Monday, March 2, 2009

Wishful Thinking And Wilful Lobbying

Further to my last posting, which was about universal HIV testing and treatment (UTT), I would like to point out that the advocates of this strategy make it clear that UTT would be combined with currently used prevention approaches. The authors are not suggesting that all the current approaches can be discontinued. They are idealistic but they do have one foot in the real world.

Some of those who have jumped on the UTT bandwaggon, on the other hand, seem to think that current approaches will cease to have much relevance. Similar remarks apply to another technical solution that was fashionable for a while and still is in some circles: mass circumcision. It was feared, even when mass circumcision was first mooted as a strategy for HIV prevention, that people would experience 'disinhibition', that they would think being circumcised meant they didn't have to bother with other precautions.

But that's the problem with bandwaggons, every new toy is seen as the future until it is replaced by the next toy. Using every strategy possible to prevent transmission of HIV is rarely discussed. In fact, strategies that don't relate fairly directly to sexual behaviour are rarely discussed even though they are numerous and would have benefits beyond HIV prevention.

Perhaps there is a feeling of unease developing among some of the loudest proponents of UTT. Maybe they are beginning to feel that many of the prevention strategies that have been employed so far have been a complete failure. Perhaps they wish to bury most of the failed strategies that emanated from dogmatic, right wing moralising rather than from any evidence, scientific, social or otherwise.

But UTT makes very good commercial sense for the makers of pharmaceutical products that are so expensive that most people can’t afford them. Given that the majority of people with HIV live in the developing world, pharmaceutical companies wouldn’t have much of a market for their products unless they could persuade governments and international institutions to pay for them with aid money. And they seem to have been very successful in this endeavour.

Much HIV policy thus far has depended on the assumption that a sexually transmitted infection can be prevented by targeting sexual behaviour and by aiming to regulate the forms sexual behaviour should take. But firstly, it was never reasonable to assume that these could be achieved. Secondly, these policies failed to take into account the determinants of people's behaviour, sexual and otherwise. These policy makers were not really interested in the effect their policies were having, they were just interested in seeming to say the right thing in front of their electorate and/or their funders.

Very early on in the HIV epidemic, HIV was handled by doctors and other technical and medical personnel and this was a period of rapid learning and adaptation. Doctors and others were quick to warn about what steps should be taken to contain what could become a serious epidemic. On the whole, they did a good job, especially considering they were working in the dark.

But HIV quickly became a football for politicians, religious leaders, journalists, pundits of all kinds and, of course, NGOs. There was little that medical practitioners could do anyway and the field was soon full of people jostling for attention. HIV attracted enormous amounts of money and at the same time deflected money, attention and personnel from other issues. These processes continue today.

Prejudices were fed by the same political and religious leaders, journalists and anyone else who felt they should have a say. We saw, and still see, moral outrage, blame (on women, sex workers, immigrants, gay men, Africans, whoever), finger wagging, posturing and anything but effective prevention strategies or the money to pay for them.

Now that this potential technical solution has come along, are we going to see a quiet retreat from these long held dogmas? And if so, will the issues of cross generational marriage, female genital mutilation, the low status of women, labour rights denied, lack of health, education and other services no longer be considered important?

The rush to embrace UTT sounds like a tacit admission that prevention strategies up to now have been a failure and that it is not possible to legislate for people's sexual behaviour. These are both true, of course, but this doesn't mean that UTT will work, whether on its own or in conjunction with existing strategies. If UTT is to work, many other conditions need to be fulfilled first.

HIV has been decontextualised and ahistoricized. Every epidemic has a history and a context. The epidemic in Kenya is different from those in Uganda and Tanzania. In fact, the epidemic in Nairobi is different from that in Mombasa. There are few sex tourists in Nairobi, for a start. But the commercial sex work that takes place in the central business district is quite different from the problems faced by the 70% of Nairobians who live in slums. The epidemic around the Mumias Sugar Company is different from the ones in the towns bordering Uganda. The problems of tea plantation workers in Kericho differ from those of the nomadic people of Northern Kenya, and so on. The determinants of HIV transmission are many and various, requiring many and various solutions.

UTT is yet another solution that is blind to such distinctions as epidemics that are driven by economic need, lifestyle, labour conditions, abuse and exploitation, poverty and whatever else. UTT assumes that HIV is primarily a medical problem and, as such, that it is the same in every country in the world.

UTT could work well in countries with good health, education and social services, buoyant countries with low levels of inequality and good legal and governance structures that protect people's rights. Kenya is not such a country, neither are any developing countries. That's why they are called developing countries.


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