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.



Claire Risley said...

What strategy we use to target an infectious disease relates to what we want to achieve. Currently, Polio is still being transmitted, despite huge reductions in incidence in the last 20 years (several thousand new cases per day -> 5 cases per day). This has led to the interesting question of whether current vertical programmes to allow eradication should continue in order to achieve eradication, or whether they should be scrapped as hugely expensive, and resources diverted into a wider-scale improvement of sanitation and linking with other programmes to bring down prevalence in the long-term instead ( The comparison with HIV reveals that HIV eradication in the short-term is entirely unfeasable, as we can't reduce transmission rate below the threshold of < 1 new case per existing case in order to achieve eradication by focussed interventions. So we are left with the horizontal, integrative approach you advocate, where all the vulnerabilities of communities are addressed, development allowed to happen, and the resulting slow decline and potential eradication of HIV to happen in the long-term.

Simon said...

Hi again, Tin Angel, thank you for your comment. I wish I could be so succinct! Yes, I am not in favour of vertical programmes. Polio eradication has been successful in some places, I wonder if that is because they also have improved health and other social services. It would be intesting to know if polio could be better approached by targeting the determinants of the disease because that should help reduce the incidence of other diseases at the same time. For the same reason, I object to putting lots of money into a cholera vaccine (which Bill Gates is doing) when good water and sanitation prevents cholera AND numerous other conditions. Somehow, I don't think the aim of people like Bill Gates is to achieve a high level of health, education or any other area of development. But perhaps that's just me.