Had some very interesting and eye opening discussions with various people yesterday, mainly around the issues of gender, the human rights based approach to prevention, and above all the way our understanding of the epidemiology of HIV & AIDS is shifting.
Although I did not attend it, there was a caucus on gender and HIV yesterday that was well attended – by about eight times as many women as men. Like most men I had assumed that this meeting would be primarily about empowering women and tackling stigma and discrimination – areas I felt myself unqualified to contribute to, so had focused my time and energy elsewhere. My error – because of course men are a gender as well as women, and any attempt to address women's rights must address men as much as it addresses women. It shows how rapidly we have polarized debates and failed to engage one another on issues that affect us all.
For example, how can we tackle the sex industry and human trafficking head on to protect vulnerable girls and women (and some boys and men) if we do not first address male sexual behaviour? Why do men pay for sex, and are there effective strategies that can reduce this behaviour? Is criminalising buying (rather than selling) sex a more effective way forward, or does it create other problems? Models developed in countries like Sweden bear watching over the long term.
But this highlights another problem – we are concerned rightly about making sure that we target prevention on vulnerable groups without stigmatizing them, and we are rightly concerned that only effective and evidence based approaches are used. But the evidence emerging from epidemiology is showing us that human sexual behaviour and choices are vastly more complex that we had initially thought.
Firstly, an article in yesterday's Independent carried a statement from Dr Kevin de Cock admitting that the long feared generalised epidemics are not on their way. India's epidemic is focussed around the sex industry, and spreads from there to the families of the men who use female and male sex workers, but not really and further. Why? Ironically because the position of women in Indian society means it is very unlikely that woman will have one or more sexual partners outside the marriage. Likewise, China's epidemic is mostly among IVDUs or is iatrogenic – the latter creating a few large clusters that have so far failed to spread dramatically. In most of the rest of the world, HIV is largely confining itself to specific groups, not spreading significantly to the wider population.
Why? Or more to the point, why are almost all the generalised epidemics confined to Africa? No one is 100% certain, but the newly emerging picture from epidemiology is that the pattern of sexual relationships in Southern Africa in particular is what is now being called "multiple concurrent partnerships". This is where an individual will have several sexual partners in steady, long term relationships simultaneously. What is more, this is not primarily a male behaviour – it is equally common between the genders. As these are regarded as stable relationships, condom usage is low. The potential for sudden explosive clusters of new infections to occur is very high – especially as the newly infected are the most infectious – HIV can rip though a network of relationships very rapidly.
We do not know much about this pattern of sexual relationships because people seldom report that it is going on, but there is growing evidence that it does occur, although at what level is unclear. It is also apparent that due its hidden nature, this is not a pattern readily amenable to behaviour change strategies – whether getting people to use condoms or remain faithful to one partner only.
Because it seems to be most common in certain segments of certain societies there is also a political dimension here – it is hard to focus on this issue without being seen as stigmatising and even racist. So much more work needs to be done on understanding this phenomenon and seeing how we can pull together a consensus between governments and civil society on how to tackle this. And how can the churches tackle this head on within their own congregations and the wider community?
Once gain this highlights the need for wider ranging strategies that address stigma, sexual behaviour change ('zero grazing', delayed sexual debut, etc), effective use of condoms, open access to HIV testing, encouraging open, public discussion of sex and sexuality, involvement of all levels and sectors of society in communicating prevention messages, clear national leadership, etc, etc. This is what Uganda and Senegal did successfully before it became the subject of heated politicised debate and reduction to arguments over "abstinence only" versus "condoms only" programmes, and other misdirected battles over prevention ideology.
One African leader from a faith based/civil society network admitted to me last night that the prevention strategies in his country were suffering from the influence of Western donors who were pushing one ideological position or another – rather than letting his nation continue to develop their strategies based on what they know works within their own communities. We can only tackle HIV by cooperation around evidence based strategies, and letting local knowledge and understanding allow appropriate and contextualised responses to be developed from within the community, rather than being imposed by external (usually Western liberal and conservative) ideologies and funding priorities.
There will be more debate around this over the next few days
