Monday, October 18, 2010

Concurrent Relationships: the Latest Stick for Beating Africans

Almost all HIV prevention programs that have taken place in African countries for the last twenty years, and most of the programs that are taking place now, assume the truth of the 'behavioral paradigm'. This is the belief that HIV transmission in African countries is primarily a result of unsafe heterosexual sex. It's important to realize that the behavioral paradigm is applied to African countries, not to most Western countries, where HIV prevalence is low and most of it is not transmitted heterosexually.

In fact, it is not so much of a paradigm, more of a 'foundation myth'. UNAIDS and other proponents of the HIV orthodoxy fully realize that not all HIV is transmitted sexually; they just don't wish to discuss that fact with Africans. They are happy to warn UN employees and associates to avoid African health facilities because of the risks of infection with various blood borne diseases. But when it comes to estimating the number of Africans infected in health facilities, they insist that the figure is negligible. Funding for prevention of such non-sexual HIV transmission is, as a result, also negligible.

Adherence to the behavioral paradigm has always been a matter of loyalty (presumably to funding) rather than evidence. And over the years even some adherents have found reason to question the foundation myth. In a sense, many of them are questioning the behavioral paradigm itself. However, they are not ready to replace it with a view of HIV epidemics that is supported by evidence. Instead, they accept that sexual behavior, per se, may not be that much different in African countries than it is in non-African countries. But they add that Africans have more 'concurrent relationships' than non-Africans and that this sort of relationship explains the very high levels of transmission found in some countries.

Eileen Stillwaggon and Larry Sawers have always opposed the behavioral paradigm in their writings but they have recently published a paper which examines the arguments for the 'concurrency' theory. They conclude that:

Promoters of the concurrency hypothesis have failed to establish that concurrency is unusually prevalent in Africa or that the kinds of concurrent partnerships found in Africa produce more rapid spread of HIV than other forms of sexual behaviour. Policy makers should turn attention to drivers of African HIV epidemics that are policy sensitive and for which there is substantial epidemiological evidence.

The lengths that advocates of the concurrency theory go to are extraordinary. They are reduced to selecting the data that fits the 'hypothesis', leaving out anything that doesn't fit, including data of poor quality and even making up or imagining data to fill in some of the gaps. Stillwaggon and Sawers' paper is long but it is a demonstration of the state of the art of the current HIV orthodoxy.

IRIN, one of the UN's news services, has covered the debate, such as it is. And to be fair, they have accepted that there is a debate, something UNAIDS don't do. But this is not just an academic dispute. The HIV orthodoxy has always presented HIV in African countries as a matter of African sexual behavior which, we are supposed to believe, is completely different from non-African sexual behavior.

This is odd because many African countries have low rates of HIV transmission, as do many parts of countries where HIV transmission is high, nationally. Odder still is the fact that most people, academics and non-academics, are happy to embrace a theory of HIV transmission that is, in a word, racist. Even worse, many people in Africa also embrace the theory!

As with the behavioral paradigm, we are supposed to believe that in some parts of Africa, concurrency is extremely common. In other parts, it is clearly not so common. For example, in North Eastern Province in Kenya, concurrency must be very low because HIV prevalence is low; even though polygamy is higher than anywhere else in the country. But in the parts of Nyanza Province where the Luo live, concurrency is very common. After all, HIV prevalence there is many times higher than it is in North Eastern Province.

Sawers and Stillwaggon refute the claim that rates of concurrency are higher in African than elsewhere, but rates differ greatly between and within African countries, also. Trying to prove an 'African' sexuality is as futile as trying to prove an Aryan sexuality. But those who are trying are no less enthusiastic, despite the lack of evidence!

Yet Halperin, Epstein, Mah and others, who have championed the evidence-free concurrency hypothesis, respond to Stillwaggon and Sawers by branding them as 'denialists'. This is ironic because it is the behavioral paradigm and it's illegitimate sibling, concurrency, that require denial of all that is known about HIV transmission. Sawers and Stillwaggon are not denying that sexual transmission occurs, nor even claiming that it is rare. They are just pointing out that non-sexual transmission must play a far larger part than the orthodox view would allow.

Halperin really reveals something about his thinking when he says "If you go out to shebeens [informal taverns in South Africa] and talk to people about sexual behaviour, I’m sure you’ll find out what’s going on. Everyone will tell you that strict mutual monogamy is the exception not the rule." If you go to pick-up joints in any country in the world you'll find out what's going on: they're pick-up joints. People don't go there to pray. But you can't build a theory about HIV transmission on a few anecdotes about what happens in shebeens.

What Epstein says about needing better scholarship is particularly poignant following Halperin's remarks. If, as she claims, donors are 'backing away' from behavioral approaches, that is good news. Most of them haven't worked. But if they think that a purely biomedical approach is what's required they are simply making the same mistake as before, concentrating on one possible mode of infection when there is more than one mode involved.

The IRIN article is certainly not balanced. But at least it mentions a few issues that the behavioral paradigm obsessed orthodoxy would prefer not to discuss. This is a start, though we should not still be making a start on an epidemic that has been around for nearly three decades. After all, HIV is not the first epidemic ever.


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