Basic Health Care is the Key; Well, One of Them

A recent article from Integrated Regional Information Networks (IRIN) argues that basic health care is vital to HIV treatment and care, as well as HIV prevention. While it is refreshing to hear expressions of this view from such an influential source, the article doesn't make any suggestions as to where money to build up basic health care in Kenya and other developing countries would come from. Most of the large sources of donor money (the President's Emergency Fund for Aids Relief (PEPFAR), the Global Fund, the Bill and Melinda Gates Foundation) are earmarked for HIV or one or two of a handful of other diseases. Even funding for so called 'neglected diseases' does not usually aim to build up basic health care. And non-transmissible diseases (for example nutritional deficiencies, various forms of cancer, type 2 diabetes, etc) receive hardly any funding at all, despite being responsible for a sizeable proportion of deaths in developing countries.

There are those who would defend these approaches to health and disease, often arguing that health care in general does benefit from programmes that address one disease or health area. But this is not good enough. There are too many diseases, transmissible and non-transmissible, that are being ignored. Health services are in a terrible state. The number of qualified health personnel is a disgrace to a country that is nowhere near the poorest in Sub-Saharan Africa. And the health infrastructure has been crumbling since the 1980s. Most health services are inaccessible to the majority of Kenyans and people will continue to die and suffer from easily curable and treatable conditions if this state of affairs doesn't change.

In addition to basic health care, many children still don't receive basic education, many don't receive enough basic education and most receive a poor standard of education. Levels of equality between males and females and between the haves and the have-nots are inexcusable and, in common with almost every country in the world, developing and developed, these are disimproving. And bad health is almost guaranteed in countries where there is little food security, very low levels of nutrition and low access to clean water and modern sanitation facilities.

The article in question refers to an ActionAid report which rightly points out that basic health care is the key to tackling HIV. But health on its own is not enough. The health of a country also depends on levels of education, social services, infrastructure, equality, opportunity and many other things. I hope this is a sign that a climate of more inclusive development programmes is on the horizon, but the global economy will not make this an easy job. continuing to involve NGOs and the private sector is all very well but most NGOs are focused on one or a relatively small group of issues. No NGO is big enough to be particularly inclusive. And the private sector are completely single minded. They will ship condoms to countries regardless of what happens to those condoms when they get there; they will ship pills to people who have no water or food. They want markets and little else.

I hope ActionAid is right but they may also like to lobby the World Bank and the International Monetary Fund while they are at it. These international financial institutions spent the last few decades persuading developing countries that the best way to develop was to reduce spending on health, education, social services and infrastructure, to limit the number of public sector personnel they employ (teachers, nurses, doctors, etc), cap spending on public sector wages and to introduce a whole host of 'austerity' measures. The institutions have continued to insist on the continuation of these measures and the introduction of even more of them, despite overwhelming evidence of the damage they were doing to people's lives. Ironically, these institutions are also big donors, so it's not as if they couldn't help out, if and when they eventually see the light.

Health and HIV don't exist in a vacuum and they are not short term emergencies. Unless developing countries are helped to develop and the many obstacles to their developing are removed, HIV treatment and eradication programmes have limited success.

HIV Treatment is Necessary but not Sufficient for Eradication

The HIV in Kenya blog has covered many aspects of development in Kenya and other African countries because HIV is a symptom of underdevelopment, poor health systems, inadequate education and few, if any, social services. However, it has been primarily concerned with prevention of HIV, as opposed to treatment and care for those already infected with HIV. This is not because I consider treatment and care to be unimportant or because it is already over funded. On the contrary, treatment and care for people with HIV and Aids should be a vital part of any country's approach to reducing the spread of HIV.

If people who are HIV positive have no expectation of treatment or care, there is no reason why they should bother being tested. If people don't get tested and don't know their status, they could continue having sex with HIV negative people and thus spread HIV further. People who are found to be HIV positive can be advised on how to take precautions against spreading HIV. They can also receive antiretroviral therapy (ART), which, when they respond to it, makes them less likely to transmit HIV.

At present, many tens of thousands of people are on ART in Kenya. Most of them are able to live a healthy life, to work and provide for themselves and their families. Many of them have been provided with conditions that can reduce the probability of their transmitting HIV to their partners.

Admittedly, some treatment and care programmes are better than others. The programmes are very expensive and require a delicate balance, so treatment can be interrupted for many reasons, such as civil disturbance, financial problems, various disasters, food shortages, etc. The majority of people who are HIV positive and requiring treatment are still not receiving it, but there are also many people who would not be alive or healthy today if they were not receiving treatment.

This is good for HIV positive people, who may number as much as 1.5 million, sexually active people. In a population of around 40 million people, that's no small feat because these 1.5 million adults would have many dependents. Many millions of people are less directly affected by HIV but would be at far greater risk if they didn't have a parent, sibling or guardian to provide for them. When you add in dependents, maybe a quarter of the population of Kenya or more need ART to be rolled out to everyone who needs it.

But even if everyone who needed ART were to receive it, this would not cut the rate of HIV transmission to a level where the epidemic will eventually 'fizzle out'. Tens of thousands of people are being infected every year, more than are being put on ART every year. The epidemic may be bumping along, with prevalence lower than it was 10 years ago, when it peaked at 10%. But this is not a good situation, this is not something to celebrate. Prevalence dropped in the early 2000s because death rates were very high. Now that death rates are lower, prevalence is going up.

Treating and caring for people who are HIV positive is only one part of preventing people from becoming infected and, eventually, reducing infection to so low a level that the epidemic will cease to be the serious threat to the country that it is now and will be for the foreseeable future. At the moment, the amount of money spent on HIV prevention is estimated to be less than 25% of total spending. And much of the money being spent on HIV prevention seems to be having very little effect.

Much more money needs to be spent on researching and implementing viable prevention programmes. Treatment and care can only be a part of a country's overall HIV eradication programme. The disease won't just go away and, right now, the number of people requiring treatment, which they will need for the rest of their lives, is going up. Kenya can't afford to keep treating people at the rate that people are becoming newly infected; the world can't afford to keep treating people at the rate that people are becoming infected, globally.

HIV will not just die out unless new infections are reduced radically. Treatment and care programmes are very necessary but, on their own, are not sufficient to eradicate HIV.

Health Related Political Footballs

It seems like a short time since the issue of mass male circumcision (MMC) became a political football and it is not even the latest issue to have that status any more. But articles about it still appear every now and again and there seem to be a handful of genuine projects aiming to roll out MMC in some countries.

The Integrated Regional Information Networks (IRIN) has a recent article on the subject and lists the countries that have made some progress towards rolling out MMC. I notice Kenya is not on the list and not much progress seems to have been made in the eight countries in the list. Most sub Saharan African countries suffer from a lack of capacity and this seems unlikely to change in the near future.

On the one hand, a country could approach HIV as if it was just one disease of many and build up their overall health services. But most donor funding goes towards a handful of diseases, the main one being HIV. Very little funding, if any, goes towards building up health services in general.

Alternatively, countries could extend the capacity of existing health services to accommodate some kind of MMC programme. The latter approach might be like the attempt to test people for HIV (in the form of voluntary counselling and testing clinics) and the attempt to distribute treatment to as many infected people as possible. But after many years and extraordinary amounts of money being spent on these areas, these efforts have had limited success.

It’s important to note also that there are still many questions about the benefits of MMC and precious little discussion about the downsides. This is worrying and gives the impression that MMC is being promoted without taking into account the welfare of the people who will be involved. Of course, that wouldn't make MMC much different from development projects in general.

But the aim of MMC, ostensibly, is to reduce HIV transmission. It is believed that circumcised men are far less likely to become infected with HIV than uncircumcised men. The level of protection offered by circumcision is a matter of debate. I hope the debate is comprehensive and well informed because any measure that could reduce HIV transmission should be welcomed.

That is, any measure that has substantial benefits and few, if any, adverse effects. And circumcision may have quite a number of adverse effects. Rather than rehearsing the possible adverse effects here, I recommend the Male Circumcision and HIV website.

But my objection to MMC is slightly different. Given that I would argue that if Kenya had good health, education and other social services in the first place, HIV would never have spread as it did and would be easier to fight now. Therefore I see little point in piecemeal programmes that address one small factor in HIV transmission at a time.

Men are becoming infected because they don't know enough about safe sex and they don't have a high level of sexual health. Women are becoming infected because they have, in general, even poorer levels of health and education than men. There are employment, infrastructure, legal, lifestyle, tribal and many other reasons why men and women continue to be infected with HIV.

All of the factors in HIV transmission need to be addressed, not just the one or two factors that seem most attractive at a given time. Why MMC seems so appealing is really not that clear but ask yourself this question: would you go to a clinic to be circumcised if you knew that 1 in 5 operations resulted in some kind of adverse effect? Would you allow a clinic to circumcise your children?

Who in their right mind would advocate a programme of MMC in a country where tens of thousands of women die giving birth or shortly after giving birth, where tens of thousands of children die of diarrhoea, acute respiratory conditions, malnutrition or other easily curable or treatable diseases or where a substantial number of people will never have access to a qualified doctor in their whole life?

Kenya needs good health services, education and other social services. I know I keep beating on about it but these other political footballs are just distractions. I guess they are supposed to distract but we shouldn't forget the problems that Kenyan people face: they relate to day to day issues, such as food shortages and high food prices, unaffordable health care, appalling educational facilities and standards, political unrest, corruption and many other things.

Tackle the issues that face people on a daily basis and the problem of reducing HIV transmission will be a whole lot easier, whatever measures are deemed most appropriate in the end.

Treatment As Prevention

An interesting discussion arose in Switzerland some months back. HIV positive people who are responding to antiretroviral therapy (ART) usually have an undetectable viral load. As a result, they are not very infectious. So discordant couples, where only one partner is HIV positive, are advised that they can enjoy a normal sex life, virtually as if neither was HIV positive.

It’s important to note that, even in countries like Switzerland, not everyone responds to ART to the extent that they have an undetectable viral load. And things can change. They need careful monitoring and advice. So this is great news for people living in countries where they get very good medical care, have good levels of nutrition, have enough money to pay for any kind of treatment and care and even have an adequate level of education to understand and discuss the implications of being in a HIV discordant relationship.

But most people don't live in rich, developed, Western countries. They are lucky to find out that they are HIV positive early enough for ART to work as well as it does in developed countries. They usually don't have access to good medical care, don't have adequate nutrition for any health status and can't afford any treatment or care, aside from the pills paid for by donor aid. And they are unlikely to have a standard of education that would allow them to follow the complex debates about sexual behaviour and lifestyle choices for HIV discordant couples and the like.

Who knows what percentage of HIV positive people on ART in developing countries are responding well and have an undetectable viral load. In most cases, nobody is checking. Things can change rapidly, like during the post election violence last year, when many people on ART were unable to get their drugs. There are stock outs, such as that experienced in Uganda on several occasions. And there is the current financial crisis, which has resulted in several countries finding that they are unable to guarantee supplies of drugs and related services, even to the minority currently on ART.

But in reality, for developing countries, the most worrying thing about the so called 'treatment as prevention' debate is that treatment is not prevention. The more people on treatment, the better, there's no doubt about that. But as more and more people are starting ART, there are still tens of thousands of people becoming infected with HIV in Kenya every year.

Treatment should support Kenya's prevention campaign but it should never become that campaign. At present, over 75% of the tens of millions of dollars being spent on HIV goes to treatment and care. 'Treatment and care', in this instance, mainly refers to drugs. Many areas of health are relevant to HIV treatment and care but once the grossly over priced pills have been paid for, there is not much left for anything else. That's why only about of third of the people who need ART at present are receiving it.

Nowhere near enough money is being spent on prevention and there is even a danger that the 'treatment as prevention' slogan could end up further skewing the way HIV funds are spent. People are being infected every day and they need education, health services, infrastructure, jobs, legal rights, equality and things like that. This is not just to do with HIV alone, it's also to do with ensuring people's human rights so they can enjoy a decent quality of life.

For too long, the development agenda has been determined by rich multinationals, such as pharmaceutical companies and the health care industry. Development has always been seen as a huge market for overpriced goods, which is why so much money goes 'into' developing countries without seeming to have much effect. It goes into the pockets of rich industrialists.

HIV treatment is vital, both for people who are already infected, those who are indirectly affected and those who are, as yet, uninfected and unaffected (if there are any of these). But prevention is also vital. And for treatment, care and prevention programmes to work properly, people need schools, teachers, hospitals, health professionals, legal protection, equality, employment and many other things.

The developing world is not populated with billions of customers; it is home to billions of extremely poor and vulnerable people. HIV needs to be prevented, not just treated.

The Hot Air of Publicity

I'm always pleased when I come across articles suggesting that too little money is being spent on HIV treatment and care and not enough is being spent on prevention. I'll be even more pleased when prevention campaigns try to expand on and explain exactly what they mean by words that have strong religious connotations, such as 'fidelity', 'faithfulness' and 'abstinence'. We probably can't do without such words but prevention campaigns need to address the circumstances in which people live, especially the circumstances that determine when, where, with whom and how often they have sex.

Slick advertising campaigns are all very well for pumping out slogans that the media can repeat endlessly but the messages, ultimately, need to make sense to people. It needs to be possible for them to protect themselves from dangers like sexually transmitted infections, unplanned pregnancies and HIV. After all, if a certain sort of behaviour is 'immoral' it needs to be possible for people to avoid it and if a certain sort of behaviour is 'moral' it needs to be possible for people to behave in that way.

For example, if having sex with someone to whom you are not married or having sex with many different people are examples of immoral behaviour, it needs to be possible for people to avoid engaging in these activities. But many people, sometimes referred to as 'commercial sex workers', are often just people who have been left with no other option when it comes to providing for themselves and their families. They need to be pragmatic because the people who are wagging the moral finger at them are certainly not offering them an alternative.

Similarly, fidelity and faithfulness are great for people who are in a certain sort of relationship, for example, marriage or any long term partnership. But both (or all) parties in a relationship need to observe the principle. Where one or both parties have other, concurrent sexual partners, there is little point in recommending 'abstinence' until marriage. If one partner chooses to 'abstain' until marriage, the other partner may not choose to. Then, even the partner who abstains could still become infected with HIV.

And plenty of research has shown that, despite lengthy HIV prevention campaigns in most countries in the world, a lot of people do not only have one partner in their lifetime, a lot of people don't only have one partner at a time and a lot of people don't see being in a long term relationship or being married as a reason not to have sex with someone else every now and again, or even frequently.

HIV prevention campaigns can continue to do what they have been doing for over two decades, lecturing people about what they should and shouldn't do, or they can look at some realities. Firstly, some people don't always do what they 'should' do and some often do what they 'shouldn't' do. Secondly, others are not always in a position to do what is considered moral or avoid what is considered immoral. These campaigns may have some kind of moral high ground but they do not have much relevance to the way people lead their lives.

Even campaigns that advocate for the use of condoms need to ensure that people are enabled to use condoms. If you are depending on sex for your income, using a condom may protect you; but agreeing to sex without a condom will pay better, often far better. If you are married or in a stable or long term relationship you may find it difficult to get your partner to use a condom. Apparently, many refuse to use a condom with their spouse or long term partner.

Slogans, wristbands and media campaigns may (or may not) have done great things in the past but they will never be enough on their own. If people are forced to have sex for money, there is a serious economic problem. If people are not able to choose to use a condom there could be a legal problem and perhaps an issue of gender inequality that needs to be addressed. There are people, usually women, who are required to sleep with their boss to get a job, keep a job, get promotion or even to get paid. This suggests serious corruption and lack of protection for people who may be particularly vulnerable.

Unless these prevention campaigns address these and other circumstances in which people live, they might as well not bother. Young girls are being encouraged or even forced to have relationships or even to marry older men, sometimes their teachers, in order to get some financial support, school fees or some other benefit. There is no point in telling them that what they are doing is wrong or in telling them about the virtues of abstinence, fidelity, condom use, virginity or any other platitude.

Campaigns in the past in Uganda, Senegal and even Kenya, have been called 'successful' but as long as people are prevented from protecting themselves, HIV and other sexually transmitted diseases will continue to spread. There may continue to be fluctuations but for real, long term success, people need to be able to avoid risky situations, they need to be self reliant, they need to be far more autonomous than they are now. The economic, health, educational, legal, employment and other conditions facing people in Kenya and other developing countries need to change drastically. The hot air of publicity will never achieve anything on its own.

It’s Homophobia that is the Problem, Not Homosexuality

The main ‘problem’ with homosexuality or same gender sex, is homophobia. People who are lesbian, gay, bisexual, transgendered or intersex (LGBTI) do not thereby have a problem. Their problems arise because of the attitudes of people who consider themselves to be ‘normal’. These ‘normal’ people also consider themselves to be Christian, Muslim, law abiding, God fearing, righteous and many other things.

In reality they are at best prejudiced, judgemental and guilty of discriminatory practices, at worst, they can be criminally violent, even murderers. At the hands of these self-appointed arbiters of moral and immoral behaviour, LGBTI are subjected to horrific persecution, they are ostracized from communities, they are considered to be and treated like second class citizens.

Everyone has some kind of sexuality and most people express their sexuality in some way. Most sexual behaviour involves other people and much of it is consensual. Of course, forced or coerced sex is a terrible crime. But anyone can force or coerce someone to engage in some kind of sexual behaviour. That means, whatever someone’s sexuality, they can choose to have sex only with those who consent and only engage in types of sexual behaviour to which their partner consents; or they can engage in behaviour that is, hopefully, criminal.

If the self-appointed upholders of ‘virtue’ object to the way that some people express their sexuality, they could object to fact that tens of thousands of people are forced to have sex every year. Thousands of these victims are children, sometimes infants. Many are particularly vulnerable, for example, orphans, young girls who have been married off by their poverty stricken parents or women who have been widowed or abandoned. But others are just ordinary people, neighbours, friends and relatives.

These ‘virtuous people’ could also object to the incalculable number of women and girls (mainly females, anyhow), who are left with no other option than to provide men with sex in return for money, food, security, accommodation, school fees or some other transaction. For every female, there is at least one man involved in these transactions. In reality, for commercial sex work to be viable, there must be a lot more males than females involved. It seems hard to believe that none of these ‘virtuous people’ overlap with the many men who engage in transactional sex.

Amnesty International (AI) have highlighted the plight of human rights abuses against LGBTI in a number of African countries, such as Nigeria, Uganda, Senegal and Rwanda. Kenya may not be the worst offender but I don’t believe their record with regard to LGBTI is particularly good.

It’s particularly galling to hear this about Uganda and Senegal when you compare it to the badly researched journalistic rubbish you also hear about how successful these two countries have been in fighting their respective HIV epidemics. Senegal has one of the lowest prevalence figures in the whole of Africa and Uganda now has far lower prevalence than it once had.

Firstly, I would question their ‘success’ and suggest that there were important factors governing HIV transmission in both countries and these factors were far more significant in determining fluctuations in prevalence than anything the Ugandan or Senegalese governments ever did. But that’s another story.

Secondly, both these countries need to watch out. Discriminating against certain groups of people who are thought to be at highest risk of transmitting HIV is not going to help reduce transmission. People who are at risk need to be targeted with education, testing, health services, support and the protection of the law. Criminalise what they do, be it homosexuality, commercial sex or anything else, and you will have little success in targeting them.

At present, both Uganda and Senegal have pretty poor records when it comes to protecting some of their most vulnerable people. Low prevalence now does not mean low prevalence in the future. Both countries are creating and maintaining conditions where HIV will spread rapidly. There will be little their HIV prevention programmes can achieve if their laws compel or allow homophobia and other discriminatory forms of behaviour to persist.

Apparently, Kenya is considering discussing LGBTI in schools. I’ll believe it when I see it. However, everyone has a sexuality. There is no point in discussing a handful of sexualities without also discussing the whole issue of sexuality with everyone. Tomorrow’s homophobes need to be targeted, future persecution needs to be prevented and that won’t happen by exceptionalising LGBTI. The biggest problems faced by LGBTI stem from the behaviour of people who are not LGBTI.

The best thing Kenya could do to reduce HIV transmission and to help those who are most at risk of being infected is to criminalise discrimination and persecution, to criminalise gender based violence, forced and coerced sex and gender based corruption. They also need to decriminalise non-heterosexual sex and commercial sex work in order to prevent and/or identify and punish criminal behaviour and, at the same time, protect the victims. They need to get away from the current situation where they are just meting out punishment to those who are thereby victimised twice over.

Targeting Sickness Versus Promoting Health

Questions of whether HIV has or hasn’t been exceptionalised and whether this is a good or a bad thing are often raised. Discussion sometimes involves the issue of horizontal health care, which deals with the overall health of a population as opposed to vertical health, which deals with particular diseases, such as polio, intestinal parasites or HIV.

I am of the opinion that HIV has been exceptionalised and that this is a bad thing. I also believe that health care should aim to be more horizontal. Vertical approaches to individual diseases have sometimes been successful, at least up to a point, but they leave out too many vital areas of health. There is little to be gained by protecting a whole population from a handful of diseases when so many of them will be wiped out by diseases that have been ignored.

Indeed, many people do die from easy to prevent and easy to treat illnesses, such as acute respiratory infections and diarrhoea. The biggest threats to health, especially among infants and children, are things like water and sanitation, poor living conditions and nutrition. These are important for adults, too, as are basic health and medical services.

Big eradication campaigns tend to ignore the most basic health needs of populations. They concentrate on a single or a small number of diseases, they tend not to develop broader health infrastructures or deal with determinants of health and they cost a lot. Often, money could be better spent on ensuring the determinants of healthy populations, but it tends not to be.

The World Health Organisation (WHO) is presently promoting a vaccine that prevents diarrhoea that is caused by the rotavirus, estimated to kill half a million children a year. It is recommended that this vaccine be included in national immunisation programmes. Rotavirus is often fatal to children in developing countries because of lack of access to clean water, sanitation and basic medical care.

However, the WHO recommends a comprehensive strategy that includes improving water and sanitation and providing some of the healthcare products that are required to deal with diarrhoeal diseases. A comprehensive strategy is crucial. There are many water borne diseases and many diseases that are caused by poor sanitation and lack of hygiene.

But this is just a recommendation from WHO. When it comes to funding programmes like this, pharmaceutical companies are always interested in having huge quantities of their products purchased for ‘aid’ projects. The problem is that you don’t cure diseases by providing countries with huge quantities of pharmaceutical products. Who will meet the logistical costs, the healthcare costs and the costs of improving water and sanitation in developing countries?

Rich institutions like the Bill and Melinda Gates Foundation have shown a lot of interest in financing projects in developing countries but much of this money tends to be spent on the development of products, things that can be sold, especially branded products that cost relatively little to produce and create a high level of dependency. For example, antiretroviral therapy for those infected with HIV, genetically modified organisms for farmers, etc. Whether this foundation or other donors would be interested in financing projects that don’t promise to make a lot of money is an open question.

Similar arguments apply to the approach that many countries take to HIV prevention. Most money that has been spent on HIV has gone towards treating and caring for those who are already infected. In Kenya, less than 25% of HIV spending has gone towards prevention and much of that goes into counselling and testing and prevention of mother to child transmission (PMTCT).

These all deserve funding, of course, it is absolutely necessary to test and treat people and to prevent mother to child transmission. But in the meantime, hundreds of thousands of children come of age every year and become sexually active. Many of them will be infected with HIV before they receive proper sex education (if they ever receive it) or go for a test or are exposed to any kind of HIV prevention activity.

It’s extraordinary that negligible amounts of prevention money go into targeting commercial sex workers, men who have sex with men and intravenous drug users, people who are at particularly high risk. But even others, who are also at risk, are unlikely to receive any more than some sort of behaviour change communication (BCC). BCC may well be wonderful, there are certainly some wild claims about how wonderful, but the fact is that HIV is still spreading. It is spreading in places where it has long been spreading and it is spreading in new places.

The problem with our approach to preventing HIV is not that the disease is exceptionalised or horizontal, the problem is that it is not working. We have known for a long time that, although people’s sexual behaviour may be somewhat influenced by BCC, it is not influenced a great deal. And the claims about changes in behaviour are not translating into lower HIV transmission. HIV prevalence in Kenya and many other developing countries has been fluctuating for many years. Rates in many places are now lower than they once were. But in other places, rates are higher.

Prevention of HIV (and diarrhoeal diseases, acute respiratory infections and any other diseases) requires us to look at people’s health, not their diseases. We need to know what healthy people are like, what their circumstances are, how to ensure that they will stay healthy, what could help them avoid health risks and risks of any other kind. That means looking at their economic circumstances, housing, nutrition, employment, education, access to information, equality and any other areas that may be relevant.

Most children will grow up and will have sexual experiences, sooner or later. Rather than wagging fingers at them and telling them to wait till they are older and possibly telling them how to reduce risks, we need to address the circumstances that make risk harder to avoid. They need more information about sex, contraception, risk, sexuality, etc. Issues of gender inequality in school, in the workplace and in society as a whole, also need to be addressed. Prevention programmes also need to include people who are HIV positive, whether they are on treatment or not.

We seem to be going the wrong way with HIV prevention. There are many things we could be doing and are not doing yet. The HIV agenda seems to be set by commercial and political interests and this can only continue to do harm. Healthy people do not make money for healthcare, nor do they make careers for politicians. But being healthy is a right and this should be acknowledged and addressed by countries and institutions that are pouring money into developing countries. We need to change direction with HIV prevention if we want to reduce transmission and eventually eradicate the disease altogether.

It Doesn’t Need to be Related to HIV to be Important

Nairobi, perhaps in common with other cities in developing countries, is a curious sort of place. Many economic, health, education, infrastructure and other social indicators are the best in the country. You would think that the majority of people there lived well, at least when compared with rural Kenyans or Kenyans living in other cities. Out of eight Kenyan provinces, only Central is anywhere near as prosperous as Nairobi.

However, an estimated three quarters of people living in Nairobi live in slums. People in cities are often better off, or are seen as being better off, than those in rural areas. Perhaps, like Nairobi, those in slums simply don't count. The government barely recognises the existence of slums except when they send in the police to shoot people, almost at random, in the name of anti-terrorism. They consider slum dwellings to be illegal and therefore not entitled to resources.

As a result, slum dwellers in Nairobi, the majority of the capital's citizens, suffer from terrible poverty. But when the country experiences food shortages, as it is doing at present, the aid tends to go to other areas and to pass over Nairobi. As a result, there are serious levels of malnutrition in this city that tries to be so Western and cosmopolitan.

Cities like Nairobi, Mombasa, Eldoret, Nakuru and Kisumu have been growing rapidly for several decades. Public services, far from growing, have stagnated or been reduced because of poor governance, internal and external. Right now, poverty, food insecurity, unemployment and other factors are driving people to cities in greater numbers. Therefore, the problems are becoming more acute.

It's very hard to demonstrate any causal connection between poverty and HIV. Rather than attempting to do so, I would argue that poverty itself is abhorrent. HIV is a terrible disease but it is just one of many. I would not argue that poverty needs to be alleviated because it causes HIV. Poverty needs to be alleviated because it denies people many of their rights. As a result of poverty people suffer numerous health problems, they often receive little or no education, they have reduced life expectancy and they live in poor and degrading conditions.

It's clear enough that some people are exposed to HIV because they are poor. But others are more vulnerable because they have not had enough education. Others still are vulnerable because of their lifestyle, their gender, their sexuality or their working conditions, etc. In Kenya, most cases of HIV are sexually transmitted, but the conditions under which people have sex, when, how often and with whom, are another matter. The things that make people more vulnerable to HIV are often not related to sexual behaviour. People who are in bad overall health, for example, are more susceptible to diseases, including HIV.

Since the 1980s, education, health and other social services have been reduced and continue to be reduced nearly thirty years later. HIV probably arrived in Kenya in the late 1970s and spread rapidly throughout the 1980s and 90s. It took a long time for the world to realise what sort of disease HIV is and to work out how to react to it. But in Kenya and many other countries, health, education and other social services were inadequate. They are still inadequate and most efforts to reduce the spread of HIV to date have failed.

HIV is still spreading in many parts of Kenya. True, prevalence has dropped in some places where it was once very high. But this is to a large extent because many people have died. In other areas, where HIV has been low for a long time, it is now increasing. And some places have had high HIV prevalence for a long time and it remains high. The figures have fluctuated over the years but the backslapping that has gone on in Kenya, Tanzania and even Uganda is premature.

The vast majority of Kenyans don't know their status. The vast majority of people who are HIV positive don't know their status. The county's health service does not have the capacity to test everyone. The country's education sector is in no condition to give even a basic education to many people, let alone sex and health education. When people become ill, many will suffer unnecessarily and die unnecessarily because of the inadequacies of the health services. Billions of dollars of aid money is going to treating and caring for people already infected with HIV but much of this, too, is being wasted.

The health of many Kenyans is bad. The determinants of health are many and various but include things like water and sanitation, food and nutrition, housing and environment, health services, education and infrastructure. Dealing with these determinants of health, may or may not directly reduce HIV transmission but people have a right to health.

Similar arguments apply to poverty. Poverty alleviation may not directly reduce HIV transmission but it will help give people access to clean water, adequate nutrition, better housing, etc. These are all rights and they don't need to be related to HIV to deserve attention.

Biofuels: Greed that Knows no Bounds

High fossil fuel prices and the need to reduce carbon emissions has made investment in biofuels seem a lot more tempting than it seemed in the past. But there are a number of problems. Firstly, total carbon emissions from the production and use of biofuels is not necessarily lower than from fossil fuels, and can even be higher. Secondly, few countries in the world have productive land to spare to grow biofuel crops in economically viable quantities.

So what do biofuel investors do? Well, they buy or lease land in developing countries, which solves the land shortage problem. And most of the carbon emissions from biofuel production, as a result, become the problem of the developing country. Developing country governments are desperate for any kind of investment and they encourage such industries with tax breaks and lax regulation. These measures are encouraged by the International Monetary Fund (IMF) and the World Bank, of course, because they always support the exploitation of developing countries for the benefit of rich countries.

But do developing countries have ‘spare’ land? Well, countries like Kenya, Tanzania, Uganda and many other African countries have a lot of land. But much of it is marginal or unproductive, more still is protected for various reasons and what’s left is nowhere near enough to produce enough food for domestic consumption. Governments of these countries talk about providing enough food, usually by asking the IMF and the World Bank for assistance, but they all still look to external ‘investors’ as if they are going to magically make hunger, malnutrition and food insecurity disappear. But on the contrary, big external investment has usually had the effect of worsening already serious social and economic problems.

In fact, much of the money going into biofuels investment is aid money. People are fond of complaining about aid money being wasted, stolen, misused or whatever but they don’t seem interested in hearing that the largest amounts of aid money go into the pockets of wealthy multinationals. Billions of dollars of aid money go into paying for condoms, drugs, infrastructure projects, defence contracts, consultancy and other goods and services provided by Western companies. That’s the main reason why so much of the aid money that is said to pour into Africa and other developing regions never seems to have much benefit.

These Western countries’ worries about fuel costs and shortages are being dressed up as a concern for the environment and even an ‘opportunity’ for developing countries. But that’s the last thing that we in the West are really worried about. If we were worried about carbon emissions we could reduce consumption, which is the only way to significantly reduce emissions anyway. And if we genuinely wanted to give ‘opportunities’ to developing countries, we would object to the way aid money is used to prop up Western companies. For example, most food aid is spent on expensive food, bought and processed in the West, transported by Western transporters, handled and distributed by Western companies. Aid money like this is being used as de facto subsidy. That’s when it’s not misused in some other way, and more often misused by Western governments than by developing country governments. Developing country governments are no angels but they are often not the major recipients of Western aid money.

It’s odd that one of the places sought for biofuels production is Saadani National Park in Eastern Tanzania. National Parks are protected, supposedly for the benefit of humankind as a whole. However, most Tanzanians will never get much benefit from Saadani. These national parks are more often frequented by tourists and the big businesses, hotels, tour operators, etc, are more often foreign owned than Tanzanian owned. Small numbers of badly paid Tanzanian employees get some benefit from the tourists and that’s better than nothing. But national parks are mainly of direct benefit to wealthier people.

But now the claim is that the production of biofuels is also for the benefit of humankind. But who is going to benefit? The Tanzanians will lose a huge and unique area of scientific interest, the few benefiting from the tourism industry will lose their livelihood and those farming or otherwise living in the area will also be denied their living. The environment will be destroyed, water will be diverted and contaminated, land will be degraded, the coastline will suffer and for what? So that Westerners can continue to overuse fuel and other resources at the expense of people in developing countries. This is not for the benefit of humankind, it is for the benefit of the rich and the relatively rich.

Far from reducing environmental degradation, the production of biofuels will cause environmental catastrophes and mostly in developing countries, the very countries that are already feeling the worst effects of climate change. Are we going to be fooled into thinking that because the carbon emissions are being moved to other countries that we have thereby reached our targets? These rich investors are treating Tanzanians and other people in developing countries as fools, at best; at worst they are treating them as just another commodity. But we in the West seem to be allowing ourselves to be fooled into thinking that we are not doing any harm, even that we are doing some good!

It might be asked if any kind of impact assessment has been carried out and yes, some assessment has been done. It has been done, as usual, by Western consultants who have an interest in being employed again and again. They, to be fair, reported some of the disadvantages as well the advantages of massive biofuels projects. But companies and officials involved will only use the bits of the report that suits them. They will knowingly continue with this work as long as it holds substantial promise for them. For instance, the land that is planned for destruction has timber that may be of greater value than the biofuel crop itself. This sounds like another case of asset stripping, like the various privatisation charades, which were (and still are) also presided over by the folk at the IMF and the World Bank.

Ultimately, millions of people will be directly affected by these biofuel projects and billions will be less directly affected. Impact assessments even accept that many people will lose their jobs and their livelihoods, many animal and plant species will be wiped out, the health of the affected populations will suffer and that the projects will be costly (though costly for whom?), etc. But if some parties can make money out of them they are very likely to go ahead.

A recent article on this subject is followed by a postscript stating that one particular project has been pulled as a result of campaigning. Indeed, several months ago many similar projects were pulled following the global financial crisis. But this doesn’t mean that developing countries will no longer be seen as a potential source of biofuels, food, metals, minerals and other resources. As soon as it becomes economically viable, at least for some parties, you can be sure that these investors will be back.

The Many Uses of Condoms

Sometimes the use of condoms to prevent infection with HIV is emphasized to such an extent that their use to prevent other sexually transmitted infections (STI) and to prevent unwanted and unplanned pregnancies is forgotten. Many STIs are easier to contract and transmit than HIV, some are difficult to treat and some increase the risk of being infected with or of transmitting HIV.

The consequences of contracting STIs other than HIV can be grave. In addition to serious illness, some STIs also affect fertility. But the consequences of unwanted or unplanned pregnancies can often be more serious, especially for younger people.

Many women who get pregnant unintentionally try to terminate the pregnancy. This is illegal in a lot of countries so they must resort to untrained abortionists or to carrying out the abortion themselves. The result can be injury, reduced fertility or death.

Many women, more than half a million a year and mainly in developing countries, die during pregnancy and childbirth. Some of them may have tried to terminate the pregnancy but there are all sorts of complications that can result in maternal death. Most of the deaths could have been averted with better and more accessible health services but also, many of these pregnancies could and should have been averted.

Certain religious and political groups have objected to the use of contraception and even to sex education. Others object to sex education for young teenagers. They feel that ready availability of contraception and widespread knowledge about sex only promotes promiscuity. However, there is plenty of evidence to show that these claims are unfounded. On the contrary, children who get comprehensive sex education are more likely to delay their sexual debut and more likely to use contraception.

Older people, married or single, need information and advice about sex, sexuality and family planning too. They need access to health services, contraception, etc. But more importantly, they need to be empowered to the extent that they are able to use contraception, whether it is to prevent conception or to avoid HIV or other STIs. Too many people say they didn’t know about contraception (or even about sex!) when they became sexually active. By the time they find out it can be too late, they may already be pregnant or already infected with an STI.

A lot of HIV money goes into ‘treatment and care’; but this really means that a lot of money goes into drugs. You need more than drugs to treat people suffering from a chronic illness like AIDS. Similarly, a smaller but still considerable amount of money goes into preventing mother to child transmission (PMTCT), also called vertical transmission. This also involves the use of drugs but again, it takes more than drugs to identify HIV positive mothers, to monitor them through pregnancy and delivery and then to monitor and care for the child.

It is estimated that 900 babies a day are born with HIV in developing countries because health services are not reaching women or because those health services are simply inadequate. Kenya, Tanzania and Uganda account for a large percentage of this figure. Pregnant women need to be tested and followed up, as do their children; drugs alone are not enough.

But to return to the condom and family planning point, many of the women giving birth to HIV positive babies didn’t want to get pregnant in the first place. Some hadn’t planned to get pregnant for all sorts of reasons, but some wanted to avoid pregnancy because they knew they were HIV positive. So, even many instances of vertical transmission could be averted by the use of condoms and other family planning techniques.

PMTCT, better maternal health and child health and many other health areas are compromised by poor health systems, shortages of trained personnel, low availability of the most appropriate drugs, etc. But maternal deaths, both from unsafe abortions and other causes, as well as vertical transmissions of HIV, could be reduced by the relatively cheap strategy of family planning.

Why throw large amounts of money at intractable problems when you could avert many of those intractable problems using relatively small amounts of money?

As always, the message from this blog is that HIV is serious. But there are other serious issues that people in developing countries face. Crucially, if some of these issues got a little more attention the question of HIV, in at least some cases, would not even arise.

Why HIV Is Not Just About Sex

I am not denying that HIV is a sexually transmitted infection and that most infections in developing countries such as Kenya occur through heterosexual sex. I am denying that abstinence or even abstinence, faithfulness and condom use programmes (ABC) on their own will reduce HIV transmission to the extent that the virus will one day cease to be endemic.

ABC programmes on their own are not enough. They are not enough because some people do not get to choose whether to have sex or not, when, how often, with whom and under what circumstances. Even if they have some choices, they probably don’t have any say in the sexual behaviour of their sexual partner or partners.

As for using condoms, they are probably the most important factor in reducing HIV transmission. But people who don’t have a choice about the abstinence or faithfulness options are unlikely to have a choice about the use of condoms either.

My scepticism about the effectiveness of ABC programmes does not mean that I think nothing can be done to reduce HIV transmission. On the contrary, many things can be done and many things can improve the effectiveness of ABC programmes, too.

In no particular order, here are some things that are involved in the transmission of HIV that have little to do with sex:

A number of people I talked to in Nairobi said that they have applied for jobs but when it comes to the selection process, they either need to give money to the prospective employer or they need to have sex with them. Those already in jobs are sometimes expected to have sex with their boss in order to get promotion or even to get paid. The rights of the employed and the unemployed are being compromised here.

Marriage is often seen as a protection against HIV but many women don’t have much say in who they marry, nor do they have much influence over their husband’s sexual behaviour. In many instances in Kenya, the man is significantly older than the woman. Therefore he probably has more sexual experience, more power in the relationship and is more likely to be employed than the woman and consequently have more control over finances.

Where women are forced to have sex for some benefit, whether it is for money, gifts, security or anything else, they risk being treated as a criminal by the police. Men who expect sex in return for some benefit are not usually treated as criminals. Therefore, women are often unable to report cases of forced or coerced sex. Victims of sexual abuse are being treated as criminals.

HIV rates are often high in certain contexts, such as in border towns, around big industries and in slums. Border areas and industrial areas often have demographic imbalances, with huge numbers of single men. Slums grow (partly) as a result of people coming to urban areas to work but only finding very low paid jobs. Transactional sex also grows in such areas and, as a result of poverty and lack of social services, people are extremely vulnerable.

HIV prevention programmes that aim to influence sexual behaviour have not been very successful in reducing HIV transmission. But that’s because these programmes have not always addressed the contexts in which sexual behaviour occurs, the contexts that so often result in sex being unchosen and/or unsafe.

Kenyan law can’t guarantee everyone a job but it should be able to guarantee that people will not have to bribe someone with money or sex to get a job, to keep a job or to get promotion or better conditions. Women need better educational opportunities, their rights need to be protected, their dependents need support, they need to be able to inherit their husband’s property, they need to be able to refuse sex with a partner who has been having sex with other women; and the list goes on.

If the country can’t provide people, especially women, with adequate employment or social benefits, it has no right to criminalise what is for so many people a last resort; commercial sex work. Women and girls are forced into some kind of commercial sex work because of extreme poverty and desperation. This exposes them to numerous dangers, HIV being just one of them.

In order to protect people from HIV, other sexually transmitted infections, unplanned pregnancies, violence and exploitation, commercial sex work needs to be decriminalised. This is one of the most urgent steps that needs to be taken in Kenya and other countries with high HIV prevalence.

So reducing HIV transmission depends on changing laws, improving education, health and other social services, reducing inequalities, especially those relating to the law, education, employment and many other measures. Once these issues have been addressed the question of influencing people’s sexual behaviour seems relatively unimportant. When people are empowered and, where necessary, protected, they will take care of their own sexual behaviour.

So far, little has been achieved in the field of HIV prevention. A relatively small percentage of money spent on HIV goes towards prevention (as opposed to treatment and support for those infected and affected) but most of that has been wasted on programmes that don’t have any effect. And they will never have any effect until these several far more important issues are addressed.

In order to reduce sexual transmission of HIV it is not necessary to influence people’s sexual behaviour; they need to be empowered to the extent that they can choose the conditions under which they have sex, how often and with whom; they need adequate laws, education, health, infrastructure and social services. In other words, people need their basic human rights to be assured. If basic rights are assured, people will be better able to look after their own less basic rights.