Thursday, August 9, 2012

Sexual Behavior and HIV: Retire the Paradigm or the Adherents?

The 'behavioral paradigm', the view that HIV is almost always transmitted as a result of unsafe sexual behavior, has tended to give rise to questions such as 'what kind of behavior could people in high HIV prevalence contexts be engaging in?' rather than 'given that high levels of unsafe sexual behavior do not correlate particularly closely with HIV prevalence, what else could explain extremely high rates of transmission of this virus, often in very short time periods?' Rather, the paradigm makes questions like the latter sound naive.

Yet the kind of hypotheses associated with this paradigm tend not to stand up to scrutiny. In high prevalence African countries, levels of unsafe sexual behavior are often higher in areas where HIV prevalence is low and lower in areas where HIV prevalence is high; those engaging in high levels of unsafe sexual behavior are often less likely to be infected and those engaging in low levels are often more likely to be infected. Types of sexual behavior said to promote the transmission of HIV are often not particularly common in areas where HIV prevalence is high or they do not, in reality, promote HIV transmission at a level that would explain some of the massive epidemics found in some parts of certain African countries.

But those who adhere to the paradigm, many of whom have dug themselves into a long and lucrative career in the HIV industry, can be loathe to accept any apparent failings in the paradigm. Findings showing that a significant proportion of HIV is probably not transmitted sexually and that sexual behavior is not the only, or is not the most important factor in transmission rates, even in sexual transmission rates, tend to give rise to a frantic scrabbling for ever less credible hypotheses. Theories about concurrency and male circumcision spring to mind; though stillborn, there are those whose careers consist of trying to breathe life into their festering carcasses.

Recent research has shown that black men who have sex with men (MSM) in the UK, US and Canada have far higher rates of infection than white MSM, even though they do not engage in higher levels of unsafe sexual behavior; in some cases they engage in lower levels of such behavior. Researchers are looking at all sorts of socioeconomic and structural differences in the circumstances of black and white MSM. But if male to male sexual transmission of HIV is not purely a matter of sexual behavior, then the same is very likely to be true of heterosexual transmission.

Heterosexual transmission is not common in Western countries, despite vigorous attempts to persuade people otherwise. And while the vast majority of people infected with HIV in high prevalence African countries engage in heterosexual sex, it is unclear what proportion of them have been infected sexually and what proportion have been infected by some other route, such as through unsafe healthcare or other skin-piercing practices. But the factors associated with transmission in Western countries, as well as the populations most affected by HIV, differ from those in African countries.

For example, black MSM in Western countries tend to be poorer, less well educated and unemployed, amongst other things. But HIV prevalence in African countries has often been higher among wealthier, better educated people and particularly among employed people, as opposed to those who are unemployed or who are not in formal employment. None of these findings are particularly new in the case of HIV epidemics in African countries; the findings about MSM in Western countries are not all very new either. But what is common to HIV epidemics in Western and developing countries is sexual behavior; not that sexual behavior is the same in both types of country, but sexual behavior is constantly cited as the cause of high rates of HIV transmission.

Nearly a year ago, an article appeared in a Tanzanian newspaper asking if homosexuality is 'unAfrican', how about living on handouts from Western countries (just think of those accepting handouts as being the 'receptive' partner in a relationship). While there is much vocal opposition to legalizing or decriminalizing homosexuality, I would ask why there is far less opposition to the insinuation that almost every mother, grandmother, wife, girlfriend, sister and daughter in high HIV prevalence countries is a slut, who will drop her underclothes and bend over for the price of a few beers?

There is a further insinuation that the men are all feckless and will sleep with just about anyone, whether they have to pay or not. But in the case of men, HIV prevalence is a lot lower. More to the point, self-reported levels of unsafe sexual behavior are consistently higher among men. So the women are not just sluts, they are lying sluts? In fact, subtract the men who have been infected through male to male sex and intravenous drug use (most are male), and it sounds as if many of the women have to actively seek out HIV positive men in order to become infected with HIV in such high numbers.

The tired old paradigm about sexual behavior doesn't seem to give rise to questions about why a virus that mostly infects MSM in Western countries mostly infects heterosexuals in African countries. To the extent that this question is asked, ridiculous types and levels of unsafe sexual behavior have to be posited to explain high levels of transmission of a virus that doesn't spread very quickly among heterosexuals in other contexts. Nor does it ask why levels of 'unsafe' sexual behavior often appear to be lower in areas where HIV transmission rates are higher. But then, those are the kind of questions that this paradigm, so treasured by UNAIDS and the HIV industry, are supposed to dismiss.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


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