Sexually transmitted infections (STI) are not highest in countries where the people are most promiscuous. According to figures on the 'Barking up the wrong tree' blog, Finland is number one in the promiscuity charts, followed by New Zealand, Slovenia and Lithuania. None of the countries in the top ten are in Africa and they are all likely to be relatively low on the STI charts.
In fact, high rates of STIs are more closely associated with crumbling health services than 'promiscuity' levels. If any avoidable and treatable disease, whether sexually transmitted or not, reaches endemic proportions in a country, that says a lot about its health services and the conditions in which people live.
But that doesn't stop journalists writing about promiscuity, immorality and groups of people who need to be targeted by whatever HIV prevention program happens to be hitting the headlines. Usually it's immoral men who are the target, even though far more women than men are infected with HIV in high prevalence countries.
Ironically, the South African health minister, Aaron Motsoaledi recommends male circumcision and public confidence in state run hospitals. Yet, elsewhere we read about the conditions in SA hospitals, which would not encourage anyone to have any kind of invasive treatment there, let alone circumcision. One of the biggest fears would be HIV and other blood borne diseases.
Some of the most popular punchbags have been truckers and other long distance drivers and sex workers. These two groups may well be promiscuous but articles about their behavior never seem to enquire into the whole range of HIV related risks they face. For example, both groups have been targeted by STI reduction programs. But HIV prevalence among sex workers in Tanzania and Kenya rocketed long before it was common in the general population. So did the STI programs inadvertently spread HIV?
In response to the motion "Can we treat our way out of the HIV epidemic?", a professor chairing the debate asked "what would happen if we targeted key populations such as sex workers, truck drivers and fishermen?" Well it depends on what they are targeted with. If it's more of the usual finger-wagging, I think the result will also be more of the same - nothing. But if some effort is made to find out why these groups are infected in such large numbers we might find our way out of the entire pandemic.
The First Ladies referred to in a recent article make a common mistake: they claim that "if the youth shun pre-marital sex and married partners are faithful to each other, Africa will get a generation of children free of AIDS". They are talking about a world where HIV is almost always transmitted sexually. This is not such a world. They may have a point about reducing sexual risk but that has never translated into reduced HIV transmission.
Despite all the talk about 'risky' sexual behavior leading to high rates of HIV transmission, research from Tanzania shows that high levels of risky behavior (multiple sexual partners and low condom use) often don't result in high HIV rates. None of the areas studied have especially high HIV rates, unless that's about to change.
The association of HIV with sex, morality, religion, etc, is not based on any evidence about how HIV is transmitted or about how transmission could be reduced. Efforts to reduce transmission in high prevalence countries have long been in vain. And as long as these ridiculous and stigmatizing claims continue to be made, HIV will not be eradicated. Abstinence is not the answer, no matter how much the HIV industry may love the concept.
Showing posts with label abstinence. Show all posts
Showing posts with label abstinence. Show all posts
Tuesday, July 12, 2011
Tuesday, August 17, 2010
Swaziland Takes Half a Step Towards Eradicating HIV
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.
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.
Friday, November 27, 2009
Self Destructiveness Seems Like a Strange Quality in a Church
I've had time to read UNAIDS's 2009 HIV Epidemic Update and it's interesting, but perplexing in many ways. Take, for example, the issue of unprotected sex with multiple partners. As a result of research into different modes of transmission and their relative importance in different countries, it was found that Kenya has a particular problem with people having unprotected sex with several different partners.
This didn't come as a big shock, of course. Many people, all over the world, have unprotected sex with several different partners. But the risk of transmitting or being infected with HIV is much higher in a country with high prevalence of HIV and certain other sexually transmitted infections (STI). And Kenya is such a country, with 7-8% HIV prevalence, high prevalence of STIs known to make one more susceptible to transmitting and contracting HIV (such as herpes simplex virus), very poor education and health services and an attitude towards condom use that is, I suspect, strongly influenced by conservative religion and politics.
The shocking thing is how many people are willing to take such risks with their sexual partners while refusing to use condoms, coupled with the fact that tens if not hundreds of millions of dollars have been spent on HIV prevention campaigns that advocate the use of condoms. A recent campaign by the extremely wealthy, powerful and conservative Population Services International (PSI) aims at stopping relationships on the side or multiple relationships. The campaign mentions condoms too but concentrates on stopping the relationships.
The trouble is that after many years of some parties campaigning for safer sex, others have been campaigning for no sex at all or no sex except inside marriage. The volume of this sort of campaigning is high and usually advocates against the use of condoms or suggests condom use only in difficult circumstances (such as where one's partner is already infected with HIV). Aside from the fact that in Kenya, Uganda and other countries, the chances of becoming infected by one's marital partner is higher than becoming infected by a casual partner, many people are not married, are no longer married or have not, as yet, been able to get married. So lecturing them about abstaining till marriage can be a rather pointless exercise.
One of the apparent results of all these campaigns that have a pseudo-moral political and religious agenda is that people have internalised the message about not using condoms but they haven't given up having sex with a number of different people. Many of the people who engage in multiple partnerships are married, so they are in danger of infecting their partner or being infected by their partner. And yet the religious and political zealots keep ranting on about condoms and how they are not the solution.
The Catholic pope is quite right when he says that HIV cannot be overcome by relying exclusively or primarily on the distribution of condoms. They need to be used, all the time, and properly in order to reduce the transmission of HIV. He may also be right about the importance of conjugal fidelity, but conjugal fidelity appears to be rather rare, perhaps more so among those married in the Catholic church than in many others. As for sexual abstinence, it appears to be rare in the Catholic church and is not even a foregone conclusion among those who profess to have taken a vow of chastity.
If we lived in the sort of world the pope is talking about, where everyone did only what they were supposed to do with regard to sexual behaviour, there would be no need for condoms or many of the other things that he and his ilk object to so strongly. But then, nor would there be HIV or other sexually transmitted infections. Maybe people shouldn't have sex except within marriage and for the purpose of procreation, according to some moral code. But people have sex, defecate, eat, drink, sleep and play.
According to the moral code of some people, having sex or exercising many other forms of human behaviour are not, in themselves, moral or immoral. Which is not to say it is not wrong to have sex with one person when you are in a relationship with someone who thinks that they are your only partner, for example. But the pope sees having sex outside the strict bounds of Catholic teaching as absolutely wrong. And using a condom to avoid an unplanned pregnancy or to protect oneself from HIV or any other STI is also wrong. Yet, in a world where people only had sex within those strict bounds, it would seem strange to even have to make a pronouncement about contraception.
Maybe the pope will keep going on about abstinence until marriage and the evils of contraception. If he does, all the worse for the Catholics who choose to listen to him. And I'm talking about the Catholics who live in this world, in Africa in particular. Because a lot of them don't seem willing to take all of his advice, preferring to select the bits they like and leaving out the bits they don't like. The pope is surprisingly influential and as a result of his influence, HIV continues to spread rapidly in Kenya and other countries. It infects innocent people, through various means, young and old people, religious and non-religious people and especially people who have sex. And that's most people, as far as I know.
This didn't come as a big shock, of course. Many people, all over the world, have unprotected sex with several different partners. But the risk of transmitting or being infected with HIV is much higher in a country with high prevalence of HIV and certain other sexually transmitted infections (STI). And Kenya is such a country, with 7-8% HIV prevalence, high prevalence of STIs known to make one more susceptible to transmitting and contracting HIV (such as herpes simplex virus), very poor education and health services and an attitude towards condom use that is, I suspect, strongly influenced by conservative religion and politics.
The shocking thing is how many people are willing to take such risks with their sexual partners while refusing to use condoms, coupled with the fact that tens if not hundreds of millions of dollars have been spent on HIV prevention campaigns that advocate the use of condoms. A recent campaign by the extremely wealthy, powerful and conservative Population Services International (PSI) aims at stopping relationships on the side or multiple relationships. The campaign mentions condoms too but concentrates on stopping the relationships.
The trouble is that after many years of some parties campaigning for safer sex, others have been campaigning for no sex at all or no sex except inside marriage. The volume of this sort of campaigning is high and usually advocates against the use of condoms or suggests condom use only in difficult circumstances (such as where one's partner is already infected with HIV). Aside from the fact that in Kenya, Uganda and other countries, the chances of becoming infected by one's marital partner is higher than becoming infected by a casual partner, many people are not married, are no longer married or have not, as yet, been able to get married. So lecturing them about abstaining till marriage can be a rather pointless exercise.
One of the apparent results of all these campaigns that have a pseudo-moral political and religious agenda is that people have internalised the message about not using condoms but they haven't given up having sex with a number of different people. Many of the people who engage in multiple partnerships are married, so they are in danger of infecting their partner or being infected by their partner. And yet the religious and political zealots keep ranting on about condoms and how they are not the solution.
The Catholic pope is quite right when he says that HIV cannot be overcome by relying exclusively or primarily on the distribution of condoms. They need to be used, all the time, and properly in order to reduce the transmission of HIV. He may also be right about the importance of conjugal fidelity, but conjugal fidelity appears to be rather rare, perhaps more so among those married in the Catholic church than in many others. As for sexual abstinence, it appears to be rare in the Catholic church and is not even a foregone conclusion among those who profess to have taken a vow of chastity.
If we lived in the sort of world the pope is talking about, where everyone did only what they were supposed to do with regard to sexual behaviour, there would be no need for condoms or many of the other things that he and his ilk object to so strongly. But then, nor would there be HIV or other sexually transmitted infections. Maybe people shouldn't have sex except within marriage and for the purpose of procreation, according to some moral code. But people have sex, defecate, eat, drink, sleep and play.
According to the moral code of some people, having sex or exercising many other forms of human behaviour are not, in themselves, moral or immoral. Which is not to say it is not wrong to have sex with one person when you are in a relationship with someone who thinks that they are your only partner, for example. But the pope sees having sex outside the strict bounds of Catholic teaching as absolutely wrong. And using a condom to avoid an unplanned pregnancy or to protect oneself from HIV or any other STI is also wrong. Yet, in a world where people only had sex within those strict bounds, it would seem strange to even have to make a pronouncement about contraception.
Maybe the pope will keep going on about abstinence until marriage and the evils of contraception. If he does, all the worse for the Catholics who choose to listen to him. And I'm talking about the Catholics who live in this world, in Africa in particular. Because a lot of them don't seem willing to take all of his advice, preferring to select the bits they like and leaving out the bits they don't like. The pope is surprisingly influential and as a result of his influence, HIV continues to spread rapidly in Kenya and other countries. It infects innocent people, through various means, young and old people, religious and non-religious people and especially people who have sex. And that's most people, as far as I know.
Wednesday, October 21, 2009
People Need Protection from Harm, Not Punishment for Being Harmed
It has been revealed at a conference in Nairobi that 60% of all new sexually transmitted infections, including HIV, occur in those aged 15-24. These are the very people who should have received, and should still be receiving in the case of those in their mid teens, the latest HIV prevention programming. The authors of the report even suggest that there may be significant under-reporting of risky sexual behaviour.
The report calls for a 'more aggressive' educational approach, whatever that may mean. In a separate article on back street abortions in Kenya, there are some worrying remarks on sex education. Aside from concentrating on abstinence, often to the exclusion of anything else, teachers who are trained in teaching sex education are under no obligation to teach it. There is no specific time set aside for them to do so and many parents would prefer teachers not to teach their children anything about sex.
Kenya has spent over 20 years resisting the call to teach their children and adults about sex, safe sex, family planning, maternal health and health in general. In particular, they have resisted advice to promote the use of condoms to prevent HIV, other sexually transmitted infections and unplanned pregnancies. The multiple uses of condoms need to be stressed.
The repeated calls for abstinence, however dressed up in pointless slogans, are useless. Years of sexual transmission of HIV, other sexually transmitted infections and unplanned pregnancies show that these 'prevention' programmes have not worked. Unfortunately, the latest National Aids Strategic Plan has little new to suggest to prevent HIV from being transmitted and it still only allocates about 30% of HIV/Aids funding to prevention. But no amount of money will make a difference if abstinence is the best they can come up with.
Countries with high rates of HIV transmission seem to be obsessed with abstinence campaigns, which have had no impact and will continue to have no impact. Telling young people that it is worth their while waiting till they are married is simply lying in the face of evidence that many people become infected by their spouse. They need to be told about the dangers they face and given ways to avoid those dangers. If condom use is the best we've got right now, we owe it to people to promote the use of condoms.
Those who object to abortion, HIV, sexually transmitted infections, promiscuous sex, unsafe sex, sexual abuse and various other things that they rail about need to embrace comprehensive sex education for everyone, young and old. Denying the existence of risky practices, commercial sex work, men having sex with men, intravenous drug use and the rest is not going to make it go away. Moralising about it and saying how bad it all is will not make it go away either.
It's very hard to legislate over people's sexual behaviour. And even behaviour that is illegal will occur, despite the threat of punishment. The least the Kenyan government can do is to reduce the amount of harm people are currently being exposed to. Many Kenyans are now experiencing the consequences of not implementing harm reduction programmes, such as the widespread promotion of condoms, decriminalisation of commercial sex work and same sex relationships, needle exchange programmes and even family planning services that would support people who end up pregnant against their wishes. People need to be protected from harm, not punished for being harmed.
The report calls for a 'more aggressive' educational approach, whatever that may mean. In a separate article on back street abortions in Kenya, there are some worrying remarks on sex education. Aside from concentrating on abstinence, often to the exclusion of anything else, teachers who are trained in teaching sex education are under no obligation to teach it. There is no specific time set aside for them to do so and many parents would prefer teachers not to teach their children anything about sex.
Kenya has spent over 20 years resisting the call to teach their children and adults about sex, safe sex, family planning, maternal health and health in general. In particular, they have resisted advice to promote the use of condoms to prevent HIV, other sexually transmitted infections and unplanned pregnancies. The multiple uses of condoms need to be stressed.
The repeated calls for abstinence, however dressed up in pointless slogans, are useless. Years of sexual transmission of HIV, other sexually transmitted infections and unplanned pregnancies show that these 'prevention' programmes have not worked. Unfortunately, the latest National Aids Strategic Plan has little new to suggest to prevent HIV from being transmitted and it still only allocates about 30% of HIV/Aids funding to prevention. But no amount of money will make a difference if abstinence is the best they can come up with.
Countries with high rates of HIV transmission seem to be obsessed with abstinence campaigns, which have had no impact and will continue to have no impact. Telling young people that it is worth their while waiting till they are married is simply lying in the face of evidence that many people become infected by their spouse. They need to be told about the dangers they face and given ways to avoid those dangers. If condom use is the best we've got right now, we owe it to people to promote the use of condoms.
Those who object to abortion, HIV, sexually transmitted infections, promiscuous sex, unsafe sex, sexual abuse and various other things that they rail about need to embrace comprehensive sex education for everyone, young and old. Denying the existence of risky practices, commercial sex work, men having sex with men, intravenous drug use and the rest is not going to make it go away. Moralising about it and saying how bad it all is will not make it go away either.
It's very hard to legislate over people's sexual behaviour. And even behaviour that is illegal will occur, despite the threat of punishment. The least the Kenyan government can do is to reduce the amount of harm people are currently being exposed to. Many Kenyans are now experiencing the consequences of not implementing harm reduction programmes, such as the widespread promotion of condoms, decriminalisation of commercial sex work and same sex relationships, needle exchange programmes and even family planning services that would support people who end up pregnant against their wishes. People need to be protected from harm, not punished for being harmed.
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.
Tuesday, March 24, 2009
A Role for the Christian Churches in Africa?
Those who refuse to accept that condoms have a role to play in reducing transmission of HIV should take note of the following findings from a study carried out in Hlabisa district, South Africa. It was found that HIV incidence (the number of new infections per year) was high and remained unchanged over a five year period, despite large scale prevention work being carried out over the same period.
HIV prevention needs to pull out all the stops. Abstinence is great if it works, being faithful is great too. Using condoms is vital where the first two don’t happen, but there are still many other things that need to be taken care of. People need education, health services, social services, they need jobs, economic security and a viable future. There are multiple vulnerabilities that allow HIV to spread and no single intervention or single set of interventions will be enough to cut transmission significantly. Transmission should be reduced by every means possible.
The South African research found that half of all new infections occurred in people who had already received a negative test result. Those who have been tested have also been counselled and thus could be expected to change their behaviour, but clearly testing and counselling are not enough.
This and other studies show that people’s behaviour is only likely to change if they are found to be HIV positive. It’s good to know that people who find they are HIV positive reduce their risky behaviour but the aim of HIV prevention should be to prevent new infections. Too much money and emphasis has gone into spectacularly unsuccessful finger wagging exercises about abstinence and Christian morality, other ill informed ‘moral’ pronouncements and downright lies and misinformation.
Most of the people who became infected during the study period were young people. Many interventions, especially school based interventions, have been shown to have little effect. They have some influence on people’s knowledge about sex, even some influence on their self-reported sexual behaviour. But most have had little or no influence on transmission of HIV or other sexually transmitted infections or even unwanted pregnancies.
In Uganda and later in Kenya, it is possible that the effect of so many people becoming visibly ill and dying resulted in behaviour change speeding up. Sadly, the pace of behaviour change may be slowing down now as a result of death rates going down. But even this doesn’t seem to have happened in the South African area in question. There are many families with several HIV positive people, some already on antiretroviral therapy (ART). Others hadn’t even heard of ART (so their behaviour could not have been affected by ‘disinhibition’, thinking that one doesn’t need to take precautions against HIV infection because treatment is available).
It is noted that Hlabisa has little employment and is mainly agricultural. Many areas of Kenya, Tanzania and other African countries are like that, the majority of people living in rural areas and living at subsistence levels. Even many of the urban dwellers live in slums and are as badly off or even worse off than rural dwellers. Most people are denied basic health, education and other social services.
It is not surprising that people receiving small amounts of schooling, or even large amounts of schooling, learn very little. Educational standards are low and those who get through school have little to look forward to. Developing countries have high disease burdens but very few health services, which are of poor quality anyhow. Water and sanitation, communications networks, transport infrastructure and other utilities have been run down for decades in Kenya and other African countries. These areas of underdevelopment need to be part of any programme intended to reduce transmission of HIV.
Given the huge following that Christian churches have in African countries, perhaps Christian leaders could preach to the as yet unconverted political leaders, business people and financiers in Africa and beyond. Perhaps they could preach abstinence from greed, dictatorship, imperialism and exploitation (although some may say these leaders are guilty of these themselves). After all, I assume they come not to call the righteous, but sinners, to repent.
HIV prevention needs to pull out all the stops. Abstinence is great if it works, being faithful is great too. Using condoms is vital where the first two don’t happen, but there are still many other things that need to be taken care of. People need education, health services, social services, they need jobs, economic security and a viable future. There are multiple vulnerabilities that allow HIV to spread and no single intervention or single set of interventions will be enough to cut transmission significantly. Transmission should be reduced by every means possible.
The South African research found that half of all new infections occurred in people who had already received a negative test result. Those who have been tested have also been counselled and thus could be expected to change their behaviour, but clearly testing and counselling are not enough.
This and other studies show that people’s behaviour is only likely to change if they are found to be HIV positive. It’s good to know that people who find they are HIV positive reduce their risky behaviour but the aim of HIV prevention should be to prevent new infections. Too much money and emphasis has gone into spectacularly unsuccessful finger wagging exercises about abstinence and Christian morality, other ill informed ‘moral’ pronouncements and downright lies and misinformation.
Most of the people who became infected during the study period were young people. Many interventions, especially school based interventions, have been shown to have little effect. They have some influence on people’s knowledge about sex, even some influence on their self-reported sexual behaviour. But most have had little or no influence on transmission of HIV or other sexually transmitted infections or even unwanted pregnancies.
In Uganda and later in Kenya, it is possible that the effect of so many people becoming visibly ill and dying resulted in behaviour change speeding up. Sadly, the pace of behaviour change may be slowing down now as a result of death rates going down. But even this doesn’t seem to have happened in the South African area in question. There are many families with several HIV positive people, some already on antiretroviral therapy (ART). Others hadn’t even heard of ART (so their behaviour could not have been affected by ‘disinhibition’, thinking that one doesn’t need to take precautions against HIV infection because treatment is available).
It is noted that Hlabisa has little employment and is mainly agricultural. Many areas of Kenya, Tanzania and other African countries are like that, the majority of people living in rural areas and living at subsistence levels. Even many of the urban dwellers live in slums and are as badly off or even worse off than rural dwellers. Most people are denied basic health, education and other social services.
It is not surprising that people receiving small amounts of schooling, or even large amounts of schooling, learn very little. Educational standards are low and those who get through school have little to look forward to. Developing countries have high disease burdens but very few health services, which are of poor quality anyhow. Water and sanitation, communications networks, transport infrastructure and other utilities have been run down for decades in Kenya and other African countries. These areas of underdevelopment need to be part of any programme intended to reduce transmission of HIV.
Given the huge following that Christian churches have in African countries, perhaps Christian leaders could preach to the as yet unconverted political leaders, business people and financiers in Africa and beyond. Perhaps they could preach abstinence from greed, dictatorship, imperialism and exploitation (although some may say these leaders are guilty of these themselves). After all, I assume they come not to call the righteous, but sinners, to repent.
Thursday, March 19, 2009
Abstinence: the Immaculate Contraception
Why is abstinence not proposed as a strategy to reduce alcohol or drug dependency? How about obesity as a result of overeating? Perhaps it’s because if those with a dependency could abstain, they wouldn’t have a dependency. Ok, some people manage to give up drugs, alcohol or overeating. That takes a lot of work and a lot of help and support. Some succeed and some don’t.
Why is abstinence not proposed as a strategy to reduce crime? Instead of having laws, why not just have a campaign to get potential criminals to vow to abstain from crime? They should know that crime is wrong and that they will be punished if they are caught. I think the answer is obvious.
But a certain Mr Pope, a man without an electoral mandate or, indeed, without any experience of sexual intercourse or sexual relationships, thinks that abstinence is the only way to avoid HIV. Well, Mr Pope, you’re quite wrong. In Nyanza province in Kenya, women are more likely to contract HIV from their husbands. Husbands also contract HIV from their wives.
Yes, both parties should abstain, of course. Everyone ‘should’ abstain, but abstinence does not protect anyone from sexual desire. One party in a relationship abstaining does not ensure that the other party also abstains.
Abstinence is an individual decision but most sexual relationships require more than one person. The issue is not about individual duties and responsibilities but rather the duties and responsibilities of people who live in close contact with other people. Each person’s life is to a large extent determined by external influences. Human behaviour and sexual desire do not arise in individuals in isolation, they arise in individuals living with other individuals.
Those external (or non individual) influences determine many things, including when, where, how often and with whom people have sexual relationships. An individual’s decision to abstain doesn’t protect them from HIV because their HIV status is also influenced by factors external to them.
As for the individual decision to abstain, well, I certainly don’t decide to do things that would put me in danger. I am fairly risk averse, I don’t enjoy pain or dangerous activities. But just as the absence of safe water and food supply would not make me any less thirsty or hungry, the relative dangers of sleeping with another person would not decrease the sexual desire I may feel.
If a person doesn’t feel much sexual desire or their desire is outweighed by other considerations, there may be no problem. If they get to decide whether to have sex and with whom, great, they are lucky. But there are many people who are not in that position, for one reason or another. Even in the Catholic Church, people are often in positions where they will have sex, whether they choose to or not.
Abstinence does not guarantee against harm because an individual decision to abstain from sex does not preclude something arising to override that decision. Nor does it guarantee that others will respect the individual decision to abstain.
But, quite frankly, I don’t want to abstain. I think that I have a right to have consensual sex with another adult. I don’t think Mr Pope agrees, but I just don’t subscribe to his views. I don’t feel the need to repress my sexual desire in order to follow his blind dogma. And I know that the absence of the opportunity to engage in sexual activity does not result in sexual desire just disappearing.
So if abstinence is not always going to work, what other options for harm reduction are there? Condoms sound like an obvious harm reduction strategy against sexually transmitted infections. Mr Pope advocates against using condoms because it is ‘wrong’. But Mr Pope and his adherents have defended many things that would also be considered wrong, so I don’t really see where his authority comes from.
Actually, that’s where my argument becomes seriously unstuck. Millions of Africans (and other people around the world) invest authority in Mr Pope and his acolytes. In Kenya and Tanzania, people constantly talk about Jesus, God, their religion, the bible, various quotations and proverbs and titbits of ‘knowledge’ from religious sources.
Mr Pope speaks for millions of people because they pay millions of pounds to support him and his religious prognostications. But beware, Mr Pope, you have many followers who go to your churches and contribute towards the obscene amounts of money you receive, but they don’t abstain. HIV rates are usually higher among those claiming to be Christian than among other religious groups.
I don’t see why Mr Pope’s religious teachings should have such a profound bearing on public health. He clearly knows nothing about public health, but that’s understandable. What I find difficult to understand is his lack of understanding about human behaviour. Even if he doesn’t feel sexual desire or if he feels it’s something he should deal with in other ways than sexual behaviour, why does he think that everyone else should feel the same way. Why does he think that others are able to behave as he does?
Mr Pope, whether you want to hear it or not; abstinence as a strategy does not work. Even if you are not interested in the many studies carried out that show that abstinence as a strategy does not work, you must be able to see that millions of your followers are infected with HIV and millions more will become infected.
I stand to be corrected on this but I think suicide is also considered wrong in the Catholic faith? Is a strategy that is known to fail to protect against HIV not suicidal? By preaching against the use of condoms and advocating abstinence, are you not in danger of increasing what is effectively suicidal behaviour, Mr Pope?
Why is abstinence not proposed as a strategy to reduce crime? Instead of having laws, why not just have a campaign to get potential criminals to vow to abstain from crime? They should know that crime is wrong and that they will be punished if they are caught. I think the answer is obvious.
But a certain Mr Pope, a man without an electoral mandate or, indeed, without any experience of sexual intercourse or sexual relationships, thinks that abstinence is the only way to avoid HIV. Well, Mr Pope, you’re quite wrong. In Nyanza province in Kenya, women are more likely to contract HIV from their husbands. Husbands also contract HIV from their wives.
Yes, both parties should abstain, of course. Everyone ‘should’ abstain, but abstinence does not protect anyone from sexual desire. One party in a relationship abstaining does not ensure that the other party also abstains.
Abstinence is an individual decision but most sexual relationships require more than one person. The issue is not about individual duties and responsibilities but rather the duties and responsibilities of people who live in close contact with other people. Each person’s life is to a large extent determined by external influences. Human behaviour and sexual desire do not arise in individuals in isolation, they arise in individuals living with other individuals.
Those external (or non individual) influences determine many things, including when, where, how often and with whom people have sexual relationships. An individual’s decision to abstain doesn’t protect them from HIV because their HIV status is also influenced by factors external to them.
As for the individual decision to abstain, well, I certainly don’t decide to do things that would put me in danger. I am fairly risk averse, I don’t enjoy pain or dangerous activities. But just as the absence of safe water and food supply would not make me any less thirsty or hungry, the relative dangers of sleeping with another person would not decrease the sexual desire I may feel.
If a person doesn’t feel much sexual desire or their desire is outweighed by other considerations, there may be no problem. If they get to decide whether to have sex and with whom, great, they are lucky. But there are many people who are not in that position, for one reason or another. Even in the Catholic Church, people are often in positions where they will have sex, whether they choose to or not.
Abstinence does not guarantee against harm because an individual decision to abstain from sex does not preclude something arising to override that decision. Nor does it guarantee that others will respect the individual decision to abstain.
But, quite frankly, I don’t want to abstain. I think that I have a right to have consensual sex with another adult. I don’t think Mr Pope agrees, but I just don’t subscribe to his views. I don’t feel the need to repress my sexual desire in order to follow his blind dogma. And I know that the absence of the opportunity to engage in sexual activity does not result in sexual desire just disappearing.
So if abstinence is not always going to work, what other options for harm reduction are there? Condoms sound like an obvious harm reduction strategy against sexually transmitted infections. Mr Pope advocates against using condoms because it is ‘wrong’. But Mr Pope and his adherents have defended many things that would also be considered wrong, so I don’t really see where his authority comes from.
Actually, that’s where my argument becomes seriously unstuck. Millions of Africans (and other people around the world) invest authority in Mr Pope and his acolytes. In Kenya and Tanzania, people constantly talk about Jesus, God, their religion, the bible, various quotations and proverbs and titbits of ‘knowledge’ from religious sources.
Mr Pope speaks for millions of people because they pay millions of pounds to support him and his religious prognostications. But beware, Mr Pope, you have many followers who go to your churches and contribute towards the obscene amounts of money you receive, but they don’t abstain. HIV rates are usually higher among those claiming to be Christian than among other religious groups.
I don’t see why Mr Pope’s religious teachings should have such a profound bearing on public health. He clearly knows nothing about public health, but that’s understandable. What I find difficult to understand is his lack of understanding about human behaviour. Even if he doesn’t feel sexual desire or if he feels it’s something he should deal with in other ways than sexual behaviour, why does he think that everyone else should feel the same way. Why does he think that others are able to behave as he does?
Mr Pope, whether you want to hear it or not; abstinence as a strategy does not work. Even if you are not interested in the many studies carried out that show that abstinence as a strategy does not work, you must be able to see that millions of your followers are infected with HIV and millions more will become infected.
I stand to be corrected on this but I think suicide is also considered wrong in the Catholic faith? Is a strategy that is known to fail to protect against HIV not suicidal? By preaching against the use of condoms and advocating abstinence, are you not in danger of increasing what is effectively suicidal behaviour, Mr Pope?
Thursday, February 19, 2009
Sex, Christians and Abstinence
Christians are unique in the animal kingdom in that they only experience the desire and even gain the ability to have sex once they are in a relationship of a sort that is approved by their church. If you don't believe me, just read a copy of a Christian bible. Ok, you have to interpret it a bit, but you'll find it there if you want to, and many people want to.
Or perhaps you would not take advice about sex from people who claim to only indulge in sexual intercourse for purposes of procreation? They are the last people I would ask for such advice. It is not supposed to be enjoyable and it is not even supposed to occur at all until approved by the church through marriage vows. Oh, and if you do 'transgress' you must feel terribly guilty and confess to someone who is probably exactly the same as you.
It's been a long time since (my last confession?) I have blogged as I have been travelling a relatively short distance very slowly. That's public transport in East Africa. And since I have reached my destination, Kigoma, Western Tanzania, there has been no electricity. The internet cafe I am writing from is supplied by a diesel generator that shudders and threatens to cut out at regular intervals. So I'll have to keep this posting short.
Several papers I have read on HIV transmission mention lack of diversion or entertainment and boredom as one of the factors in transmission. The man I am staying with mentioned the boring evenings several times and we killed some time by working late, by candle light, taking a long walk, stopping in a pub for a soda and chatting. But we would both have preferred to do something more entertaining or even just read with real electric lights.
Reading is not a big thing in Tanzania. It's very hard to get books and many people have difficulty with reading large amounts of text. So I don't even expect a big demand for books to develop any time soon. TV is popular but those who can afford TV may not be able to afford a generator to run it. Radio is a possibility, but evening with so few things to do and so little money to spend inevitably leads people to pursue cheaper and more readily available activities.
But there doesn't need to be a power cut or lack of things to do for sex to be an option, it's not just a way of filling in time. People don't need to list sex as a hobby no more than they need to list eating. They won't die if they don't have sex but nor will sexual desire go away. In fact, the desire for sex will not go away even if a load of Christians shout very often and very loudly about how you will die if you have sex of a sort they don't approve of.
One of the most extraordinary consequences of the HIV pandemic is the reaction of the Christian churches. They have been preaching abstinence, restraint, poverty and whatever else while practicing the opposite for two thousand years. They manage to attract the poorest people to give away a large chunk of their pittance to a church that lives in splendour. And they are supposed to abstain from their natural desires because of the dogma of people who, very often, know little about abstinence.
Even ostensibly secular states, such as the US, have spent millions of dollars at home and in developing countries on 'abstinence only' sex education. The word 'abstinence' is not just the absence of sex, a run of bad luck, perhaps. It refers to a decision to not have sex until marriage. The word has inherent religious and moral connotations. The policy has been a failure in the sense that most pledgers have sex as much as non-pledgers. In fact, many pledgers soon deny that they took a pledge. Worse still, the pledgers are less likely to use condoms or any form of birth control.
Here in East Africa, I have come across many interpretations of 'sex education', 'abstinence', moral issues, etc. There are those who teach 'abstinence' without even telling people what sex is. Of course, they know, vaguely, what sex is. But they are supposed to be teaching sex education. The word 'abstinence' is not clearly understood by people but even if plain English was used (without the religious and moral baggage), it seems difficult to comprehend the imperative to avoid doing something when you don't know what that something is.
Sex education programmes need to be mindful of what sex is, especially for those who claim not to indulge in sex. HIV is spread, to a large extent, by sex between heterosexuals. But people can be taught what sex is, what sexually transmitted infections are, how to ensure that you don't take risks that might result in unwanted pregnancy or sexually transmitted infection, etc. And the conditions of people's lives, the conditions that determine when, where and how sexual intercourse takes place, these have little to do with sex.
So if people are too squeamish or moral or religious or whatever to talk about sex, and I really think they should avoid the subject, they could better spend their time and money on infrastructure, poverty, gender inequality, poor health and education and many other areas of people's lives. It could be claimed, by the way, that many orphanages, schools and hospitals are run by religious institutions. But the money they spend represents a fraction of the money extracted from church followers. In areas like Kigoma, perhaps some of the churches could consider 'tax exemptions' or monetary rebates from the very poor.
Or perhaps you would not take advice about sex from people who claim to only indulge in sexual intercourse for purposes of procreation? They are the last people I would ask for such advice. It is not supposed to be enjoyable and it is not even supposed to occur at all until approved by the church through marriage vows. Oh, and if you do 'transgress' you must feel terribly guilty and confess to someone who is probably exactly the same as you.
It's been a long time since (my last confession?) I have blogged as I have been travelling a relatively short distance very slowly. That's public transport in East Africa. And since I have reached my destination, Kigoma, Western Tanzania, there has been no electricity. The internet cafe I am writing from is supplied by a diesel generator that shudders and threatens to cut out at regular intervals. So I'll have to keep this posting short.
Several papers I have read on HIV transmission mention lack of diversion or entertainment and boredom as one of the factors in transmission. The man I am staying with mentioned the boring evenings several times and we killed some time by working late, by candle light, taking a long walk, stopping in a pub for a soda and chatting. But we would both have preferred to do something more entertaining or even just read with real electric lights.
Reading is not a big thing in Tanzania. It's very hard to get books and many people have difficulty with reading large amounts of text. So I don't even expect a big demand for books to develop any time soon. TV is popular but those who can afford TV may not be able to afford a generator to run it. Radio is a possibility, but evening with so few things to do and so little money to spend inevitably leads people to pursue cheaper and more readily available activities.
But there doesn't need to be a power cut or lack of things to do for sex to be an option, it's not just a way of filling in time. People don't need to list sex as a hobby no more than they need to list eating. They won't die if they don't have sex but nor will sexual desire go away. In fact, the desire for sex will not go away even if a load of Christians shout very often and very loudly about how you will die if you have sex of a sort they don't approve of.
One of the most extraordinary consequences of the HIV pandemic is the reaction of the Christian churches. They have been preaching abstinence, restraint, poverty and whatever else while practicing the opposite for two thousand years. They manage to attract the poorest people to give away a large chunk of their pittance to a church that lives in splendour. And they are supposed to abstain from their natural desires because of the dogma of people who, very often, know little about abstinence.
Even ostensibly secular states, such as the US, have spent millions of dollars at home and in developing countries on 'abstinence only' sex education. The word 'abstinence' is not just the absence of sex, a run of bad luck, perhaps. It refers to a decision to not have sex until marriage. The word has inherent religious and moral connotations. The policy has been a failure in the sense that most pledgers have sex as much as non-pledgers. In fact, many pledgers soon deny that they took a pledge. Worse still, the pledgers are less likely to use condoms or any form of birth control.
Here in East Africa, I have come across many interpretations of 'sex education', 'abstinence', moral issues, etc. There are those who teach 'abstinence' without even telling people what sex is. Of course, they know, vaguely, what sex is. But they are supposed to be teaching sex education. The word 'abstinence' is not clearly understood by people but even if plain English was used (without the religious and moral baggage), it seems difficult to comprehend the imperative to avoid doing something when you don't know what that something is.
Sex education programmes need to be mindful of what sex is, especially for those who claim not to indulge in sex. HIV is spread, to a large extent, by sex between heterosexuals. But people can be taught what sex is, what sexually transmitted infections are, how to ensure that you don't take risks that might result in unwanted pregnancy or sexually transmitted infection, etc. And the conditions of people's lives, the conditions that determine when, where and how sexual intercourse takes place, these have little to do with sex.
So if people are too squeamish or moral or religious or whatever to talk about sex, and I really think they should avoid the subject, they could better spend their time and money on infrastructure, poverty, gender inequality, poor health and education and many other areas of people's lives. It could be claimed, by the way, that many orphanages, schools and hospitals are run by religious institutions. But the money they spend represents a fraction of the money extracted from church followers. In areas like Kigoma, perhaps some of the churches could consider 'tax exemptions' or monetary rebates from the very poor.
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