Huge Birth Control Programs Don't Work: Time to Give Education a Chance

I recently moved from a job as grant proposal writer for an NGO working in several different development areas to a similar job in a secondary boarding school for girls, which is being built in a country where many girls don't even finish primary school. So I was comforted to find an article entitled 'Women's Education Slows Population Growth'. That women's education can have such profound and positive consequences is not the issue, that has been recognized for a long time, at least by those working in education. But the priority is so often given to population growth, rather than to education or any other development area.

A shocking proportion of 'development' money and a disturbing number of development related insitutions concentrate almost exclusively on population control, in some form or other. They bang on about an unmet need for contraception as if many women will have depleted health or lives as a result of lacking birth control methods, when they are likely to be in far greater need of better nutrition, healthcare, security, governance, equality, infrastructure and, indeed, education. Shovelling contraceptives into rural communities may be a lot easier than providing people with what they need, but without the education and other development areas being addressed, the only gain will accure to the pharmaceutical companies who produce contraceptives.

Similar remarks apply to a lot of other 'health' programs, which target whatever health issue is currently fashionable and well funded; many of them are also necessary, but they would work a lot better if people had the level of education to capitalize on them. Otherwise, they can just go through the motions of attending numerous courses, often for the per diem they may be paid or the free lunch or other minor benefits on offer. I have met people who have been to various 'training courses' only to attend the same course several more times, sometimes provided by the same NGO as before. Training courses are a great way to spend money and it's easy enough to gather data that allows the donor to pronounce the intervention successful. Some health drives pick out some particular disease, perhaps a water borne disease, without addressing water and sanitation in the area. The current drive to 'eliminate' polio is a cases in point; those who attend immunization drives go home to drink contaminated water and contract something else.

Education itself, as we found in my own country, Ireland, is not enough when there are no jobs to go to. And here in Tanzania, women are not considered to be able to do many jobs that they would in fact be well able to do, if they had the education. Sadly, they are considered to be able to do many jobs that are not particularly appropriate for them when they are too young, too old, pregnant, childraising or breastfeeding, but that's another matter. I always feel a bit dishonest when I tell people about how important education is when there is little guarantee many of them will ever get to use it, especially girls and women.

As if there are not enough obstacles, also, school-going girls who become pregnant are excluded from school. In the rare instances where they are allowed to return to school, most do not. This is to 'set an example', we are told. And it does. It shows that girls who get pregnant will be treated very harshly, whereas the boys or men who make them pregnant, generally, will not. The fact that underage girls being made pregnant by older men is a serious crime doesn't get the girls off the hook. Men don't appear to be prosecuted, boys are generally not excluded from school and the strong prejudice against females appears to be practiced by the very institutions that might be in a position to change things.

According to the article, the average birth rate is less than half in regions where education is valued; as I'm working in one of those regions, I'm hoping that birth rates are lower because education is valued. However, even expensive schools with nice, well-funded buildings and facilities, don't always have especially high educational standards. As a fundraiser, sometimes I can see funds for all sorts of things, but not so many that clearly improve education. There is not so much available for good teachers or other provisions that would make a difference. And many fundraisers are tasked with raising money for the buildings, which is important, but often distracts from the ultimate purpose of these buildings.

So, as the article suggests, it's not the correlation between higher standards of education and lower birth rates that is important; it is the priority that is given to education. Proponents of the population control theory of development, so beloved throughout the last fifty years (and still loved by the Rockefeller Foundation, the Gutmacher Institute, the Gates Foundation, Population Services International, Family health Internationa and many more), never appeared to realize what needed to come first, that with development of education, health, infrastructure and the rest, lower birth rates would follow. Similarly, poverty is pervasive in Tanzania, but lower birth rates does not have much direct effect on poverty; rather, lower poverty rates result in improved health, education and the like.

For education to be of benefit, many other things need to be in place as well. But one thing is for sure; reducing birth rates and hoping that other development areas will benefit accordingly has not worked. The funding these charlatans have received urgently needs to be directed towards people's true needs, which are still education, health, a decent standard of living, security, food security and the rest, just as these are the true needs of all people.

Give those Women a Pat on the Head

Those in the Aids industry often talk about gender and empowerment in relation to reducing HIV transmission. But what do they mean? Do they mean that women would be able to protect themselves from HIV if only their rights were recognised, such as the right to decide when, where, with whom and under which circumstances to have sex? Well, gender inequality is repulsive in many ways and it has numerous negative consequences. Gender equality is a human right and we should strive for full gender equality everywhere and remove barriers to equality.

But in developing countries like Kenya, people face all sorts of risks that make them vulnerable to diseases, not just HIV. And the risk of sexually transmitted HIV is higher where women don't have rights to negotiate or determine their sexual or reproductive life. The Aids industry seems anxious to inform women about these rights but they don't seem to regard women's rights to safe healthcare as being important, or as having any relevance to their sexual or reproductive life. These issues only merit brief mention every now and again. I read or scan through hundreds of articles every week and rarely come across one that even mentions the non-sexual risks of HIV.

To repeat myself, gender inequality is repulsive and such inequalities are probably involved in transmission of all sorts of disease and exposure to many risk factors, such as lack of access to clean water and sanitation, adequate housing and a clean environment. But gender inequality itself does not transmit HIV. HIV is a virus transmitted from person to person, through sexual intercourse, by HIV mothers giving birth or breastfeeding or through unsafe medical or cosmetic procedures.

It may sound like hair splitting, but people will continue to have sex (I presume) even if gender inequalities are reduced, they will continue to have children and they will continue to avail of medical and cosmetic procedures. Ensuring that women have the right to choose the circumstances under which they do these things is all very well, but what sort of choices are women going to make when, firstly, they don't know anything about unsafe medical and cosmetic practices and secondly, they have no influence on how those practices are carried out or how to make them less risky?

The truth is that the Aids industry is very much in the dark about how HIV is transmitted in most countries. They know that medical and cosmetic transmission occurs but they have not investigated instances of these kinds of transmission. They have chosen to concentrate on sexual risk to the exclusion of all other risks. They have made a choice about the health and welfare of people, especially women (who are exposed to far more healthcare and cosmetic risks than men), that disempowers women in developing countries. By deciding what risks women need to avoid and ignoring others, the Aids industry is doing the opposite to what it says: it is beating the empowerment drum while silently spreading disempowerment.

Incidentally, the HIV 'gender imbalance' in Kenya is quite curious in many ways. North Eastern province has the worst Gender Development Index (GDI) but also the lowest HIV prevalence. This province also has the highest percentage of girls married by the age of 18. The province with the lowest percentage of girls married by age 18 and one of the best GDI figures, Nairobi, has the second highest HIV prevalence.

Looking at it another way, in Central and Eastern provinces there are four HIV positive women for every one HIV positive man. These two provinces have little in common, with Central having the best set of development indicators and Eastern having one of the worst. Central province has only half the HIV prevalence rate of the country as a whole but Eastern has only a third, in other words, very low HIV prevalence. According to the received Aids industry view, somehow, a small group of men manage to infect a very large group of women. What, exactly, is the Aids industry saying about the sexual behaviour of people in these provinces?

Compared to that, there are only two HIV positive women for every one HIV positive man in North Eastern and Rift Valley provinces. As you move to the provinces with 'more equal' HIV epidemics, where there are only 1.5 HIV positive women for every HIV positive man, you find that these three provinces all have relatively good GDI scores but they account for half of the HIV positive people in Kenya. The Aids industry may interpret this as showing that sexual behaviour in these provinces is not as risky as that in some other provinces. Yet this lower level of risk seems to give rise to much higher rates of HIV transmission.

The oddest ratio of all is found in Coast province, where there are only 1.3 HIV positive women for every one HIV positive man. This looks more like a truly sexually transmitted disease, where male and female prevalences are similar enough. But this is also the province where there is likely to be the highest rates of intravenous drug use (mostly men) and sex tourism (which doesn’t seem to result in large numbers of HIV positive tourists). Even men having sex with men is said to be high here but I don't think that is borne out by the evidence. But is this infection ratio really a reflection of sexual practices here being quite different from those in other provinces? It would be difficult to say without investigating, not just sexual practices, but also any other ways in which HIV could be transmitted.

HIV transmission patterns are very complex and vary a lot, even within a country like Kenya. Gender is, of course, relevant. But perhaps it's not relevant for the reasons the Aids industry wants us to believe. There is little to be gained by patronising campaigns that tell women how hard their lives are but that also ignore the very risks that could most easily be avoided. Gender inequalities don’t just relate to people’s sexual behaviour, they relate to people’s access to healthcare, education and other social goods. Gender inequalities also relate to the sorts of information that people have access to. The Aids industry currently ensures that women don’t have access to adequate information that would allow them to protect themselves and their children from HIV and other diseases.

Women can be empowered and stigma can be reduced at the same time by accepting that HIV is not just transmitted sexually. To work out what proportion of HIV is transmitted sexually and non-sexually, the Aids industry needs to stop obsessing with people's sex lives and further humiliating them. The industry needs to investigate the numerous women who are HIV positive when their partners are HIV negative and the numerous children who are HIV positive but who were probably not infected by their mothers. Simply telling people that being HIV positive is not their fault while making it clear that you think it probably is their fault is not going to help people to avoid HIV risks or to reduce stigma.

Bandying about words like 'gender', 'empowerment' and 'stigma' is not going to reduce HIV transmission as long as non-sexual HIV transmission is left out of the picture. At present, the strategy of the Aids industry simply disempowers people and increases stigma. Don't just pat people on the head and tell them it's not their fault, show them how HIV is being transmitted and how they can protect themselves and others.

Women Are Not Mere Instruments in the Fight Against Aids

One of the recurring themes on this blog is my claim that HIV transmission is not just about sex. In fact, sexual transmission of HIV is not just about sex. What I mean is that there are circumstances surrounding sexual behaviour that determine whether the risk of HIV transmission is higher or lower. And if those circumstances are ignored by the many so called HIV prevention programmes, those programmes will fail.

So far, most HIV prevention programmes have been designed with the assumption that reducing HIV transmission is all about influencing sexual behaviour. This is sometimes referred to as the 'behavioural paradigm'. And most HIV prevention programmes have failed. UNAIDS emphasizes the fact that HIV is now the leading cause of death in women of reproductive age. Considering current rates of maternal illness and death from non Aids related causes in developing countries, this is truly shocking.

But here is the more shocking bit: "up to 70% of women worldwide have been forced to have unprotected sex". If women are subjected to violence to this extent, this is the real outrage. That women do not have the right to choose when to have sex, whether to have sex, with whom to have sex or any of the other circumstances is horrifying. These are the sorts of circumstances surrounding sexual behaviour that I am talking about.

But these rights are not just about sex. If a woman doesn't have these rights, you can be sure there are many other rights she doesn't have. The problem here is that the rights of a huge proportion of women are being denied. Women do not have rights just so that they don't contract HIV or any other sexually transmitted infection. And if a woman does have these rights, the issue of whether she does or doesn't have a say in the circumstances surrounding sexual intercourse will not arise. Not everyone will make the best decisions, of course. But the problem is that at present, some parties are being denied this right.

Michel Sidibe, the executive director of UNAIDS, is wrong on several counts. 'Gender issues' do not need to be addressed because this is a way of reducing transmission of HIV. Gender issues need to be addressed because they have so long been ignored. Ensuring rights for women is not just a useful way of ensuring that the Millennium Development Goals are realised. Women are not mere instruments in the fight against Aids.

In Africa, 60% of the people living with Aids are women. Women are far more vulnerable to being infected than men. Yet so much HIV programming ignores the circumstances in which people live and work. The recent emphasis on mass male circumcision is a good example of an intervention that falls for this behavioural paradigm. It also purports to protect men, to some extent, from HIV. The extent to which it protects women is very unclear.

But most HIV prevention programming uses the same paradigm and has done ever since HIV was found to be mainly a sexually transmitted infection. Women's rights have been mentioned, often in this instrumental way that UNAIDS seems to favour. Even economic, health and educational inequalities have been mentioned. Well these are the issues that need to be targeted, not just mentioned. But most of the big money goes into the tired old finger wagging about what people should and shouldn't do in bed.

The issue of violence against women does not need to be 'integrated into HIV prevention programmes'. This is completely the wrong way around. The issue of HIV prevention needs to be integrated into programming that addresses gender inequalities in social intercourse, marriage, work, education and health. HIV is not bigger than all these and until these are successfully targeted, HIV will continue to elude our best efforts.

Punishing Victims; Protecting Perpetrators

Several Christian organisations and churches in Kenya are claiming 'victory' because the draft constitution has been rewritten to specify that life begins at conception. They threatened to sabotage the whole constitution if this was not done. As a result of their threats, other clauses have also been removed. Kenyans will not now have a right to health care, in particular, reproductive health care. Also, the clause stating that no one may be refused emergency medical treatment has been removed. And there is a phrase that specifically rules out abortion unless the life of the mother is in danger.

Abortion is already illegal in Kenya, but this has not prevented several hundred thousand woman and girls seeking abortion every year. The majority of these abortions, an estimated 800 per day, are unsafe, being carried out in insanitary conditions by untrained personnel. Those who go through these unsafe abortions are less likely to seek professional medical attention and less likely to receive it. As a result, over 2000 die every year, adding considerably to the thousands of maternal deaths that occur.

In what sense have these Christian groups achieved a victory? They don't appear to be opposed to the fact that rape and forced sex often goes unpunished because it is carried out by the more powerful against the powerless. It is carried out by adults against young people, even children. Those who should protect the victims, church leaders, political leaders, teachers, police and others, are often the perpetrators.

If, as Christians are so fond of claiming, life is sacrosanct, why are the lives of certain people so unimportant? Why are human lives so unimportant as to be denied the right to health and the right to make their own reproductive decisions? Women should be able to choose when to have children, under what conditions and with whom. Where these rights have been denied, why should they be made to pay for someone else's crime?

Nothing that these Christians have done will reduce the incidence of unsafe abortions, of seriously compromised reproductive health for women, of women suffering and dying unnecessarily. Nothing that these Christians have done will reduce the incidence of rape and forced sex. Victims of crime should be entitled to protection, not punishment. Perpetrators of crime deserve punishment, especially when those perpetrators are in a position that gives them a level of power that they subsequently abuse.

One priest has said 'we should not victimise the innocent unborn children' but what about the woman or girl who has already been victimised and is now to be punished, perhaps for the rest of her life? Kenya is in dire need of good leadership and the interference of interested parties, whether they be political, religious, commercial or whatever else, is frustrating this need. The country also needs good health care and equal rights for all people, regardless of gender, sexual orientation, tribe, wealth and anything else. But some of the Christian churches clearly have other ideas.

Lack of Logic in the Received View of the HIV Pandemic

Something I have always found mysterious about UNAIDS' view (it's something of a received view) of the course of the HIV epidemic is that they estimate that the number of new infections peaked in Sub-Saharan Africa (SSA) some time in the mid 1990s. And they reckon that the reason new infections began to drop from then on can be put down to the success of HIV prevention and education programmes in changing the sexual behaviour of people, especially men who have sex with men (MSM), commercial sex workers (CSW), intravenous drug users (IDU) and young women.

With few exceptions, most SSA countries were doing very little to treat people with HIV or to prevent the transmission of HIV in the 1990s. Treatment was in its infancy and was inaccessible to the majority of Africans. And where prevention programmes had been implemented, they consisted of little more than mass education campaigns. They had very little influence on people's behaviour in the 1990s. And why would they have much influence? They had only started and only in a few countries, Uganda being one of the countries that started HIV prevention early. But even the nature and effectiveness of Uganda's HIV prevention campaign is still being hotly debated. Prevalence there has changed little in years and sexual behaviour indicators have long been sliding in the wrong direction.

What bothers me is that even if widespread prevention activities started in the mid 1990s, it would take many years for them to have much effect. That's if they actually had any effect at all. Ok, I can't research every country in SSA, but in the case of Kenya, very little was being done in the 1990s. It was only in the early 2000s that some serious work started, say 2002 or 2003. And the Kenya Aids Indicator Survey (KAIS) makes it quite clear that HIV prevalence, which had been dropping before 2003, actually increased and is now higher, after half a decade of HIV prevention work.

What I'm getting at is this: if rates of HIV transmission peaked in the mid nineties, then it did so for some reason other than the fact that every country had implemented widespread prevention programmes. The reason I suggest this is because prevention just wasn't a big thing then, at least, not big enough to explain why the epidemic started to 'decline'. I'm not saying that rates of transmission didn't drop, just that they didn't drop because of prevention programmes.

Another reason for thinking that prevention programmes didn't have much influence on rates of HIV transmission is because even after they did start, there is little evidence that they could have been the cause of the drop. There is plenty of evidence that most current HIV prevention programmes have little or no effect. In Kenya's case, scaling up HIV prevention programmes seem to have resulted in an increase in prevalence, the total number of people living with HIV. This doesn't tell us if transmission rates have decreased, so what about transmission? Are there still lots of people becoming newly infected?

According to the KAIS, transmission patterns are changing. Numbers infected in urban areas have dropped but numbers infected in rural areas have increased, especially among men. The majority of Kenyans, 75% or more, live in rural areas. Poorer and less well educated people are now being infected in greater numbers. The majority of poor and less well educated people live in rural areas and most Kenyans are poor and badly educated. These trends all follow what KAIS refer to as a 'rapid scale up of HIV prevention, care and treatment services'.

A recent article in AllAfrica.com quotes UNAIDS as claiming that their successful prevention and education programmes have *finally* begun to change the behaviour of those who are most at risk. If this is only happening in recent times, how can they claim that it had anything to do with a decline in incidence that began in the mid 1990s. But Kenya, along with many other SSA countries, have explicitly not targeted some of the groups who are thought to be most at risk, MSM, CSWs, IDUs and young women. The well presented 'Modes of Transmission Survey' for Kenya makes it quite clear that these groups are still being ignored.

There may be isolated signs of people's behaviour changing in some ways. All sorts of movements may have achieved great things, especially relating to HIV treatment and increasing access to treatment. I certainly wouldn't claim that all the billions that have been poured into HIV for over two decades has been wasted. But I have yet to see clear evidence that HIV transmission has declined as a result of prevention efforts. I think the epidemic has its own dynamics, like any epidemic, but I am not convinced that the enormous Aids industry has had much influence on its course. I just hope I'm wrong.

HIV and Sexual Behaviour

It sometimes appears that it is difficult for big HIV donors and NGOs to accept that they can waste a lot of money concentrating solely on trying to influence people's sexual behaviour with a view to cutting HIV transmission. They seem to have the attitude that sexual behaviour takes place in a kind of social vacuum and that it is completely unrelated to the way people live their non-sexual lives. Perhaps these organisations don't view gender inequalities, economic inequalities, differences in educational status or social status or intergenerational differences as having any bearing on sexual behaviour.

A paper entitled 'Food Insufficiency Is Associated with High-Risk Sexual Behavior among Women in Botswana and Swaziland' is part of a whole body of research that challenges the view that targeting individual sexual behaviour should be the main approach to cutting HIV transmission. This 'behavioural' view tends to imply, without arguing or demonstrating, that the cirucmstances in which people live and work are irrelevant to their behaviour, their sexual behaviour and, therefore, their relative risk of becoming infected with HIV, or of transmitting it if they are already infected.

The paper finds that food insufficiency results in increased sexual risk taking, especially among women. The sorts of sexual risk are inconsistent condom use with non-regular partners, transactional sex, intergenerational sex (usually where the female is the younger party) and lack of control over the circumstances of the sexual relationship. The paper recommends targeted food aid and income generation programmes and also an improvement in women's social and legal status.

The fact that HIV is sexually transmitted does not mean that transmission can successfully be reduced merely by 'teaching' people about safe sex, by distributing condoms and facile 'messages' or by lecturing people, children and adults, about right and wrong. This is not a new discovery. But as soon as HIV was found to be sexually transmitted, the whole issue was hijacked by political and religious (and later commercial) crusaders. And it's only occasionally that people have been able to wrestle back some control over HIV as a human rights, health or development issue.

If the conditions under which HIV spreads are to be changed, people need health, education and social services that are accessible to all, female as well as male, rural as well as urban, poor as well as rich. People need to be enabled to ensure their own health and the health of their children and dependents. People need their rights to be recognised and upheld by the law. The right to food is particularly important.

Seeing the connection between food insufficiency and risky sexual behaviour shouldn't take much genius. Surely those who think HIV is just a matter of sexual behaviour don't think that being hungry or having hungry children makes people feel a stronger sexual urge or enjoy risky sex more? So if the limit of their HIV prevention programmes consists of things like behaviour change communication, mass male circumcision and, eventually, HIV vaccines and microbicides, they will find HIV continuing to spread.

Behaviour Change for Journalists

The BBC can be funny sometimes, though not very funny. The title of one of their articles runs "Is Zuma's sex life a private matter?" and they promptly answer it in the negative by writing about it. Perhaps the author would have been wiser to ask about the president's attitude towards women and equality, since they have taken the liberty of asking about his sex life. But even an organisation as well (publicly) funded as the BBC often can't resist asking the same questions as almost every other journalist in the mainstream media.

The media needs to get past the connection between HIV and sex. True, HIV is mainly transmitted sexually. But rates of HIV transmission depend on many other things, such as the relative economic circumstances of the people involved, their relative levels of power in relationships (whether ephemeral or otherwise), their levels of education and access to information, their levels of health and nutrition and the like. Indeed, the nature and accuracy of the information to which people have access may also be significant; exalted claims about the role of the media in HIV publicity campaigns certainly suggest this.

Studies have shown that there is no strong correlation between rates of HIV in different countries and levels of what is considered to be unsafe sexual behaviour, for example, multiple concurrent partnerships. In other words, some places where rates of multiple concurrent partnerships are low, HIV rates are high and vice versa. High rates of HIV transmission in South Africa are, to the extent that they are well understood, explained by many things other than sexual behaviour.

If the BBC is really concerned about HIV transmission, it shouldn't be beyond the capacity of the corporation to research the subject a bit better than the average tabloid newspaper. They could even have discussed the fact that Zuma didn't use a condom during his extra-marital relationship and is well known for being against the use of condoms. Sadly, there is very little to HIV prevention in South Africa, or any other developing country, aside from condoms.

It may never become a popular view that HIV has numerous transmission routes and that many of the circumstances in which people live and work determine whether they will be infected with HIV and whether they will go on to infect others. HIV will probably always be viewed as such an extraordinary disease that it is transmitted in isolation from people's overall health and welfare, and that issues such as gender, power and politics are completely irrelevant. But it seems unlikely that the BBC will stick its neck out and adopt an unpopular view.

Hate the Sinner, Love the Sin

Recently, a Kenyan friend of mine posted a question on Facebook the jist of which was 'if a promiscuous woman is called a whore, what is a promiscuous man called'? She got some facetious replies but it is a very important question. Why do we vilify women who sleep with men? There are many words for women seen as promiscuous but I can't think of any for men. There must be a lot of men who love sex but there must also be a lot who hate women. Could it really be common for men who love sex to also hate women? It seems likely.

A workshop in South Africa recently argued that "society's expectations and presentation of women makes them more vulnerable to catching sexually transmitted infections (STIs) and HIV". There appears to be a deficit of respect built into societies, languages and behaviours and it seems so self defeating. The workshop pointed to "the need for woman and girls to be empowered for them to make informed decisions when negotiating safe sex".

We (humanity) are facing a dangerous situation and it seems that several decades of HIV/AIDS has done little to change attitudes. Men are very often in a position to do things and talk about things that women are not able to do and talk about without censure. Men often say that there are things they find it difficult to talk about and they would never talk about them in front of women. Women, too, are expected to remain silent about certain things and to only discuss others with other women.

I have talked to people who run HIV prevention programmes and they often mention how the content needs to be different when the audience is young or female. It's true that the content needs to be produced with a particular audience in mind. But maybe there is also a place for discussion between males and females. Perhaps it would be enlightening if men were to get to know what women think and if women were to get to know what men think, especially what men think about women and sex, for example.

Why is it more shocking to hear a woman swear or to see a woman drinking or spending time in a bar or, god forbid, time in a bar with men? Men go to bars to hang out with their friends, to drink and to meet women. If they think the women they meet in bars are 'whores', why don't they stop going to the bars and go to church halls instead? Or perhaps they could persuade their 'nice' female friends to go to the bar with them. But that would take us back to square one because women who go to bars are just not nice, apparently.

The workshops also argued that “[i]n the rural set up mostly, women who [negotiate] for safe sex are viewed as promiscuous and wayward”. It's sensible for anyone to insist on safe sex, whether they are male or female. There is something wrong already if the woman has to negotiate. The fact that she is considered promiscuous or wayward is almost laughable, especially considering the reasons why she might feel the need to negotiate; perhaps she knows that a lot of men are happy to have sex without a condom.

People here, male and female, often tell me that women are not supposed to be forward, they are not supposed to make the first move. Men see women who ignore this code of conduct as objects of suspicion and even as in some way evil. Is there something inherently about men that makes them better at making decisions that relate to friendship and sexual relationships? I don’t think so, but perhaps I’m just lacking in some way.

When it comes to negotiating about or even discussing sex, there is a need for greater levels of mutual respect and equality. People are people, gender is not a species. This needs to start in classrooms and among young people. So, if people object to teaching children about sex and safe sex, the least they could do is teach about equality and respect.

A person who has sex with other people is just a person. A person who has sex with lots of other people is also just a person, though they need to exercise a lot of care, as do the people they sleep with. But a sizeable majority of women who have sex, do so with men. It’s not as if there is a small group (or large group) of people who, in some way, are responsible for all the illicit sex in the world.

Quite frankly, if I was a woman, I would be called a whore. I go to bars, I meet women, I’ve even had the temerity to sleep with some women. But as a man, calling me a whore just doesn’t have the same import. And I don’t think the solution is to find an equivalent term for men to right the balance. I think it would be preferable to see sex as something that occurs between people, male and female.

Kenya's Neighbours, Uganda and Tanzania

How does Kenya’s HIV epidemic compare to those of neighbouring Uganda and Tanzania?

Well, HIV probably arrived first in Uganda, next in Tanzania and then in Kenya. After that, it took very different courses in each country. It spread quickly and rose to a peak prevalence of 14% in Uganda. It spread less quickly in Tanzania and peaked at below 8%. And, having started later in Kenya, it spread quickly and prevalence peaked at just over 10%.

As the graph below shows, there has been a gradual decline in prevalence in Uganda and in Tanzania. However, the decline in prevalence in Kenya reversed around 2004 and now stands at 7.8%, higher than it was back in 2002.



The next graph shows that death rates also have very different patterns in each country. Aids deaths started later in Kenya, as you would expect if HIV arrived later. But the number of deaths rose very rapidly and peaked at perhaps over 140000. This is far higher than Uganda and Tanzania, whose rates peaked at 120000.



Death rates in all three countries are now declining. One would expect this trend to be enhanced as anti-retroviral therapy (ART) is rolled out because this keeps more people living with HIV alive for longer.

The graph below plots the estimated numbers of people living with HIV and Aids. The rising number in Kenya is probably due to a combination of new infections and people living longer because of ART. The fact that the number in Tanzania is stable could be for similar reasons, except that there, the death rate is still pretty high. This is, of course, just one analysis and a quick and dirty analysis, for that matter. It’s possible that Uganda has a low rate of new infections at present; I don’t have access to recent figures.



Personally, I think the above figures alone can tell us very little about how the HIV epidemics stand in these three countries at the moment. I think the way HIV affects a country, how the epidemic spreads, waxes and wanes, depends on many things. Of particular importance are health and health services, education and literacy, various economic factors, social services, infrastructure and much else.

The annual Human Development Report collects national figures and uses them to calculate indices of various aspects of development. Thus, the gender development index shows inequalities between men and women in health, education and economic welfare; the life expectancy index shows the relative achievement of a country in life expectancy at birth; the education index brings together adult literacy and school enrolment; and the human development index (HDI) brings together health, education and economic welfare, being a composite of the education index, the life expectancy index and the GDP index. The GDP Index shows the gross domestic product per capita for a country.



There is a large amount of overlap among these figures, but they are all reproduced here to show how the three countries stand in relation to each other. From this chart, they would all seem pretty close together. In most cases, Kenya is a little better off than Uganda and Uganda is a little better off than Tanzania. If these factors also have an influence on the course a HIV epidemic takes in a country, each country’s epidemic may become more and more alike, despite their initial differences.

However, if you look at trends in the HDI (the only one for which historical trends are supplied), Kenya is not only out of step with Uganda and Tanzania, after being ahead of them for many years; Kenya’s HDI has also been declining for a long time. Over the same period, Uganda and Tanzania’s HDI has been improving.



Well, putting all these figures together doesn’t really put one in a position to analyse each country in sufficient detail to make predictions about what will happen next. Out of the three countries, only Kenya is seeing prevalence increase, after an initial improvement. It’s possible that Uganda and Tanzania’s prevalence are levelling off and will rise, but it’s hard to say.

However, a recent paper shows that prevalence is still increasing in Tanzania in more rural areas, though it is declining in less rural areas. Bear in mind, over 80% of people in Tanzania live in rural areas. Another paper suggests that the behaviour change that was said to have reduced HIV prevalence in Uganda substantially in the nineties and early 2000s is now reversing, that condom use is declining and unsafe sex is increasing.

Rural areas in Tanzania are less likely to benefit from HIV education, perhaps any education, from health services and other social services. And those in Uganda who are deciding to ignore the safe sex message, if the message is still being broadcasted, may need to be approached in a different way. What worked during a time of high prevalence followed by a time of high death rates, may not work now that the word ‘Uganda’ is usually accompanied by mentions of the country’s success in reducing HIV prevalence.

Among all the indicators relating to sexual behaviour that are collected by Demographic and Health Surveys, none show that one of the three countries is significantly ‘better’ or ‘worse’ than the other. These figures, even taken all together, don’t suggest why Tanzania’s prevalence never reached as high as Kenya’s or why Kenya’s never reached as high as Uganda’s.

Some health indicators show Tanzania to be in a far better position than the other two countries, despite public expenditure on health being lower. However, some of Tanzania’s health indicators are far poorer than the others. Other figures are very similar to those found in Uganda and Kenya. Education indicators are similarly mixed, though Kenya again has the highest level of public expenditure in education.

Some gender related figures do differ greatly. Kenya has very few female MPs, just over 7% them being women. For Uganda and Tanzania, the figures are 29.8% and 30.4%, respectively. More births are attended by skilled health personnel in Tanzania. And the rates of female genital mutilation are much higher in Kenya (32.2%) than in Uganda (0.6%) or Tanzania (14.6%).

Figures for communications, access to communications and media, water and sanitation vary somewhat here and there but there is still a surprising amount of similarity in these areas. All three countries have seen high population growth in the last thirty years and are predicted to continue growing. Demographic figures are also reasonably similar.

A notable exception is the urban population as a % of the total population, which stood at 20.7% in Kenya in 2005, 24.2% in Tanzania but only 12.6% in Uganda. Uganda also had a low urban population in 1975 and this is expected to continue. Urban population is thought to be a highly significant factor in the spread of HIV by some analysts. However, it is also argued that the HIV epidemic was unusual in Uganda, having started in rural areas and spread from there. In Kenya and Tanzania it was said to have started in urban areas.

In a nutshell, I think HIV spread readily in these countries because of poor health, education, social services, water and sanitation, governance, social cohesion and many other things. Many measures have been taken to reduce the spread of HIV, in the fields of health, education and other areas. However, unless the original development conditions that allowed HIV to spread are improved vastly, HIV will continue to spread.

The people of Kenya, Uganda and Tanzania may well need HIV education, but they are in far greater need of teachers and affordable, accessible schools. HIV health programmes are great, but only where there is an affordable, accessible health service. There is little point in educating people about sexual health and behaviour while ignoring reproductive health, sanitation, nutrition and other aspects of health.

As long as HIV is seen as a short term (or even medium term) crisis that will be resolved by crisis measures, it will continue to spread. Small gains may be made here and there, but without ensuring a healthy, well educated, secure population, HIV will never be conquered.

The conditions that allowed HIV to take hold and reach high levels in so many countries have been around for a long time and the HIV community seems to have allowed itself to be distracted by crises and crisis measures. It is the long term issues that need to be resolved, the same problems of poverty, exploitation and underdevelopment that have been around for as long as anyone can remember.

Gender and HIV

There are numerous factors involved in the spread of HIV in Kenya. For example, high levels of disease and bad health, especially sexual and reproductive health, under funded health systems, poor nutrition, low levels of food security and sanitation, crumbling education systems, high levels of urbanisation, high population density and demographic imbalances, high levels of circular migration and dangerous labour practices.

A lot is known about curing some diseases but, more importantly, it is well known that many diseases are avoided by good nutrition, sanitation and healthy lifestyles. Again, it doesn't take a genius to work out that large groups of men working in cities and around mines will eventually be followed by small groups of commercial sex workers. It's not difficult to provide transport for the men to return home regularly or even to provide accommodation for wives, families and partners. It's not difficult, just rare. The point is, we know what would alleviate some of these factors, even if we don't necessarily know how to implement these measures or are not in a position to do so at present.

However, all these factors have played a part in the transmission of HIV because, for various reasons, they have been given very little attention (unless lip service counts as attention). The reasons for this could include poor leadership and governance or greed and selfishness on the part of a powerful few. The powerful few are not just leaders and other people in Kenya; one must include interested parties who neither come from nor live in Kenya, nation states, economic partnerships, multinationals and even international organisations that usually represent the wealthy, despite a pretence of representing everyone equally.

But one of the less tractable factors in the spread of HIV is gender, a factor operating at many levels. From the top down, slightly more than half of all Kenyans are female. Yet only around 7% of Kenya's MPs are female. Females are also more likely to be poor, have less access to education and health services, are less likely to be employed in the formal sector and are more likely to be dependent, economically and in other ways (usually on men).

At a guess, 100% of Kenyan MPs are in the wealthiest 20% of the population. In contrast, nearly 50% of Kenyans live on less than 2 dollars a day. Put all this together and most Kenyans are not particularly well represented by their elected leaders, this being especially true of Kenyan women.

From the bottom up, around half of Kenyan women have experienced violence as adults, around one quarter in the 12 months preceding the interview (Kenya Demographic and Health Survey, 2003). There are high levels of gender violence across income brackets, employment status, educational levels, rural or urban residence and province, although levels do vary somewhat. This violence is most likely to be perpetrated by a partner, though teachers and mothers are second and third, respectively, in the list of most likely perpetrators.

A specific form of violence that most affects females is Female Genital Mutilation (FGM), sometimes referred to as 'female circumcision'. This is thought to affect more than 30% of females. It is still practiced in some areas, despite being prohibited by law for some years. As well as violating human rights, FGM renders women more susceptible to infection with HIV and other sexually transmitted infections (STI). FGM also contributes to maternal deaths and many serious reproductive health problems. The operation is usually carried out by women but the demand for it is said to come from men.

The practice of FGM is declining but it is far higher in Kenya than neighbouring Uganda or Tanzania. Another practice, which is also said to be declining, is violence against children. It, too, is prohibited by law but still practiced and defended on the grounds that children need to be disciplined. Of course, violence against children is not gender based but it is odd that what is seen as justified on the grounds of discipline in the case of children is also seen as justified on the grounds of discipline in the case of women, but not in the case of men.

But perhaps the most worrying thing about gender violence is the percentage of people, including women, who think it is acceptable for husbands to beat their wives, either as punishment or to assert authority. It is not hard to find people who defend violence against women (and children) or who see it as a normal part of life and not, therefore, a problem.

Nor are these the only gender issues. Women often have little or no right to inherit land or property from their husband. In some places, when a woman is widowed, she herself is 'inherited' by a member of her husband's family. Girls are often encouraged to marry early, sometimes to save their family the cost of their upkeep. They often marry older men who are more likely to be sexually experienced and even infected with HIV or other STIs. In fact, despite the popularity of 'abstinence only until marriage' HIV prevention programmes, married women in Kenya are more likely to be infected by their husbands than unmarried, sexually active women.

Despite being more likely to be responsible for the health and education of children and dependents (including those infected with HIV), women have less access to education, health and other health services and they are, partly for those very reasons, more vulnerable to HIV and other STIs.

So the issue of gender and how it relates to the spread of HIV is not just intractable, it is also multifaceted. I am not able to do it full justice in such a short space. I hope to return to it, often. But I don't want to end with the impression that 'gender' only refers to the female gender.

For several years after HIV was identified, more men were found to be infected than women. In some areas, that is probably still the case. If a small number of commercial sex workers gather round a mining town where the population is predominantly male, more men than women may end up infected. However, if those men return home and infect their partners, it is likely that there will eventually be more HIV positive women.

In Kenya, the ratio of infections was 1 female to 1.2 males in 1986. In 2006 that ratio was 2 females to 1 male. However, in 2007, the ratio had moved in the opposite direction again and now stands at 1.6 females to 1 male.

This may have happened because men are taking more risks and/or fewer precautions, because women are taking fewer risks and/or more precautions or some other reason. I admit, this analysis is fairly speculative. But if a higher proportion of males are infected now, the potential for them going on to infect other women, perhaps several women each, is very high. (In Kenya, most women are infected by men, as opposed to intravenous drug use, blood transfusion, etc). In addition to reversing the ratio of females to males infected, this could also result in a substantial increase in national prevalence.

Now, men, generally, are less likely to become infected with HIV, are likely to become infected later in life than women, are often in a better position to protect themselves (and, therefore, their partners) against HIV and other STIs and they have often received more education.

Therefore, it may be possible to intervene with measures that specifically target men. Men may need to be targeted with different HIV messages than women and, for various reasons, there may be more time and opportunity for effecting such interventions.

For example:

- men who work away from home for long periods, in tea, sugar or cut flower industries, need to be able to return home regularly (using affordable transport); or their family needs to be able to visit or live with them (in decent, affordable accommodation)
- delays at borders that give rise to men visiting commercial sex workers need to be reduced, presumably by those interested in reducing the costs of, and barriers to, trade
- men need to be engaged in dialogue with women and other men to identify and influence attitudes that result in women’s lower status in commerce, politics, marriage, sexual relations and many other areas

There are others (and I must make it clear, I adapted these examples from Eileen Stillwaggon’s AIDS and the Ecology of Poverty), but most intervention efforts at present seem to emphasize a ‘one size fits all’ approach. There are many problems involved in HIV prevention but also, many approaches.