People can often be heard moaning about the disintegration of traditional family values (and Christian values, etc), especially in the context of discussions about HIV transmission. In the old days, children respected their elders, they paid attention to what they said, they discussed their relationship and marriage plans with their family, they didn't have sex before marriage, etc. We've probably all heard it in some form or other.
But there's a bit of a contradiction in being told to place absolute trust in people who can sometimes become part of the problem, such as parents, teachers or employers. HIV programmes often aim to instill in young people the belief in their own self efficacy, the belief that they can decide when, where and with whom to have sex. Yet sometimes, the person who is demanding sex from them is a parent, a relative, a teacher or someone else who is supposed to be in a position of responsibility.
Also, people in positions of responsibility, religious leaders and political leaders, for example, are telling people how to behave and how to live their lives. Either people have a degree of autonomy or they do what they are told. Personally, I think respect is due to some people and not to others. Children (and adults) need the ability to judge who is entitled to respect. They need to see that respect is not always due to people just because of their position. They need to be able to decide for themselves what to do and what to avoid doing.
Politicians often abuse their position, police take the law into their own hands, parents do many things that are harmful to their children, religious leaders often lie to suit their church's dogma, adults often abuse younger people, strong people often take advantage of weak people. There is no rule of thumb about who is to be respected and who is not. Such rules of thumb lead people into dangerous positions.
I met a young Tanzanian woman recently who told me that she almost had to drop out of college because she failed four out of seven of her exams. She was sure that she had only done one exam badly but to get a recheck she had to pay a lot of money for each one. She approached each teacher and discussed it. One of them suggested that if he were to do this 'favour' for her, she would need to think about a 'favour' she could do for him. She said she would prefer to pay.
She was lucky that she works as a volunteer HIV counsellor. She was also lucky that she had the money. As it is, she cannot afford to live in student accommodation and needs to stay with relatives. So she is lucky that she has relatives that are close to her college. Many people would not be so lucky.
This is not an isolated incident. I came across an article recently about children who are coerced into having sex and even long term relationships with their (already married and sometimes HIV positive) teachers. The teachers often agree to give them money or to pay for their schooling. Girls who become pregnant are excluded from school and that's often the end of the agreement. They end up much worse off than they were before.
To make matters worse, parents and guardians sometimes encourage these relationships because they can't afford to pay school related expenses and fees. The children are let down by those closest to them, the people they are supposed to treat with respect. They are being abused emotionally, sexually and physically by people who are teaching them to be submissive towards their parents and teachers.
Children must be very confused. The people who are telling them to respect their elders are abusing them. The people who are telling them to make decisions for themselves are lying to them and undermining their ability to make decisions. The people who tell them that lying is wrong also tell them lies. I met a Catholic priest here recently who asked me if it was really true that there are tiny holes in condoms that allow the HIV virus to pass through. I told him to check with the WHO (World Health Organization), who have a lot more experience with health and reproduction that the Catholic Church.
It's very disobedient of him to refuse to follow the teachings of his church. But if there is a god, I'm sure the priest's decision will be understood.
Wednesday, April 1, 2009
Tuesday, March 31, 2009
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.
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.
Monday, March 30, 2009
The Cherry Picking Theory of HIV Programming
When HIV started spreading across Africa, it hit more densely populated areas first. This is not surprising, given that it is primarily a sexually transmitted infection (STI). It was noticed early on that mobile populations were at particularly high risk, which is also not surprising.
But mobile people come into contact with less mobile people. People in densely populated areas move to, or move to and from, less densely populated areas. Those living in less densely populated areas are likely to be infected later in an epidemic and at a slower rate. But this also means that they are probably not going to be targeted by specific prevention campaigns and they are less likely to be exposed to media and other messages about HIV.
Coupled with this, people in more remote areas are less likely to have access to health, education or other social services. The poor infrastructure and isolation that, at first, gave them protection, now means that they are more likely to be infected with HIV and other STIs without knowing and with less likelihood of finding out.
The fact that they are living in less densely populated areas does not mean that they are not vulnerable. One of their vulnerabilities also turns out to be their relative isolation. This is not a contradiction. Over time, the once protective effect of isolation turns out to imply a whole host of vulnerabilities.
This is one of the reasons why I would argue that HIV is a factor of underdevelopment (and retrogressive development). HIV spreads best where there are multiple vulnerabilities. The virus is also hardest to prevent in these same areas. It is the vulnerabilities that need to be targeted, not the people assumed to be vulnerable.
At present in Kenya, Tanzania and other countries, HIV is spreading in more isolated areas. But health facilities and social services tend to be concentrated in urban and semi urban areas. Between 80 and 85% of these populations live in rural areas. This is changing, many people are moving to urban centres. But this is not a reason to continue to deny the vast majority of people the services they need.
Of course, the process of moving to urban areas, or moving to and from urban areas, exposes people to a new set of vulnerabilities as well. Prevention programmes are not keeping up with changes, nor do they even seem to be aware of trends that have been evident for some time. So there have been many articles recently about HIV infecting isolated populations in greater numbers and these usually express surprise at the trend.
The fact that some people seem less vulnerable now does not mean that this will always be so. Things change. Also, the fact that HIV spreads slower in less dense populations doesn't mean that these populations are ok; HIV spreads among vulnerable people. Prevention programmes need to aim to slow down the spread of HIV. Targeting so called vulnerable groups can often miss people, indeed, the population in general, who are considered not vulnerable enough.
Northern Kenya, which is very sparsely populated, has nomadic people who were once assumed to be safe from HIV. Prevalence there is very low and has been for some time. But HIV is there. Low prevalence can become high prevalence. In fact, people in Northern Kenya are probably the most vulnerable, taken as a whole. Few people have access to health or other social services, education and literacy levels are among the lowest in the country. Now that the HIV community have noticed the problem, they will find that there is very little infrastructure and most programmes will run up against things like lack of attendance in schools and low levels of health and education.
HIV arrived in a very underdeveloped country in the 1980s and has experienced retrogressive development since then. 25 years later, solutions to HIV are still appropriate to a short term emergency. For HIV prevention to work, people need to be well educated, they need a good level of health, water and sanitation and the rest. In other words, they need development. HIV continues to deflect attention from all these other problems which are factors in the spread of HIV. The result of this serious underdevelopment is that the very facilitators of any subsequent prevention programmes are missing.
If aid agencies are just realising that pastoralists and other groups are not 'safe', they have been ignoring evidence that has been around for a long time. They have made a lot of unwarranted assumptions. Everyone is vulnerable to HIV and this been the case for a long time. Whatever the utility in targeting groups, we should forget that people who don't belong to those groups are also in need of attention.
When it looked as if HIV could be eradicated purely by such targeting, these approaches may have been justified, but that was a long time ago. 'Remote' communities are also very mobile and this should have hinted at their relative vulnerability.
At one time, it appeared odd that Northeastern Province was, in many ways, the least developed province. Yet it had the lowest prevalence in the country, at around 1%. That's lower than Senegal, Washington DC and Ukraine, for example. But there is no reason why HIV should stay low, there or in other places where there are a lot of vulnerable people. For example, it should be borne in mind that female genital mutilation is higher there than anywhere else. Young girls marry very young, usually to much older men. These are other worrying issues but these two factors are very significant and they need attention, regardless of the rate at which HIV is spreading.
It’s fashionable to say that HIV is spread by lots of people being promiscuous and careless but only some HIV is spread this way. Many others are infected because they are vulnerable, for numerous reasons. No amount of pure HIV programming will address their vulnerabilities but this is one of the reasons why much of the pure HIV programming to date has been so unsuccessful.
But mobile people come into contact with less mobile people. People in densely populated areas move to, or move to and from, less densely populated areas. Those living in less densely populated areas are likely to be infected later in an epidemic and at a slower rate. But this also means that they are probably not going to be targeted by specific prevention campaigns and they are less likely to be exposed to media and other messages about HIV.
Coupled with this, people in more remote areas are less likely to have access to health, education or other social services. The poor infrastructure and isolation that, at first, gave them protection, now means that they are more likely to be infected with HIV and other STIs without knowing and with less likelihood of finding out.
The fact that they are living in less densely populated areas does not mean that they are not vulnerable. One of their vulnerabilities also turns out to be their relative isolation. This is not a contradiction. Over time, the once protective effect of isolation turns out to imply a whole host of vulnerabilities.
This is one of the reasons why I would argue that HIV is a factor of underdevelopment (and retrogressive development). HIV spreads best where there are multiple vulnerabilities. The virus is also hardest to prevent in these same areas. It is the vulnerabilities that need to be targeted, not the people assumed to be vulnerable.
At present in Kenya, Tanzania and other countries, HIV is spreading in more isolated areas. But health facilities and social services tend to be concentrated in urban and semi urban areas. Between 80 and 85% of these populations live in rural areas. This is changing, many people are moving to urban centres. But this is not a reason to continue to deny the vast majority of people the services they need.
Of course, the process of moving to urban areas, or moving to and from urban areas, exposes people to a new set of vulnerabilities as well. Prevention programmes are not keeping up with changes, nor do they even seem to be aware of trends that have been evident for some time. So there have been many articles recently about HIV infecting isolated populations in greater numbers and these usually express surprise at the trend.
The fact that some people seem less vulnerable now does not mean that this will always be so. Things change. Also, the fact that HIV spreads slower in less dense populations doesn't mean that these populations are ok; HIV spreads among vulnerable people. Prevention programmes need to aim to slow down the spread of HIV. Targeting so called vulnerable groups can often miss people, indeed, the population in general, who are considered not vulnerable enough.
Northern Kenya, which is very sparsely populated, has nomadic people who were once assumed to be safe from HIV. Prevalence there is very low and has been for some time. But HIV is there. Low prevalence can become high prevalence. In fact, people in Northern Kenya are probably the most vulnerable, taken as a whole. Few people have access to health or other social services, education and literacy levels are among the lowest in the country. Now that the HIV community have noticed the problem, they will find that there is very little infrastructure and most programmes will run up against things like lack of attendance in schools and low levels of health and education.
HIV arrived in a very underdeveloped country in the 1980s and has experienced retrogressive development since then. 25 years later, solutions to HIV are still appropriate to a short term emergency. For HIV prevention to work, people need to be well educated, they need a good level of health, water and sanitation and the rest. In other words, they need development. HIV continues to deflect attention from all these other problems which are factors in the spread of HIV. The result of this serious underdevelopment is that the very facilitators of any subsequent prevention programmes are missing.
If aid agencies are just realising that pastoralists and other groups are not 'safe', they have been ignoring evidence that has been around for a long time. They have made a lot of unwarranted assumptions. Everyone is vulnerable to HIV and this been the case for a long time. Whatever the utility in targeting groups, we should forget that people who don't belong to those groups are also in need of attention.
When it looked as if HIV could be eradicated purely by such targeting, these approaches may have been justified, but that was a long time ago. 'Remote' communities are also very mobile and this should have hinted at their relative vulnerability.
At one time, it appeared odd that Northeastern Province was, in many ways, the least developed province. Yet it had the lowest prevalence in the country, at around 1%. That's lower than Senegal, Washington DC and Ukraine, for example. But there is no reason why HIV should stay low, there or in other places where there are a lot of vulnerable people. For example, it should be borne in mind that female genital mutilation is higher there than anywhere else. Young girls marry very young, usually to much older men. These are other worrying issues but these two factors are very significant and they need attention, regardless of the rate at which HIV is spreading.
It’s fashionable to say that HIV is spread by lots of people being promiscuous and careless but only some HIV is spread this way. Many others are infected because they are vulnerable, for numerous reasons. No amount of pure HIV programming will address their vulnerabilities but this is one of the reasons why much of the pure HIV programming to date has been so unsuccessful.
Wednesday, March 25, 2009
UNAIDS: a Development Paradox
A recent UNAIDS newsletter demonstrates the paradox of the existence of such an institution as UNAIDS, whose brief is a single, sexually transmitted virus, HIV. The newsletter concentrates on homophobia, harm reduction programmes for drug users, sex work and the role of condoms in reducing HIV transmission (and, presumably, other sexually transmitted infections and unwanted pregnancies).
The paradox stems from the reflection that all these issues predate HIV, they will probably all continue after the HIV pandemic has subsided, if that ever happens, and they are all very important issues in themselves. That is, their importance goes well beyond their connection with the transmission of HIV. Therefore, there were already programmes to address these issues before HIV was even heard of, so where does UNAIDS fit in?
Homophobia, for example, is abhorrent and an infringement on human rights. There are organisations all over the world fighting homophobia. Does the arrival of UNAIDS add to the work that these organisations are doing or does it water the message down? The message seems to become 'homophobia is bad because it plays a part in spreading HIV'. Homophobes may even see this as an endorsement of their position. Perhaps I'm wrong, perhaps UNAIDS strengthens these organisations and has a genuine role to play.
Harm reduction for drug users is another issue that has been associated with HIV transmission. Yet, evidence that harm reduction programmes work for injecting drug users has been around for a long time. It's only political pragmatism that has prevented such programmes from being implemented in many countries. Does relating these programmes to HIV reduction strengthen or weaken advocacy for harm reduction programmes?
UNAIDS have embraced the view that there is no single approach to HIV, that each country needs to gather detailed data on how HIV spread in their country and implement different approaches as appropriate to that context. I am one hundred percent in agreement with them as this is one of my own findings. But I saw that as an indication that UNAIDS may therefore be superfluous, however well intended. I think of all development issues are addressed, HIV reduction will not be such an intractable problem.
Commercial sex work (or transactional sex) is surrounded by numerous factors in the transmission of HIV. Sex workers are vulnerable because they are poor, or poorer than their clients, they are unprotected by the law and perhaps even victims of abuse by officers of the law, they are stigmatised by the public, they have little access to health and other social services, stemming from their poverty, lack of those services, their legal position, etc.
Sex workers suffer terribly, they have multiple vulnerabilities and, as a result, they often play an important part in the transmission of HIV. But they have suffered abuse and been denied their rights for as long as anyone can remember. This relates to HIV but HIV transmission stems from many other problems that are not just about HIV. Where does UNAIDS fit in here? Do they become advocates for the decriminalisation of sex work? This would be great but should they join other organisations already involved in such advocacy or is there a niche for them, somewhere?
The (male) condom is something of a symbol of the fight against HIV. They appear on websites about HIV, in particular, on UNAIDS's site. But condoms have been around for a long time and played a significant part in the decades of work carried out by those who believed that development simply meant population control. Those organisations, FHI (Family Health International), PSI (Population Services International), TFGI (The Futures Group International), and others, were spectacularly unsuccessful in getting condoms accepted. However, they were considered the most deserving recipients of hundreds of millions of the dollars that were subsequently ploughed into HIV reduction.
Is UNAIDS going to become one of them, a family planning organisation? There is no doubt that sexual and reproductive health are very important issues; they are also an important part of the fight against HIV but I think UNAIDS see themselves as playing all of the above roles. Yet they are playing all of those roles in an importantly qualified way. It seems that they are playing those roles to the extent that this will reduce HIV transmission.
Every single factor in the transmission of HIV needs to be addressed but also, every single factor that I can think of needs to be addressed, irrespective of its part in HIV transmission. Each factor in the transmission of HIV is also an area of underdevelopment. HIV spread in places where there are high levels of economic and gender inequality, poverty, poor health, low standards of education, low levels of social services, poor infrastructure, especially in the area of water and sanitation. Governance, legal institutions and civil society are also factors in the transmission of HIV.
UNAIDS have some of the best personnel in the HIV world, they have some of the best resources and they have access to pots of money. But I'm still at a loss to understand why HIV has been singled out from all other diseases and development problems and given this special UN institution. Especially as many of these other diseases and development problems played a crucial part in the spread of HIV.
I suppose the paradox is that there is a sense in which UNAIDS is concerned with all of these issues but is, at the same time, only concerned with HIV.
The paradox stems from the reflection that all these issues predate HIV, they will probably all continue after the HIV pandemic has subsided, if that ever happens, and they are all very important issues in themselves. That is, their importance goes well beyond their connection with the transmission of HIV. Therefore, there were already programmes to address these issues before HIV was even heard of, so where does UNAIDS fit in?
Homophobia, for example, is abhorrent and an infringement on human rights. There are organisations all over the world fighting homophobia. Does the arrival of UNAIDS add to the work that these organisations are doing or does it water the message down? The message seems to become 'homophobia is bad because it plays a part in spreading HIV'. Homophobes may even see this as an endorsement of their position. Perhaps I'm wrong, perhaps UNAIDS strengthens these organisations and has a genuine role to play.
Harm reduction for drug users is another issue that has been associated with HIV transmission. Yet, evidence that harm reduction programmes work for injecting drug users has been around for a long time. It's only political pragmatism that has prevented such programmes from being implemented in many countries. Does relating these programmes to HIV reduction strengthen or weaken advocacy for harm reduction programmes?
UNAIDS have embraced the view that there is no single approach to HIV, that each country needs to gather detailed data on how HIV spread in their country and implement different approaches as appropriate to that context. I am one hundred percent in agreement with them as this is one of my own findings. But I saw that as an indication that UNAIDS may therefore be superfluous, however well intended. I think of all development issues are addressed, HIV reduction will not be such an intractable problem.
Commercial sex work (or transactional sex) is surrounded by numerous factors in the transmission of HIV. Sex workers are vulnerable because they are poor, or poorer than their clients, they are unprotected by the law and perhaps even victims of abuse by officers of the law, they are stigmatised by the public, they have little access to health and other social services, stemming from their poverty, lack of those services, their legal position, etc.
Sex workers suffer terribly, they have multiple vulnerabilities and, as a result, they often play an important part in the transmission of HIV. But they have suffered abuse and been denied their rights for as long as anyone can remember. This relates to HIV but HIV transmission stems from many other problems that are not just about HIV. Where does UNAIDS fit in here? Do they become advocates for the decriminalisation of sex work? This would be great but should they join other organisations already involved in such advocacy or is there a niche for them, somewhere?
The (male) condom is something of a symbol of the fight against HIV. They appear on websites about HIV, in particular, on UNAIDS's site. But condoms have been around for a long time and played a significant part in the decades of work carried out by those who believed that development simply meant population control. Those organisations, FHI (Family Health International), PSI (Population Services International), TFGI (The Futures Group International), and others, were spectacularly unsuccessful in getting condoms accepted. However, they were considered the most deserving recipients of hundreds of millions of the dollars that were subsequently ploughed into HIV reduction.
Is UNAIDS going to become one of them, a family planning organisation? There is no doubt that sexual and reproductive health are very important issues; they are also an important part of the fight against HIV but I think UNAIDS see themselves as playing all of the above roles. Yet they are playing all of those roles in an importantly qualified way. It seems that they are playing those roles to the extent that this will reduce HIV transmission.
Every single factor in the transmission of HIV needs to be addressed but also, every single factor that I can think of needs to be addressed, irrespective of its part in HIV transmission. Each factor in the transmission of HIV is also an area of underdevelopment. HIV spread in places where there are high levels of economic and gender inequality, poverty, poor health, low standards of education, low levels of social services, poor infrastructure, especially in the area of water and sanitation. Governance, legal institutions and civil society are also factors in the transmission of HIV.
UNAIDS have some of the best personnel in the HIV world, they have some of the best resources and they have access to pots of money. But I'm still at a loss to understand why HIV has been singled out from all other diseases and development problems and given this special UN institution. Especially as many of these other diseases and development problems played a crucial part in the spread of HIV.
I suppose the paradox is that there is a sense in which UNAIDS is concerned with all of these issues but is, at the same time, only concerned with HIV.
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.
Monday, March 23, 2009
Belt and Braces but no Trousers
On a number of occasions on this blog, I have expressed scepticism about technical solutions to the HIV epidemic. Such solutions include mass male circumcision (MMC), universal testing and treatment (UTT) and universal condom distribution. I am not suggesting that these technical solutions do not work, on the contrary, they are effective. But there are two major problems; no single solution is likely to work on its own and structural conditions in developing countries mean that technical solutions face serious, often insurmountable, barriers to success.
Even condom distribution requires some level of infrastructure, education and communications. MCC faces the problem of seriously scarce, under funded and understaffed health facilities. Large scale testing has been dogged by the fact that many facilities are static and centralised, whereas the majority of Kenyans live in rural areas. Recently, it was demonstrated that many people are receiving incorrect results, either false positives or false negatives. This results from lack of training and quality control and probably many other things. And treatment has had problems as a result of disruptions such as food shortages, civil disturbances and economic problems.
A recent survey carried out in Bungoma, Western Kenya, showed that even in clinical settings, around 17% of people circumcised suffered adverse effects. The figure was about double that for circumcisions carried out in traditional settings. So this would not make circumcision a tempting option for Kenyans unless a huge amount of money is spent on developing health facilities. I don't oppose circumcision as long as it is an elective operation but I don't think circumcision in traditional settings will ever be a wise option.
Testing facilities in Kenya, as well as being in short supply, are just not reaching enough people. Some Kenyan policy documents mention mobile testing units, but they don't seem to be common yet. There continues to be a problem with testing facilities being in urban and semi urban areas. This means that many will not be able to access them, for various reasons. Cost is one factor but people are also less likely to know about HIV and testing when they are isolated from what are highly centralised and relatively inaccessible services. There is also talk about door to door testing and similar methods but this has only been carried out to a limited extent so far.
Those already being treated for HIV have, in many cases, had their treatment interrupted because of post election violence in Kenya, because of ongoing civil disputes in Zimbabwe, because of an economic crisis in Botswana, because of political disputes in South Africa and because of war in Sudan. There are, doubtless, many other instances where treatment has been shown to lack sustainability and this is often a problem with technical solutions.
The history of the epidemic in Kenya shows that there were many factors in the spread of HIV, relating to health, the economy, the environment, infrastructure, labour practices, gender and many other areas. Given this, it is no wonder that a single solution will have little chance of reducing HIV transmission. Condoms will remain in warehouses or on shelves, stay unused or be used incorrectly. Drugs, too, will be unused or misused because lack of support, education or other enabling conditions.
All of these technical solutions are good and together, along with any other strategies, could see HIV decline significantly in the next few decades. But if we ignore the overall development of countries like Kenya, each solution will have little success, perhaps none. Kenya is suffering from underdevelopment, many development indicators are moving in the wrong direction. This has been going on for decades and has been obvious for decades.
Developing health, education and other social services may seem too expensive or too difficult. But this is not an optional extra, it is a prerequisite to the success of any of the currently popular technical solutions.
Even condom distribution requires some level of infrastructure, education and communications. MCC faces the problem of seriously scarce, under funded and understaffed health facilities. Large scale testing has been dogged by the fact that many facilities are static and centralised, whereas the majority of Kenyans live in rural areas. Recently, it was demonstrated that many people are receiving incorrect results, either false positives or false negatives. This results from lack of training and quality control and probably many other things. And treatment has had problems as a result of disruptions such as food shortages, civil disturbances and economic problems.
A recent survey carried out in Bungoma, Western Kenya, showed that even in clinical settings, around 17% of people circumcised suffered adverse effects. The figure was about double that for circumcisions carried out in traditional settings. So this would not make circumcision a tempting option for Kenyans unless a huge amount of money is spent on developing health facilities. I don't oppose circumcision as long as it is an elective operation but I don't think circumcision in traditional settings will ever be a wise option.
Testing facilities in Kenya, as well as being in short supply, are just not reaching enough people. Some Kenyan policy documents mention mobile testing units, but they don't seem to be common yet. There continues to be a problem with testing facilities being in urban and semi urban areas. This means that many will not be able to access them, for various reasons. Cost is one factor but people are also less likely to know about HIV and testing when they are isolated from what are highly centralised and relatively inaccessible services. There is also talk about door to door testing and similar methods but this has only been carried out to a limited extent so far.
Those already being treated for HIV have, in many cases, had their treatment interrupted because of post election violence in Kenya, because of ongoing civil disputes in Zimbabwe, because of an economic crisis in Botswana, because of political disputes in South Africa and because of war in Sudan. There are, doubtless, many other instances where treatment has been shown to lack sustainability and this is often a problem with technical solutions.
The history of the epidemic in Kenya shows that there were many factors in the spread of HIV, relating to health, the economy, the environment, infrastructure, labour practices, gender and many other areas. Given this, it is no wonder that a single solution will have little chance of reducing HIV transmission. Condoms will remain in warehouses or on shelves, stay unused or be used incorrectly. Drugs, too, will be unused or misused because lack of support, education or other enabling conditions.
All of these technical solutions are good and together, along with any other strategies, could see HIV decline significantly in the next few decades. But if we ignore the overall development of countries like Kenya, each solution will have little success, perhaps none. Kenya is suffering from underdevelopment, many development indicators are moving in the wrong direction. This has been going on for decades and has been obvious for decades.
Developing health, education and other social services may seem too expensive or too difficult. But this is not an optional extra, it is a prerequisite to the success of any of the currently popular technical solutions.
Saturday, March 21, 2009
Dogma: a Pope’s Best Friend
HIV prevention experts have an uphill struggle as it is. HIV is mostly spread by sexual intercourse and a large proportion of the world's population engages in sexual intercourse at some time. Quite a number of people claim not to have sex but many of them turn out to be liars.
As one of the most effective ways of reducing the transmission of HIV is by using condoms, HIV experts advocate the use of condoms, unless the aim is to have children. But some religious groups, Catholics in particular, are opposed to the use of condoms.
Now, I hate to point the finger, but some of the more notable liars about their sexual behaviour have been Catholics. Worse still, the Catholic leader, Mr Gregory Pope, seems to assume that everyone chooses whether to have sex, when, where and with whom. This is not the case and some highly publicised instances of people denying other people's right not to have sex involved Catholics, often prominent ones. I'm surprised Mr Pope hasn't heard about this.
But there are a lot of things that have passed Mr Pope by, especially matters relating to sexual behaviour (and misbehaviour). He and some of his followers subscribe to the myth that latex condoms have tiny holes that the HIV virus can pass through. No, Mr Pope, there is just one hole in a condom, and it's supposed to be there.
Of course, this is not to say that things can never go wrong. For example, people can carelessly rip a condom when opening the package, perhaps by doing so with their teeth. They can damage the condom in various ways and there is a need to be careful. But this indicates that they need sex education that includes instructions on how to use condoms, preferably from people who have had experience of using them.
You say that promotion of condom use and sex education give rise to greater promiscuity; there is plenty of evidence to demonstrate that this is not the case. There is also plenty of evidence to demonstrate what happens when people don't receive any sex education or only receive half baked rubbish, such as 'abstinence only' claptrap. The result of not educating people about sex is very high rates of HIV and other sexually transmitted infections (also unwanted pregnancies).
You see, Mr Pope, people who get abstinence only education, people who take vows of abstinence, perhaps even Catholic priests and brothers, still have sex; they just don't bother to use condoms, perhaps because they have never heard of them or because they have been given incorrect information about them.
You call for a responsible attitude toward sex? People need education, discussion, information, enlightenment, not the lies that anti condom campaigners have been spewing out. How do you expect people to develop a responsible attitude towards sex when you are not even responsible enough to tell the truth? Is lying no longer a sin? Or does it depend on who tells the lie or what the consequences are? Perhaps things have changed since I was a Catholic.
Look, Mr Pope, you don't know what you are talking about. Please consult the World Health Organisation, the UNFPA and UNAIDS. These organisations are experts in public health. They will tell you that "[t]he male latex condom is the single, most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections." They will also confirm that "[y]oung girls and women are regularly and repeatedly denied information about, and access to, condoms. Often they do not have the power to negotiate the use of condoms. In many social contexts, men are resistant to the use of condoms."
I suggest you read this position statement carefully. It has just been revised and it contradicts many of the things you say. There's no excuse for being so badly informed and your attitude toward these matters is grossly irresponsible. I think it could justly be called culpable ignorance, if it really is ignorance.
It's interesting that one of the people who defended Mr Pope works for a Catholic NGO in Senegal. He says that his NGO doesn't promote condoms. I recently blogged about Senegal because the country has the lowest HIV prevalence in all of Africa. But one thing that has long been very common in Senegal is the use of condoms. Thankfully, this particular NGO wasn't the only one working there.
In contrast to Senegal, Rwanda and Burundi, considered to be very Catholic countries, have high rates of HIV and low rates of condom use. Also, because sex before marriage is frowned upon, for religious reasons, many men have their first sexual experience with a commercial sex worker. I know, spotting contradictions in Catholicism is like shooting fish in a barrel!
But sadly, some people will grasp at any excuse to justify their behaviour. Many people are already reluctant to use a condom to prevent unwanted pregnancy or sexually transmitted infections. There are myths surrounding most aspects of HIV, how it's transmitted, how to avoid it, how to cure it, etc. But with myths, people can accept the bits they like and ignore the bits they don't like. People who don't like condoms still enjoy sex and they are not going to see Mr Pope's solution as desirable or even viable.
So Mr Pope's pronouncements about condoms not working very well and promoting promiscuity will certainly appeal to people who just don't want to use condoms. He is, effectively, preaching to the converted, telling people who don't like condoms that it is wrong to use them and that it won't help them, anyway.
No doubt, a Catholic who becomes infected with HIV, despite following Mr Pope's thoughtful advice, will have their just reward in heaven. How comforting. But let's not deceive ourselves; preaching against the use of condoms is promoting the transmission of HIV.
As one of the most effective ways of reducing the transmission of HIV is by using condoms, HIV experts advocate the use of condoms, unless the aim is to have children. But some religious groups, Catholics in particular, are opposed to the use of condoms.
Now, I hate to point the finger, but some of the more notable liars about their sexual behaviour have been Catholics. Worse still, the Catholic leader, Mr Gregory Pope, seems to assume that everyone chooses whether to have sex, when, where and with whom. This is not the case and some highly publicised instances of people denying other people's right not to have sex involved Catholics, often prominent ones. I'm surprised Mr Pope hasn't heard about this.
But there are a lot of things that have passed Mr Pope by, especially matters relating to sexual behaviour (and misbehaviour). He and some of his followers subscribe to the myth that latex condoms have tiny holes that the HIV virus can pass through. No, Mr Pope, there is just one hole in a condom, and it's supposed to be there.
Of course, this is not to say that things can never go wrong. For example, people can carelessly rip a condom when opening the package, perhaps by doing so with their teeth. They can damage the condom in various ways and there is a need to be careful. But this indicates that they need sex education that includes instructions on how to use condoms, preferably from people who have had experience of using them.
You say that promotion of condom use and sex education give rise to greater promiscuity; there is plenty of evidence to demonstrate that this is not the case. There is also plenty of evidence to demonstrate what happens when people don't receive any sex education or only receive half baked rubbish, such as 'abstinence only' claptrap. The result of not educating people about sex is very high rates of HIV and other sexually transmitted infections (also unwanted pregnancies).
You see, Mr Pope, people who get abstinence only education, people who take vows of abstinence, perhaps even Catholic priests and brothers, still have sex; they just don't bother to use condoms, perhaps because they have never heard of them or because they have been given incorrect information about them.
You call for a responsible attitude toward sex? People need education, discussion, information, enlightenment, not the lies that anti condom campaigners have been spewing out. How do you expect people to develop a responsible attitude towards sex when you are not even responsible enough to tell the truth? Is lying no longer a sin? Or does it depend on who tells the lie or what the consequences are? Perhaps things have changed since I was a Catholic.
Look, Mr Pope, you don't know what you are talking about. Please consult the World Health Organisation, the UNFPA and UNAIDS. These organisations are experts in public health. They will tell you that "[t]he male latex condom is the single, most efficient, available technology to reduce the sexual transmission of HIV and other sexually transmitted infections." They will also confirm that "[y]oung girls and women are regularly and repeatedly denied information about, and access to, condoms. Often they do not have the power to negotiate the use of condoms. In many social contexts, men are resistant to the use of condoms."
I suggest you read this position statement carefully. It has just been revised and it contradicts many of the things you say. There's no excuse for being so badly informed and your attitude toward these matters is grossly irresponsible. I think it could justly be called culpable ignorance, if it really is ignorance.
It's interesting that one of the people who defended Mr Pope works for a Catholic NGO in Senegal. He says that his NGO doesn't promote condoms. I recently blogged about Senegal because the country has the lowest HIV prevalence in all of Africa. But one thing that has long been very common in Senegal is the use of condoms. Thankfully, this particular NGO wasn't the only one working there.
In contrast to Senegal, Rwanda and Burundi, considered to be very Catholic countries, have high rates of HIV and low rates of condom use. Also, because sex before marriage is frowned upon, for religious reasons, many men have their first sexual experience with a commercial sex worker. I know, spotting contradictions in Catholicism is like shooting fish in a barrel!
But sadly, some people will grasp at any excuse to justify their behaviour. Many people are already reluctant to use a condom to prevent unwanted pregnancy or sexually transmitted infections. There are myths surrounding most aspects of HIV, how it's transmitted, how to avoid it, how to cure it, etc. But with myths, people can accept the bits they like and ignore the bits they don't like. People who don't like condoms still enjoy sex and they are not going to see Mr Pope's solution as desirable or even viable.
So Mr Pope's pronouncements about condoms not working very well and promoting promiscuity will certainly appeal to people who just don't want to use condoms. He is, effectively, preaching to the converted, telling people who don't like condoms that it is wrong to use them and that it won't help them, anyway.
No doubt, a Catholic who becomes infected with HIV, despite following Mr Pope's thoughtful advice, will have their just reward in heaven. How comforting. But let's not deceive ourselves; preaching against the use of condoms is promoting the transmission of HIV.
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