Anal Sex Can Be Dangerous But Likely to Be Ignored in African Countries

Ostensibly, Kenya's Modes of Transmission Survey aims to establish what factors are driving the country's HIV epidemic. I say 'ostensibly' because there are two glaring figures that cast doubt on all the other figures. The first is the figure for men having sex with men (MSM), which is lumped together with HIV in prison populations. The second is the figure for health facility related infections, which, at 2.5%, is extremely low compared to WHO figures for unsafe injections alone, which could be 8 or 9 times higher.

However, I've mentioned health facility related infections on many occasions, so I'll concentrate on MSM on this occasion. Prison populations would be at risk of HIV transmission through heterosexual sex, like everyone else. But more importantly, those infected through intravenous drug use are more likely to be in prison, given that the practice is a crime. Those in prisons may also be more likely to be infected through tattooing, taking blood oaths and, arguably, through unsafe healthcare.

That puts the provenance of one third of Kenya's HIV infections in serious doubt, the proportion either claimed to be or suspected of being from MSM and/or unsafe healthcare. The fact that another half of infections are said to come from relatively low risk sex makes the Survey seem like a pretty blunt instrument. But anal sex, whether homosexual or heterosexual, is known to be high risk sex. And, despite the need to target MSM, it is completely unclear what proportion of people engage in this practice.

What is clear is that MSM (and others engaging in anal sex) are not targeted particularly well. For a start, the practice is illegal and the country's Prime Minister Odinga recently called for the arrest and imprisonment of all practicing homosexuals. As a result of such attitudes and outbursts, who Kenya's MSM are and where they are is not only unclear, but likely to remain so.

Given these circumstances, it's not surprising that a survey of male sex workers providing services to men in Mombasa found that 35% of respondents did not know that HIV can be transmitted through anal sex. It is therefore unlikely that heterosexuals are aware that anal sex is an efficient transmitter of HIV, regardless of the gender of those involved, or that it is far more dangerous for the receptive partner.

Just over 20% knew that a water based lubricant should be used with latex condoms and again, it seems unlikely that heterosexuals engaging in anal sex are any more likely to know this. They are probably less likely to be targeted with correct information, despite evidence that many people think that anal sex does not transmit HIV at all. Even if people knew, they would be unlikely to find an appropriate lubricant easily. Many are said to resort to household products, some of which are more likely to weaken condoms than reduce the risk in any way.

Odinga, the Modes of Transmission Survey and the current calls for homosexuality to be punished even more severely than it already is suggests that Kenya is more interested in pointing the finger than in dealing with serious problems that are not just going to disappear. After frittering away tens of millions of dollars of donated HIV funds, Kenya was refused funding on several occasions.

And now, despite the continued lack of transparency, the Global Fund has decided to give the country nearly 40 billion Kenyan shillings in funding. The Global Fund, going by its title, is earmarked for HIV, TB and malaria, rather than for health systems or infrastructure. So its effects are going to be limited.

But ignoring risky sex (along with most non-sexual modes of transmission) and concentrating mainly on those who don't engage in risky sex seems like completely the wrong way to go about things. For a start, let's stop pretending that the majority of people are at risk of being infected sexually and find out why people engaging in low risk sex seem to be the largest contributor to Kenya's HIV epidemic.

The least we can ask of the Global Fund, then, is that even if they are not prepared to spend anything on non-sexually transmitted HIV, they should seriously consider targeting those who are genuinely at risk of sexual transmission: MSM and sex workers, and perhaps some others.