it and they all, like this one, talk about the report as if these figures are new and surprising. It is not surprising that there are more people living in rural areas infected with HIV. The vast majority of Kenyans live in rural areas. Prevalence is lower in rural areas than in urban areas but the absolute numbers are higher. This is not a new trend.
Various commentators in various articles have resolved to deal with trends noted by the KAIS report but many of these trends go back many years. Even the KAIS figures are already two years out of date. And there are likely to be quite different trends now because, in case these commentators haven't noticed, some profound changes have taken place in the lives of all Kenyans. There was a violent election campaign, a violent election and a particularly violent post election period, during which many people were killed, injured and displaced. There have been energy shortages, food shortages, water shortages, a global economic collapse, increasing unemployment and, no doubt, countless other pressures on people's lives.
Some things are not the same now as they were two years ago, when data was collected for KAIS. They are certainly not the same as they were in 2003. But the HIV prevention work that is being carried out by Kenya's health and HIV agencies is pretty much unaffected by anything that has happened in the last ten and perhaps even twenty years.
Consequently, HIV prevention continues to be given low priority and takes forms that continue to have little or no impact. That's why a recent survey of 13-19 year olds shows that, many years and tens of millions of dollars later, less than 50% understand what abstinence means. More importantly, only 20% understand what being faithful means and only 7% fully comprehend condom use. The question is, do the 48% who can say what abstinence means really understand sex and safe sex? I think the answer is clearly 'no'; all they have taken in is a definition. They will not be able to protect themselves adequately, despite being able to parrot definitions of abstinence and the like.
HIV prevention work in Kenya needs to do new things, not continue with the failed, dogmatic activities of the past. Children (and adults) need to know what sex and safe sex are, they need to know how to protect themselves and often, they need protection. There are young people pouring into Nairobi and other cities now, they are desperate for work and until they find work, countless thousands will become involved in some form of transactional sex. People's living conditions need to be changed so that they don't face such dangers.
HIV policy needs to be based on what is happening now, not what was happening, or what someone thought was happening, years ago. And policies that failed years ago need to be changed, not shored up with excuses. HIV trends can change very quickly and all Kenyans are at risk of becoming infected, though some are at higher risk than others. There is no point in just concentrating on high prevalence areas, as one Kenyan WHO representative suggests; low prevalence areas can quickly become high prevalence areas. Also, absolute numbers can be a far better indicator than percentages when it comes to describing how an epidemic is spreading.
But the Kenyan government needs also to concentrate on people's lives, livelihoods, environments and opportunities. People still need the things they have always needed, health, education, social services, infrastructure, good housing, employment and protection from harm. Relevant authorities such as the National Aids Control Council and, indeed UNAIDS, need to be able to distinguish between the things that change and the things that don't change.
Friday, September 18, 2009
Good Leadership and Facing the Realities Around HIV/Aids
Still trying to familiarize myself with the area around Nakuru, the towns, villages and rural areas. More importantly, I'm trying to get a picture of the organisations and initiatives that I hope to work with, their members, leaders, qualities, interests and levels of activity.
Some are very active and productive, with keen participants and strong projects. I couldn't help agreeing with the home based care worker I met yesterday who said he thought leadership is the key. I don't believe for a moment he was talking about himself as he is a very modest man. But in Salgaa, he gives excellent leadership and gets excellent results. Leadership does appear to have a vital bearing on the success or failure of support groups and their activities.
Peter knows all of the people in his two community support groups very well because he lives near many and pays regular visits to others, travelling many kilometers every week on his bike, on a hired motorbike or on public transport. There is no substitute for covering as much of this large area as possible, as often as possible.
But the results of his work include regular meetings, high levels of support given to and given by participants; Peter and others working in the area can tell you all about each participant and they know when someone is sick or in trouble. Not everyone takes an equally active part, of course, but compared to some other support groups that don't even meet most of the time, Salgaa has a very healthy community.
Most importantly, people there who are on antiretroviral therapy (ART) are taking their medication as they should. This means they gradually become as healthy as they were before they were affected by the opportunistic infections that appear in people in advanced stages of HIV. This is one of the primary aims of the support groups and in that respect, they are doing very well.
As for HIV prevention, the area has not been so lucky. The Kenya National Aids Control Council has never really spent much time, effort or money on HIV prevention. They talk about it a lot but neither Kenya, nor any country in the world, have really implemented programmes that demonstrably reduce HIV transmission. Calling their programmes, such as they are, 'evidence based', does not mean they have had any effect.
And some organisations never learn. After many years of bleating about sexual abstinence and how it reduces transmission, even though it clearly does not, many of those involved in HIV prevention are still coming out with the same tripe.
Yes, young people need to know they can refuse those who try to persuade them to have sex. And those who are in a position to refuse either don't have sex or they only have sex under circumstances they choose. That's great for people who have freedom of choice but fails to address those who, for many reasons, don't have the choice or don't have much choice.
Children (and adults) need to know the reality of sex and choice and many other things. Abstinence campaigns, even ones that include partner reduction and condom use, do not have a history of teaching realities. There are still many adults who believe all sorts of rubbish about condoms, circumcision, reproduction and other vital matters. And there are still people who use the word 'abstain' all the time and have very little useful knowledge about what they are supposed to be abstaining from. It's sex, it's a big subject and it goes far beyond a few over used slogans.
These bogus HIV prevention campaigns demonstrate something else, besides leadership, that is missing from initiatives that fail: reality. There is plenty of money and therefore plenty of 'leadership' behind abstinence and the related sanctimonious parphenalia. But because they are not rooted in the realities of people's lives, they have little or no impact on their lives.
In Salgaa, the support groups don't just have good leadership. The groups arose from the realities of living with HIV/Aids. People need to get on with their lives, facing the same realities that may well have resulted in their becoming infected. They don't survive by refusing to accept the realities, rather, those who refuse to accept the realities become sick and die.
Monday, July 27, 2009
Radical Needs to be More Radical Than This
The Global Citizen Summit on HIV and AIDS, which took place in Nairobi in May came to some interesting conclusions. The conference called for a more radical plan to prevent HIV and treat those who are HIV positive.
They endorsed universal testing, for a start, which is particularly commendable because it is not part of the much hyped plan to test everyone and treat everyone found to be HIV positive. Not that I think that would be a bad thing to do, I just doubt the feasibility of such a huge and expensive undertaking at a time when fewer than 20% of people know their HIV status and the 30% of so HIV positive people on treatment may not be on treatment for long because of funding shortages.
But the more people tested, the better, whether there is treatment available or not. At least if people know their status they can take some measures to avoid infecting others.
The Summit also concluded that the Abstain, Be faithful, use a Condom strategy (ABC) is now obsolete, that it was a great strategy but that it had failed. I'm not sure what was so great about it if it failed but better late than never.
More worryingly, they came up with a strategy called SAVE or safer sexual practices, access to medication, VCT and Empowerment.
It's all very well to conclude that a strategy has failed and needs to be replaced but I wonder about the wisdom of replacing one costly slogan with another? Not that there is anything wrong with any of these aims, they are all good. But one of the problems with ABC was the dogmatism that went with it and the way it was indiscriminately shoved down the throats of everyone for so many years when it was clearly wrongheaded.
A single slogan with however many sub slogans is not what is needed. There are many conditions surrounding the transmission of HIV and they vary from place to place. Trotting out some slogan, no matter how enlightened it may seem in comparison to the moribund ABC campaigns, will simply not be appropriate for most contexts.
HIV is just one disease but its transmission is assisted by many different circumstances. People in a Nairobi or Mombasa slum have different vulnerabilities from commercial sex workers in smart clubs and tourist resorts. Men who have sex with men and women who have sex with women have different needs from long distance drivers, orphans and vulnerable children, single mothers in isolated rural areas, people on slave wages in export processing zones (EPZ) and underpaid workers on sugar or tea plantations.
The unwillingness to accept that HIV is transmitted in so many different contexts is one of the reasons why attempts to reduce its spread have been so unsuccessful. HIV is not just about sex, it's not just about commercial sex workers, intravenous drug users or same sex relationships, it's about so many different things. There is no single slogan that can be used and there is no single slogan needed. Marketing is to persuade people that they need something they may not need, good health and safe sex are not like that.
Some things do not work on commercial or economic principles and a really radical approach to HIV would reject the use of these failed approaches. A lot of money has been spent on expensive campaigns when what people need is good information and education. Marketing and the patronising slogans that go with it are no substitute for these.
They endorsed universal testing, for a start, which is particularly commendable because it is not part of the much hyped plan to test everyone and treat everyone found to be HIV positive. Not that I think that would be a bad thing to do, I just doubt the feasibility of such a huge and expensive undertaking at a time when fewer than 20% of people know their HIV status and the 30% of so HIV positive people on treatment may not be on treatment for long because of funding shortages.
But the more people tested, the better, whether there is treatment available or not. At least if people know their status they can take some measures to avoid infecting others.
The Summit also concluded that the Abstain, Be faithful, use a Condom strategy (ABC) is now obsolete, that it was a great strategy but that it had failed. I'm not sure what was so great about it if it failed but better late than never.
More worryingly, they came up with a strategy called SAVE or safer sexual practices, access to medication, VCT and Empowerment.
It's all very well to conclude that a strategy has failed and needs to be replaced but I wonder about the wisdom of replacing one costly slogan with another? Not that there is anything wrong with any of these aims, they are all good. But one of the problems with ABC was the dogmatism that went with it and the way it was indiscriminately shoved down the throats of everyone for so many years when it was clearly wrongheaded.
A single slogan with however many sub slogans is not what is needed. There are many conditions surrounding the transmission of HIV and they vary from place to place. Trotting out some slogan, no matter how enlightened it may seem in comparison to the moribund ABC campaigns, will simply not be appropriate for most contexts.
HIV is just one disease but its transmission is assisted by many different circumstances. People in a Nairobi or Mombasa slum have different vulnerabilities from commercial sex workers in smart clubs and tourist resorts. Men who have sex with men and women who have sex with women have different needs from long distance drivers, orphans and vulnerable children, single mothers in isolated rural areas, people on slave wages in export processing zones (EPZ) and underpaid workers on sugar or tea plantations.
The unwillingness to accept that HIV is transmitted in so many different contexts is one of the reasons why attempts to reduce its spread have been so unsuccessful. HIV is not just about sex, it's not just about commercial sex workers, intravenous drug users or same sex relationships, it's about so many different things. There is no single slogan that can be used and there is no single slogan needed. Marketing is to persuade people that they need something they may not need, good health and safe sex are not like that.
Some things do not work on commercial or economic principles and a really radical approach to HIV would reject the use of these failed approaches. A lot of money has been spent on expensive campaigns when what people need is good information and education. Marketing and the patronising slogans that go with it are no substitute for these.
Thursday, December 18, 2008
Calling the (Self) Righteous
Recent research shows that HIV attacks normal, healthy genital tissue in women. Previously, it was thought that skin had to be broken or damaged to be infected. No doubt, breaks in tissue or other damage may increase the risk of infection. But it seems that even healthy women are far more vulnerable to HIV than previously thought.
The researchers conclude that treatments such as vaccine are needed. But they also conclude that condoms are clearly needed as they protect against infection. Those favouring the 'ABC' (Abstain, Be faithful, use a Condom) approach to HIV prevention must take note that abstaining and even being faithful are not enough. Many monogamous women are infected by their husbands or by their partner. Yet some people involved in HIV prevention insist that abstinence on its own or abstinence combined with faithfulness are enough.
Abstinence on its own, or even abstinence plus being faithful (where abstinence alone is not possible), are not enough to protect people from HIV. Abstinence is just not an option in many circumstances and being faithful can also be elusive. Abstinence, faithfulness and using condoms are only three aspects of avoiding HIV, other sexually transmitted infections (STIs) and unwanted pregnancies.
Those working in HIV prevention who are squeamish or downright bloody-minded about the use of condoms need to reconsider their stance. Are they interested in preventing HIV or are they merely interested in prognosticating at the expense of the people whose interests they claim to be protecting? People have sex. They may 'abstain' or refuse to have sex or avoid having sex under certain circumstances. But when they have sex, and most people do sooner or later, they need to know what the dangers are and how to protect themselves.
Those who are forced to resort to commercial sex work will need to be particularly careful, of course. But they will also need the protection of the law against violence, rape and other forms of abuse. They will need access to information, to health care and to legal services. These are not readily available to commercial sex workers at present.
Indeed, they are not readily available to the majority of Kenyans. ABC is not enough to protect most people from HIV and other sexually transmitted infections. It never was enough and it never will be enough. When will the moral crusaders realise that they are wrong and that they are creating and upholding the conditions that allow HIV to spread in Kenya and other countries?
Some argue that ABC and other campaigns are suitable for adults but not for children. I would argue that such campaigns are not enough for adults but also that children are even more vulnerable than adults. Therefore children need, not just more strategies and education, but more protection.
Children themselves, when asked, say they feel they are being denied access to knowledge about how to protect themselves from HIV. Under the UN Declaration of Commitment on HIV/AIDS, 2001, children are those below the age of 15. Most young people over the age of 15 don't even receive the vital information they need but the ones who are not targeted, those under 15, are exceptionally vulnerable.
Many of them are already sexually active, often having sexual experiences that they do not choose to have. In other words, they are being coerced or somehow pressurised into having sex. It seems unlikely that those forcing minors to have sex are taking precautions against HIV. So what chance have those minors?
Questions about how to inform children about sexuality and the dangers involved are difficult and may take some time to resolve. But they won't be resolved by pretending that it is unnecessary to even discuss sex and sexuality with them. The belief that children who are informed about sex are more likely to have sex has long been discredited.
Children who are informed about sex are more likely to put off having sex for the first time till later in life, often till they have finished school. They are more likely to understand risks, for example, the risks involved in sleeping with men who are older than them. They are more likely to know about and use condoms. They are more likely to be able to negotiate safer sex.
Perhaps it's not children who have a problem with knowledge of sex and sexuality, perhaps it's adults; parents, guardians and teachers. This problem is not confined to developing countries. Where I grew up, Ireland, teachers and parents alike had problems talking about sexuality. I suspect that many still do. Having spent much of my adult life in the UK, I know that most people there find sex and sexuality difficult to talk about.
That's a problem that needs to be faced, not denied and avoided. The sooner we, as adults, sort out our problems with the subject, the sooner we can protect our own children and young people.
On the subject of moral crusades and righteous indignation, the Kenyan HIV and AIDS Prevention and Control Act, 2006, worries many people. For many years, those involved in HIV prevention and the care of those infected with HIV have been fighting to reduce stigma. This act may increase stigma. If people are to be encouraged to know their status, which is said to be the first step in reducing the spread of HIV, they need to know that they will not be discriminated against in any way if they happen to be HIV positive.
Once everyone knows about the dangers of HIV, once everyone has access to HIV testing and HIV care, once the health and welfare of Kenyans are adequately accounted for, then the question of willful transmission can perhaps be addressed more equitably. But we are nowhere near that stage yet. It would be a mistake to put any obstacles in the way of wider testing and greater openness.
More women than men are infected with HIV, but also, more women know their HIV status than men. Already, women have been the victims of stigma and discrimination, despite the fact that they are not more responsible than men for the spread of HIV. How will this law affect women, who are usually tested when they are pregnant, and those who are willing to be tested? Whoever the law is designed to protect, it seems likely to fail.
Reducing transmission of HIV requires that the rights and responsibilities of everyone be upheld, not just the rights of those who are uninfected. The fight against HIV will necessarily involve those who are infected, just as much as those who are not infected. If their rights had been upheld in the first place they would not now be HIV positive.
Don't exclude HIV positive people, children or anyone else from the prevention equation.
The researchers conclude that treatments such as vaccine are needed. But they also conclude that condoms are clearly needed as they protect against infection. Those favouring the 'ABC' (Abstain, Be faithful, use a Condom) approach to HIV prevention must take note that abstaining and even being faithful are not enough. Many monogamous women are infected by their husbands or by their partner. Yet some people involved in HIV prevention insist that abstinence on its own or abstinence combined with faithfulness are enough.
Abstinence on its own, or even abstinence plus being faithful (where abstinence alone is not possible), are not enough to protect people from HIV. Abstinence is just not an option in many circumstances and being faithful can also be elusive. Abstinence, faithfulness and using condoms are only three aspects of avoiding HIV, other sexually transmitted infections (STIs) and unwanted pregnancies.
Those working in HIV prevention who are squeamish or downright bloody-minded about the use of condoms need to reconsider their stance. Are they interested in preventing HIV or are they merely interested in prognosticating at the expense of the people whose interests they claim to be protecting? People have sex. They may 'abstain' or refuse to have sex or avoid having sex under certain circumstances. But when they have sex, and most people do sooner or later, they need to know what the dangers are and how to protect themselves.
Those who are forced to resort to commercial sex work will need to be particularly careful, of course. But they will also need the protection of the law against violence, rape and other forms of abuse. They will need access to information, to health care and to legal services. These are not readily available to commercial sex workers at present.
Indeed, they are not readily available to the majority of Kenyans. ABC is not enough to protect most people from HIV and other sexually transmitted infections. It never was enough and it never will be enough. When will the moral crusaders realise that they are wrong and that they are creating and upholding the conditions that allow HIV to spread in Kenya and other countries?
Some argue that ABC and other campaigns are suitable for adults but not for children. I would argue that such campaigns are not enough for adults but also that children are even more vulnerable than adults. Therefore children need, not just more strategies and education, but more protection.
Children themselves, when asked, say they feel they are being denied access to knowledge about how to protect themselves from HIV. Under the UN Declaration of Commitment on HIV/AIDS, 2001, children are those below the age of 15. Most young people over the age of 15 don't even receive the vital information they need but the ones who are not targeted, those under 15, are exceptionally vulnerable.
Many of them are already sexually active, often having sexual experiences that they do not choose to have. In other words, they are being coerced or somehow pressurised into having sex. It seems unlikely that those forcing minors to have sex are taking precautions against HIV. So what chance have those minors?
Questions about how to inform children about sexuality and the dangers involved are difficult and may take some time to resolve. But they won't be resolved by pretending that it is unnecessary to even discuss sex and sexuality with them. The belief that children who are informed about sex are more likely to have sex has long been discredited.
Children who are informed about sex are more likely to put off having sex for the first time till later in life, often till they have finished school. They are more likely to understand risks, for example, the risks involved in sleeping with men who are older than them. They are more likely to know about and use condoms. They are more likely to be able to negotiate safer sex.
Perhaps it's not children who have a problem with knowledge of sex and sexuality, perhaps it's adults; parents, guardians and teachers. This problem is not confined to developing countries. Where I grew up, Ireland, teachers and parents alike had problems talking about sexuality. I suspect that many still do. Having spent much of my adult life in the UK, I know that most people there find sex and sexuality difficult to talk about.
That's a problem that needs to be faced, not denied and avoided. The sooner we, as adults, sort out our problems with the subject, the sooner we can protect our own children and young people.
On the subject of moral crusades and righteous indignation, the Kenyan HIV and AIDS Prevention and Control Act, 2006, worries many people. For many years, those involved in HIV prevention and the care of those infected with HIV have been fighting to reduce stigma. This act may increase stigma. If people are to be encouraged to know their status, which is said to be the first step in reducing the spread of HIV, they need to know that they will not be discriminated against in any way if they happen to be HIV positive.
Once everyone knows about the dangers of HIV, once everyone has access to HIV testing and HIV care, once the health and welfare of Kenyans are adequately accounted for, then the question of willful transmission can perhaps be addressed more equitably. But we are nowhere near that stage yet. It would be a mistake to put any obstacles in the way of wider testing and greater openness.
More women than men are infected with HIV, but also, more women know their HIV status than men. Already, women have been the victims of stigma and discrimination, despite the fact that they are not more responsible than men for the spread of HIV. How will this law affect women, who are usually tested when they are pregnant, and those who are willing to be tested? Whoever the law is designed to protect, it seems likely to fail.
Reducing transmission of HIV requires that the rights and responsibilities of everyone be upheld, not just the rights of those who are uninfected. The fight against HIV will necessarily involve those who are infected, just as much as those who are not infected. If their rights had been upheld in the first place they would not now be HIV positive.
Don't exclude HIV positive people, children or anyone else from the prevention equation.
Subscribe to:
Posts (Atom)
