Global HIV Policy: Blame, Stigma and Finger-Wagging

With HIV/AIDS, it's always been easier to blame individuals for their reckless behavior than to examine the conditions people live in and figure out which of these conditions may explain why HIV prevalence varies from a fraction of a percent in some populations to 25% in others and even 40% in some demographic groups.

The idea that whole populations have hundreds of times less sexual experience than other groups is not credible, especially where birth rates may be very high in some countries with low HIV prevalence. India is an example of a country with high birth rates and HIV prevalence lower than 1%. There is no reason to think that Indians in general shy away from sex.

While prevalence is a lot lower than 1% in most demographic groups in India, it is 30-40% in some demographic groups in several African countries. In fact, prevalence among Indian sex workers is only 7%, which is about the same prevalence as found in Kenya, Tanzania and Uganda. Yet sex workers in India face terrible risks, far worse than most sexually active people in African countries.

That HIV prevalence is not correlated with individual sexual behavior is nothing new. But some researchers have shown that HIV prevalence is correlated with malaria prevalence, something that is clearly not just a matter of individual behavior. Whether it makes HIV positive people more likely to transmit the virus, HIV negative people more likely to be infected or both is not clear. I have only seen the abstract. But it is one more nail in the coffin for the 'individual responsibility' theory of HIV prevention.

People in high malaria prevalence areas are more than twice as likely to be HIV positive as those in low prevalence areas. Some people have been calling for research into cofactors in HIV transmission for years but such research is still relatively uncommon. But similar research was recently carried out on schistosomiasis (bilharzia) as a co-factor and it was found to be associated with higher HIV prevalence. Tuberculosis also makes people more likely to transmit and to be infected with HIV.

Further loosening the connection between HIV and individual sexual behavior, it has also been shown that "a number of biological factors are critical in determining whether an unprotected sexual exposure to HIV results in productive infection". Mentioned are "viral factors, host genetics, and the impact of co-infections and host immunology" but again, I only have access to the abstract.

These researchers even have the effrontery to claim that "HIV sexual transmission is very inefficient". That's true, but it's not something that the sex obsessed HIV industry likes to dwell on. Global HIV prevention policies are based on blame, stigma, finger-pointing and finger-wagging, not research. But these upstarts go on to mention destigmatizing the issue, leading to new and more effective strategies for prevention. Whatever next?


Another batch of researchers conclude that because new HIV infections among discordant couples (where only one partner is infected) are twice as likely to occur among those trying to have a baby, this must be a result of higher levels of 'risky' sexual behavior. Having sex with your partner is not risky, or shouldn't be. But having a baby seems to be, especially for the female partner. Perhaps the researchers would like to assess the non-sexual risks that pregnant women face, such as unsafe health care.

The researchers may well be right and their research is certainly very interesting. But any research into HIV transmission among discordant couples, especially where pregnancy is involved, is incomplete without some clarification about how the women are being infected. Sure, they must be having sex if they are trying to have children, but this does not mean that transmission is always sexual.

The 'concurrency' card is still frequently played by those in the know (about how to receive copious amounts of funding) but it is still unsupported by clear evidence that it is common or that it really does explain high rates of HIV transmission. This research from Kenya pours cold water on the concurrency theory, finding that only 3.5% of females and 4% of males were engaged in concurrent partnerships in the previous six months.

The authors claim their findings suggest that: "concurrency expands individuals' sexual networks and bridges additional networks involving partners' other sexual partners". Perhaps, but with such low rates of concurrence, it's unlikely to do so to any great extent.

We need credible explanations for high rates of HIV transmission and viable prevention interventions, not the institutional racism and sexism that we have come to expect from UNAIDS and their ilk. UNAIDS have spent long enough showing that they are not capable of acting on research, especially research that exposes their prejudice for what it is. It's time for them to stand aside and let an unbiased institution take over.

Sexism, Racism, Homophobia and Individual Responsibility

The Kenyan Prime Minister, Raila Odinga, has called for the arrest of people involved in same sex relationships. Why he thinks that this will help anyone living in Kenya is a complete mystery. But he will probably gain the support of various 'christian' groups, right wing political interests and, of course, the police themselves.

There is a widespread belief that same sex relationships, especially men having sex with men (MSM), play a significant part in transmitting HIV. It is true that anal sex, whether among MSM or heterosexual couples, is a very efficient transmitter of HIV. But this is not, by any stretch, the biggest contributor to any high prevalence epidemics in Africa, if official figures are to be believed.

Official figures claim that the biggest contributor to the highest prevalence African HIV epidemics is heterosexual sex between married or cohabiting couples. In Kenya, low risk heterosexual sex accounts for 44% of all transmission. In other words, low risk sex is the biggest contributor, while whole populations are being warned against high risk sex.

Another 20% is said to be accounted for by casual heterosexual sex and the figures are similar in Uganda. Again, casual heterosexual sex is not exactly high risk when transmission probabilities can be as low as 1 in 500 male to female and 1 in 1000 female to male. Many factors can increase or decrease the transmission probability but casual heterosexual sex is not nearly as dangerous as many would have us believe.

But a word of caution about these figures. UNAIDS estimate that only 2.5% of transmission results from unsafe health care. This figure clearly came to someone in a dream and was found to be so attractive that the entire HIV mainstream have accepted it ever since. However, WHO estimates HIV transmission from unsafe injections alone to be 14% or higher. And various other medical procedures make a contribution that has yet to be fully investigated.

So, sex workers and their clients are thought to contribute 14% to Kenya's epidemic. But sex workers, like pregnant women, often have to put up with numerous injections, which means that sex is the least of their worries when it comes to serious diseases such as HIV, hepetitis and various other blood borne infections. Even sex work on its own may not carry as high a risk of HIV transmission as we are told.

Then we come to MSM. But the Kenyan Modes of Transmission Analysis doesn't even have an exact figure for this. Instead, we are given a figure for MSM plus prison populations. There are many ways prisoners could be infected with HIV, including unsafe health care, tattooing, sharing shaving equipment and various other routes.

This makes it quite unclear how much men having sex with men contributes to the country's epidemic. The figure is likely to be considerably lower than that for unsafe injections and probably half that from unsafe health care as a whole. And it's only a fraction of the contribution from heterosexual sex among married people and people in regular partnerships.

Personally, I think all of the figures in the Kenya Modes of Transmission Analysis are in need of careful review. They may be the official figures, the ones that policy is based on, the ostensible basis for funding allocations, etc. I just don't accept that sexual transmission is as high as these figures claim, nor that non-sexual transmission is so low.

But there is nothing in these figures that justifies punishing people who are at high risk of being infected with HIV, whether they are MSM, sex workers or intravenous drug users. In Uganda's Modes of Transmission Survey, sex workers account for less than 1% of transmissions while intravenous drug users account for even fewer. Added together, these three groups are estimated to contribute far less than unsafe medical injections.

Odinga has since denied that he made such a statement about gays and said that "gays have rights". But he was only playing to the gallery. What one politician says is unlikely to have much impact unless it resonates strongly with what people already believe. I would suggest that he made the initial statement because he had a fair idea what people believe about MSM. He can whip up a bit of righteous indignation but I doubt if he can significantly influence the views of large groups of people. Therefore, his retraction is futile.

There are several major prejudices at work here. The first is homophobia, the belief that heterosexual sex is the only kind of sexual relationship that is acceptable to humanity. The second is anti-African racism, the belief that Africans have too much sex, mostly 'unsafe' sex, and that they care little about their own health or the health of those around them.

A third major prejudice, perhaps the most prevalent one on every continent, is the belief that women are less capable of making decisions that affect their lives and the lives of those they care for. HIV in Africa is a virus that infects women in far higher numbers than men. It is women who face the highest risks from unsafe medical practices, in addition to the exaggerated risk of heterosexual sex. The claim that HIV transmission is a matter of individual responsibility is the main source of the stigma that has had such horrrifying results in African countries.

HIV, Individual Responsibility and Blame in a Neoliberal Agenda

Yesterday, I argued that there can be a tendency to make diseases of poverty seem like matters of personal responsibility, lifestyle decision and behavior. Some diseases, such as diabetes, may occur in poor and rich countries. Whether people in rich countries suffer from diabetes because of their irresponsible dietary choices may or may not be true. But people in developing countries usually do not have a great deal of choice about what to eat. High starch staples may fill a person up as cheaply as possible, but they can also contribute to chronic health conditions.


Similarly, poverty and unemployment can be painted in terms of individual responsibility. An article about the Grameen Bank and its founder, Mohammad Yunus, traces the desire to attribute development problems to individual responsibility back to neoliberal rhetoric.


In the past, I have also argued that HIV is not solely transmitted through individual sexual behavior. Sexual behavior can be relevant, but so is individual susceptibility, the health environment in which people live, levels of equality and empowerment, etc. Indeed, HIV is not solely transmitted through sexual behavior, either. It can also be transmitted through unsafe medical and cosmetic practices.


The fact that health seeking behavior can often be elective and that cosmetic practices may almost always be elective does not mean that HIV transmission through these routes is avoidable. Many people are unaware of the risks involved and know little about how to reduce their exposure to them. Others are just not in a position to ensure that medical and cosmetic instruments and processes are hygienic and risk free. They may be too sick, very young or otherwise unable to do anything about it.


The country that spends more per head on health, the US, sometimes experiences nosocomial outbreaks of certain diseases, that's outbreaks that are caused by medical treatment or processes. Actual HIV transmission is now rare, though it does still happen. But many people have, on several recent occasions, been exposed to risk of infection with HIV, hepatitis and perhaps other diseases. And other recent instances of infection have occurred.


In contrast, African countries only spend a few dollars per head of population. Out of 450 HIV positive children in Mozambique, 22 (nearly 5%) were found to have HIV negative mothers. Unsafe healthcare is 'suspected'. The fact that many of the children were infected with the same strain of HIV as their mothers does not mean they were infected through the usual mother to child routes. In other words, the number infected through unsafe healthcare could be a lot higher. But, despite many such findings in African countries, investigations are few and far between.


An article that mentions the outbreak in Mozambique concludes:

These neglected routes of HIV acquisition need due attention urgently. Education of staff in health-care services must be continuously pursued to reduce nosocomial risk, and a sufficient supply of disposable needles and syringes and maintenance of high-quality screening of blood donors must be top priorities.

You may think that it's a straightforward matter to reduce nosocomial risks. However, the typical allocation of funding to this area of HIV prevention is about 1%. Given how poor and inaccessible health services are in African countries, even this 1% is unlikely to have any noticeable impact on nosocomial transmission.


So, where HIV is transmitted sexually, there are many reasons why this is not just a matter of 'individual responsibility'. We have long been aware that many people don't know their HIV status or their partner's status and that even when risks could be avoided in theory, it is not always possible in practice. But we must also recognize the fact that many HIV positive people, perhaps a substantial proportion, are not infected with HIV through sexual intercourse. If people don't recognize the possibility they will not see the need to protect themselves.


The HIV industry has gorged itself on HIV prevention programs that, predominantly, assume individual responsibility. There is, and always has been, plenty of evidence to show that this assumption is wrong. The pitifully low success rates of these programs over many years should have been taken as a warning sign. Like poverty and poverty related diseases, HIV is probably very rarely a matter of individual responsibility. HIV prevention programing needs to be developed accordingly.

Don't Blame the Poor for Diseases of Poverty

Diabetes is often referred to as a disease of the relatively affluent because it can be caused by some of the habits that are common in better off, urbanized areas. It can be associated with foods that have high levels of sugar, often highly processed foods, along with a sedentary lifestyle.

However, it can also be a disease of the very poor, those who have little choice over which staple food they rely on for almost all of their nutritional needs. In Tanzania and Kenya, for example, many people rely on staples that are high in starch, and little else. Maize, white rice, white bread and a small number of other foods can make up the bulk of the daily diet of most people.

An article in the New York Times may give the impression that there are lots of Africans suffering from diseases of affluence. I'm not sure why this article is about such a small sector of the East African population, though it may well be true that there are more wealthy people now than before. But diabetes is far more common than affluence.

I accept that the article is quite clearly about the African middle class, but the association of diabetes with increasing wealth is disingenuous. There are people suffering from diabetes who are neither affluent, urbanized nor sedentary. Are we supposed to see people in such circumstances as being responsible for their suffering from the disease?

The same article mentions lung cancer. One of the biggest killers in developing countries is acute respiratory conditions. This is not because most people smoke cigarettes, live close to a polluting but highly lucrative (for them) industry, live in a city or do anything else that relates to affluence. It is because they are exposed to living conditions that render them susceptible to serious lung problems. It is also because health facilities are poor and inaccessible.

In fact, if any generalization can be made about diarrhea, water-borne diseases in general, nutritional deficiencies and acute respiratory conditions, it is that they affect more babies and infants than adults. In adults, respiratory conditions affect women more than men. Also women and children are far more likely to be living in poverty than men.

The majority of people do not have access to private transport, some don't even have access to public transport. Most do not work in offices, most don't even have formal jobs of any kind. Most still have to walk to health facilities and social services, or even do without them. There are, presumably, risk factors for cancer, heart disease and strokes that relate to poverty as well as to affluence.

Urbanization has been a trend for a long time but it is unlikely to contribute that much to diseases of affluence in East Africa. Urban dwelling poor people are probably even more deprived than rural dwelling poor people and they face additional health hazards that those in rural areas don't face. These hazards include air quality, pollution, road traffic accidents, occupational hazards, violence and others.

I don't wish to belittle common health conditions, regardless of who suffers from them. But it is poor people who need better and more accessible health services, whether urban or rural dwelling. And many people are suffering from preventable and curable conditions that relate to their diet, their environment, their economic circumstances and adverse social conditions, not just from their 'lifestyle'.

An article about health in Zimbabwe illustrates the point: "70% of diseases and deaths in the country, caused by malnutrition, diarrhea, malaria and pregnancy-related complications, are preventable." Similar figures can be found for Kenya and Tanzania. It's a popular game in the press, in development and in politics to deflect attention from the problems people face that are beyond their control and to concentrate on issues that are, ostensibly, a matter of individual responsibility. There is a lot of public health work that needs to be done. Poor countries are not 'like' rich countries when it comes to health.