Friday, July 30, 2010

You're Promiscuous, But in the most Non-Pejorative Sense Possible

Since mentioning the Vienna Declaration (on drug policy) yesterday, I have heard that Kenya is one of the countries that 'may' be funded to supply intravenous drug users with sterile injection equipment. The Declaration objects to current policy in many countries, which criminalizes intravenous drug use and does not permit 'harm reduction' programmes, such as injection equipment exchange.

For many years it has been known that harm reduction programs can help reduce a social problem such as intravenous drug use. These programs can also play a part in reducing transmission of viruses such as HIV and hepatitis. Despite the evidence, a lot of governments of countries with high levels of intravenous drug use refuse to allow harm reduction programs, some as a result of HIV funders banning this particular use of funds. These funders argue that distributing sterile injection equipment will give rise to increased intravenous drug use, although this has been shown to be untrue.

One of the biggest sources of HIV prevention funding is the US's PEPFAR Program (President's Emergency Plan for Aids Relief). This fund has been criticized since it began for having various clauses banning certain types of program, including supply of sterile equipment to intravenous drug users. Even when PEPFAR didn't specifically ban measures, things perceived to be deprecated were often avoided for fear of losing funding. Now, apparently, PEPFAR has relaxed some of its conditions. Let's hope perceptions also relax.

According to NASCOP (Kenya's National Aids Control Program) head, Dr Nicholas Muraguri, needle sharing is second only to blood transfusion when it comes to HIV transmission efficiency. Intravenous drug use with contaminated equipment is estimated to account for 3.8% of new HIV infections a year. Reducing this risk with an injection equipment exchange program could prevent hundreds of new infections every year. However, intravenous drug users are worried that police will still harass them, especially if they find them with injecting equipment.

But it is highly significant that Dr Muraguri acknowledges that injection equipment sharing is an important mode of HIV transmission. The WHO estimates that around 17% of HIV infections in Africa are due to unsafe injections. That's injections in healthcare settings, not injections relating to intravenous drug use. It's not just injections that can spread HIV, either. All sorts of medical procedures can carry a risk if adequate precautions are not taken to ensure blood safety and sterile conditions. I hope Dr Muraguri will get behind a program that takes measures to reduce medical transmission, given how efficient a transmitter of HIV it is.

Adding together injection safety for intravenous drug users and medical safety, this may account for around 30% of all HIV transmission. Almost all current HIV prevention programs in African countries assume that HIV is mainly transmitted sexually. However, changing sexual behavior will have no impact on non-sexual HIV transmission (sounds obvious, but try telling UNAIDS) and some programs, such as mass male circumcision, could increase non-sexual transmission.

It's time to move away from the rather atavistic attitude that people with HIV must have done something bad and should be punished accordingly. The effect of this attitude has been to punish people who are vulnerable, such as women, children or poor people, or who are already persecuted and discriminated against, such as intravenous drug users, men who have sex with men and sex workers. This sort of atavism has resulted in HIV continuing to spread, even in countries that have the wherewithal to avoid a serious epidemic. And it continues to be a barrier to reducing transmission in countries with serious epidemics.

But if you insist that most HIV in Africa is transmitted sexually, as the HIV industry does, you are thereby branding Africans as sexually promiscuous if they are found to be HIV positive. If you insist that Africans tend to be sexually promiscuous, it is pointless to then call for stigmatization of HIV positive people to be avoided, as the HIV industry does. Equating a HIV positive diagnosis with sexual promiscuity is what gives rise to HIV positive people being stigmatized.



rojer said...

I agree ! No other disease .Tb, or Hepatitis has a stigma problem as they are known to be transmitted by non sexual transmission . The excessive focus and funding for intervention strategies of Sexual transmission are creating the stigma problem! All interventions need to be addressed and % factor is irrelevant and misleading. U can close the screen door, then the door , then the window but if you forget the opening in the exhaust fan in the toilet the mosquito can get in the room and you will get infected. Focussing on safe healthcare practices and all types of blood exposures is important to break the cycle of infection and resolve the self created stigma problem.Rajiv Nath. India

Simon said...

Rojer, thank you for your comment, you're right. Although TB sometimes has a stigma that it acquires from its close connection with HIV. I hope HIV prevalence stays relatively low in India but if they ignore unsafe healthcare things could change there very fast.