Idle Arguments Support Blinkered Policy

I'm developing a tendency to write very long blog posts and this means that I'm less likely to pick up errors. My last post contained a serious error in the second paragraph that probably made the following paragraphs difficult to understand. I have inserted a correction and apologise to anyone who may have found my argument hard to follow as a result.

In future I need to remind myself that if I can't form a conclusion in less than 1000 words, I probably need to do more thinking than writing. Perhaps even 1000 words is too long and I should aim for 500-700? Anyhow, I thank people for their patience and especially those who have taken the trouble to let me know when they have spotted an error.

In a nutshell, I don't disagree with Mr April's conclusion, that opt-out testing is superior to opt-in testing. I just think the argument is idle and should be completely unnecessary in the first place.

People originally advocated for opt-in HIV testing because those found positive risked being stigmatized. They risked being stigmatized because of the mistaken belief that HIV positive people are in some way immoral or bad (although these qualities are usually implied rather than stated). Unfortunately, the risk of being stigmatized is still very real, despite the evidence that HIV infection is not mainly, as the HIV orthodox view claims, a result of unsafe sexual practice.

Arguments like those presented by April presuppose the truth of the behavioral paradigm, this view that HIV is mainly transmitted through unsafe sex. Attempts to test as many people as possible for HIV in high prevalence populations have been thwarted by the resulting stigma and discrimination, which arises from the behavioral paradigm, even though this paradigm is completely unsupported by evidence.

It shouldn’t take a philosopher or medical ethicist to spot policy that has been formulated on the basis of naked prejudice. But as long as the offending paradigm is retained in HIV policy making, people will continue to be stigmatized. The stigma is a consequence of the paradigm.

To the extent that philosophers or ethicists fail to take account of how things actually are on the ground, their arguments will be, as Wittgenstein might say, ‘wheels that are turning but are not themselves turning anything’. Perhaps Mr April even thinks that UNAIDS, the WHO, the Harvard Medical School, the CDC or the Johns Hopkins School of Public Health are able to inform him about how things are on the ground. But he is mistaken. All they can offer is their prejudice, which he seems to have accepted.

It could be argued that, because Mr April’s arguments are not based on anything happening in the real world, they have no consequences. But his arguments are developed in places where HIV policy is also developed. Therefore, people in high HIV prevalence countries suffer the consequences of the stigma and prejudice that arises from current policies. In fact, what is happening in the real world, unlike academic arguments in certain institutions, has little noticeable influence on policy. But policy can have a huge and overwhelmingly destructive influence on the real world.

Born Obsolescent But Still Around, Unfortunately

Apparently a report has found that the IMFs (International Monetary Fund) fiscal and monetary policies have stifled Kenya's fight against HIV and TB. They concluded that restricting government spending on health resulted in poor health outcomes.

That's not just a conclusion, that's almost a tautology. Poor healthcare always, everywhere, gives rise to poor health outcomes. I applaud the report writers but I wonder what influence their findings and recommendations will have in the secretive and atavistic 'Bretton Woods' institutions. The report even found that HIV/Aids work is now almost totally dependent on donor funding.

Virtually anyone who has studied HIV, its spread and the almost total (but extremely expensive) failure to reduce its spread, would have, and probably have, come to the same conclusions. But what effect has research ever had on the way the IMF does its work?

The report also concludes that the IMF's policies are partly to blame for Kenya's poor economic performance. But this is true of the economic performance of every country that the IMF has interfered in. In the whole history of the IMF, they do not have one single success story. They beat on about reform, democracy and accountability. Yet they have never been reformed, they are not in the least bit democratic and they are not accountable to anyone.

It's odd that both the World Bank and the IMF can produce reports that, at the same time, boast of the great things that they have done and also admit the failures that, essentially, are the great things they have done. Anyhow, the full report is available, but keep a sick bag handy.

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 Policy in a Vacuum

For some time it has been claimed that HIV testing plays a big part in reducing transmission of HIV because people who find out that they are HIV positive can take precautions to avoid spreading the virus. More importantly, it has been claimed that people who find out that they are HIV negative take steps to stay that way.

Well, of course it is good for people to be tested, whether they turn out to be positive or negative. Most people in most countries with a serious HIV epidemic don’t know their status. Those found to be positive can be given counselling, advice and, where required, medication. Those found to be negative can also be given counselling and advice.

But in South Africa, it has been noticed that many people who receive a negative result have subsequently increased their risky behaviour [http://www.plusnews.org/Report.aspx?ReportId=85033]. The goal to test as many people as possible is still perfectly valid but people need to modify their behaviour as a result of going through the testing and counselling process.

This sort of trend is not confined to South Africa. It has been noticed in Uganda that there was a 50% reduction in condom use among people who tested negative for HIV. In Zimbabwe, similar phenomena occurred and people also increased the number of their sexual partners, too.

The story is not all bleak because it is said that the opposite is true of young people testing negative in the US. They, apparently, go on to reduce their sexual activity and take other measures to avoid risky practices. That’s comforting because the US has the highest HIV prevalence in the developed world.

But it doesn’t answer the question of how to resolve the problems in South Africa, Uganda and Zimbabwe. Clearly, testing and counselling can’t be abandoned. And the mere knowledge that a negative test result can sometimes give rise to increased unsafe sexual behaviour should be of great help to policy makers and implementers.

But I think also that this is an important reflection of the fact that HIV is not just about sex. If you like, sex is not just about sex. People have sex for all sorts of reasons, aside from obvious ones, such as having babies, having fun, doing ones duty, etc.

The circumstances in which people live often determine whom they have sex with, how often, what kind of sex they have, how many partners they have, when they have sex and where they have sex. And many people are not in a position to choose or control all of these circumstances.

For example, a man who runs a community based organisation in Kibera slum in Nairobi points out that 66% of girls in slums enter the sex industry at some time, some at a very early age. Their economic and social circumstances play a big part in whether they can avoid becoming involved in the sex industry or not. Knowing that they are HIV positive or HIV negative may not play much part in how they behave after they have been tested.

Married women do not always have the option to demand that their partner uses a condom, even if they know that their husbands have other partners or may already be infected with HIV or other sexually transmitted infections.

Many Kenyans live in poverty, many are short of food all or most of the time, clean water and adequate sanitation are non-existent for most people, electricity and other modern conveniences are just not readily available. Given these circumstances, people face many hazards already. Unsafe sex may just be one hazard of many.

It’s not the sex itself that threatens people but a whole array of circumstances that determine people’s sexual behaviour, their relative risks and vulnerabilities.

It is probably beyond the scope of voluntary counselling and testing services to provide Kenya with the means to develop its health, education, infrastructure and social services. But these matters need to be dealt with in the forthcoming National AIDS Strategic Plan, whenever the government gets around to publishing it. The last one (and the one before) concentrated on a narrow range of HIV prevention programme possibilities.

Let’s hope the next one takes a broader outlook and takes into account the connections between people’s sexual behaviour and the circumstances in which they are forced to live.