Wednesday, June 2, 2010

Paying Ugandans to Transmit HIV

For years, we have been blasted with ‘news’ about how successful Uganda was at controlling its HIV epidemic in the early days of the virus. Even articles about HIV in other countries were almost guaranteed to refer to Uganda’s ‘success’ and this was usually put down to the country’s adoption of ABC (Abstain, Be faithful and use a Condom) programmes. This is despite the fact that ABC campaigns didn’t exist anywhere in the late 1980s and early 1990s, at a time that HIV prevalence rates in Uganda were dropping fast. It wasn’t until many years later that Uganda and other countries were sold this rather spurious set of claims, which went so far as to claim that abstinence alone was responsible for falling HIV prevalence.

But it became rather embarrassing in the early 2000s, when Uganda’s prevalence rates appeared to be flatlining and perhaps even rising. Now that it has become too obvious for even the usual suspects at UNAIDS, CDC, WHO and the journalists who spread their wisdom to continue claiming that all is well in Uganda, people are asking what went wrong and how can the country get back on the right track. The UNAIDS Uganda country co-ordinator, Musa Bungudu, is interviewed and his answers show serious lack of understanding about HIV in general and HIV in Uganda in particular.

He emphasises the ‘behavioural change approach that helped Uganda to reduce HIV prevalence in the past’. Among the many who have echoed the praise for Uganda, there have been a few who have questioned the history of HIV there and especially the reasons given for Uganda’s early success and the country’s subsequent failures to eradicate the virus. In an article entitled ‘How Uganda Reversed Its HIV Epidemic’, a number of authors who worked in Uganda in the 1980s and 1990s (Gary Slutkin, Sam Okware, Warren Naamara, Don Sutherland, Donna Flanagan, Michel Carael, Erik Blas, Paul Delay and Daniel Tarantola) remember things very differently.

The story they give is that a campaign was mounted to inform people about all the modes of transmission and ways to avoid infection. Rather than just being a behaviour change campaign aimed at sexual behaviour, people were informed about medical transmission and other non-sexual modes, research and monitoring were carried out to determine who was at risk and why, etc. And these were, we are told, the usual strategies for an early Aids programme. The epidemic in Uganda was one of the first to peak. Therefore, the country would have benefited a lot more from such a campaign than countries where HIV was peaking later, once the ABC and abstinence only adherents managed to wrest most of the money from genuine health professionals.

In contrast, in Kenya, the epidemic peaked 10 years later, by which time politicians, religious leaders and commercial interests had taken the front seat and all reason and sense was stuck in the boot, where it languishes to this day. Interestingly, a completely coincidental sexually transmitted infection (STI) programme had been rolled out in Nairobi, just before HIV had been identified. During the time this programme was going on, HIV prevalence rose from very low rates (determined through stored blood samples) to prevalence rates of over 80%, only to drop dramatically as the STI programme was phased out. Aside from this remarkable coincidence, Kenya as a whole did as little as possible to reduce the spread of HIV and as much as possible to deny that there was even a serious epidemic in the country.

So, Uganda were successful in the early days of the epidemic and people often ask why, what did they do that other countries could have done and what were they doing that they are not doing now. Well, perhaps it was the adoption of the behavioural paradigm, so beloved by politicians, religious leaders and other bigots, the belief that HIV is mostly transmitted by unsafe heterosexual intercourse in African countries because, as the story goes, Africans have inordinately more sex than everyone else. And even Mr Bungudu, a Ugandan, doesn’t seem to feel the need to question the possibility that this behavioural paradigm is wrong.

He mentions that HIV prevalence was perhaps as high as 20% in the 1980s and that it dropped to about 6% by 2000, which would have been, to a large extent, due to very high death rates in the 1990s. He mentions that prevalence is even increasing but, most importantly, he notes that the rate of new infections is increasing. About half the HIV positive people who need antiretroviral treatment (ART), which means that HIV prevalence, the number of people living with HIV, should be rising. But Uganda continued with the programmes said to reduce HIV transmission, so why are they not working now?

One explanation appears to be that the country did, indeed, start off well, approaching every mode of transmission, not just sexual transmission. But once they embraced ABC, abstinence only and anything else that followed from the behavioural paradigm, transmission by all non-sexual routes started to increase. The country, effectively, abandoned a major part of their earlier campaign. In this pursuit, they were amply supported by their major donors, who didn’t want to hear about anything but sexual transmission and ineffective behaviour change campaigns. In fact, most countries are afraid to run any campaign that doesn’t explicitly mention sexual transmission to the exclusion of all other routes of transmission for fear of losing their funding. They are right to worry about losing their funding. But, as a result, they have lost control of the epidemic.

Bungudu then performs the classic UNAIDS trick of attributing most new HIV infections to low risk sex (entailing the contradiction that a virus that is difficult to transmit sexually is frequently transmitted sexually). Most new infections have been found to be among married people. Worse still, most of those infected are women whose husbands are HIV negative. Does Bungudu want to subscribe to the racist view that, not only do most Africans have a lot of sex, but also that many married women are sleeping with people other than their husbands, perhaps for money? To explain such high rates of sexual HIV transmission among married women whose husbands are HIV positive would require that they sleep with an awful lot of other men. HIV negative people married to HIV positive partners can remain HIV negative for years, even if they have regular unprotected sex.

But yes, Bungudu mentions high levels of unfaithfulness and all the other explanations that UNAIDS cling to, even saying that “a poor woman is likely to go out with a rich man for his money. If he is infected, she may get HIV.” What he doesn’t seem to appreciate is that this would take an awful lot of poor women having an awful lot of sex with a lot of rich people (are there many rich people in Uganda?). But we know that, for a long time, HIV prevalence was higher in richer sectors of the population. And this trend was as true for rich women as for rich men. The problem with everything that Bungudu says is that it all presupposes the truth of the behavioural paradigm. And it all ignores the obvious conclusion, that sexual behaviour does not explain why HIV is so high in some African countries and so low in most other countries.

Continuing the official line, which I suppose he has to do if wants funding to continue, Bungudu reflects on the fact that prevention messages are not getting to remote communities. He completely misses the fact that HIV prevalence in remote areas has always been lower than in urban areas. But once ‘messages’ start reaching these areas, in the form of assumptions about people’s sexual behaviour, HIV transmission tends to rise. This is being experienced in Gulu, now that the area is being ‘developed’. Prevalence has doubled in the last few years despite the fact that roads, hospitals, schools and other social services are being built.

It is a good thing that all these amenities are being built and I’m certainly not arguing otherwise. But if the HIV message continues to be about sexual transmission and excludes non-sexual routes, many more people in Gulu and other areas will continue to be infected. People like Bungudu and others need to open their eyes, to question what is happening and not just to repeat the prejudiced rubbish they have been fed by international health institutions.

The only hopeful thing Bungudu mentions is that Uganda’s HIV efforts are about 90% foreign funded. If the Ugandan government can find a way to provide more of the funding, they may be able to find a way to turn the epidemic around. But only if they also reject the simplistic and highly prejudicial maunderings that make up international HIV policy to date. Otherwise, the fact that most Ugandans are not able to access health services could be the only thing that gives them some protection from HIV. But if Ugandans are not prepared to stand up for other Ugandans in the face of such prejudice, no one else will.



Simon said...

The Ugandan president, Yoweri Museveni, also seems to know little about HIV. He's worried about increasing prevalence, so congratulations for that, but he doesn't seem to recognize some of the warning signs about why Uganda's HIV campaigns are not doing well.

He claims that there is now an emphasis on condoms over abstinence and he is right that there were not a lot of condoms in the 1980s and early 1990s, so they couldn't have had much part to play in reductions in HIV transmission.

But nor was there, according to evidence, much talk about abstinence, or even ABC campaigns, which were trumped up much later and not even in Uganda, for that matter.

Perhaps is President Museveni were to speculate about why current campaigns are not successful, he might wonder if some, perhaps most, HIV transmission is non-sexual.

Apparently some experts warn that ABC might be outdated and that this is because most infections are among people in long-term monogamous relationships. But this is yet another sign that HIV transmission may be dominated by non-sexual modes.

ABC is not just outdated now, it was stillborn in Botswana in the late 1990s. But everyone, for some reason, wanted to claim to be the parents.

HIV campaigns are not just directed at the wrong age groups, they are directed at the wrong mode of transmission. How many hints do Museveni and others need?

Anonymous said...

From your writing, you create the impression that you are an expert on HIV in Africa. For starters, Africans know and understand their problems better than foreigners, many of whom come to Africa claiming to be 'experts' at things they dont even understand.
What you have done in your blog is only critisize and have not given any constructive recomendations of what YOU think is the best way to go around things as far as HIV prevention is concerned. You even show ignorance by saying the UNAIDS boss Musa Bungudu is a Ugandan. He is not. Those living in Uganda know that he is a recent appointee, only a few months in the country and if you found his undertanding of issues quite wanting, then that explains it for you. But from his experience as a UNAIDS country rep in more than five African countries surely qualifies him for the role. So if you can get that wrong, then its difficult to beleive what else you are writing here.
Use your blog to create more constructive debates by concentrating on 'HIV in Kenya'.

Philip Katuntu

Simon said...

Dear Philip
thank you for your comment. I am sorry for assuming Mr Bungudu is Ugandan but I hardly think that casts doubt over my knowledge of HIV in Uganda, as well as in Kenya. You don't seem to have indicated any factual inaccuracy, aside from my assumption about Mr Bungudu's nationality.

You may be right about Africans knowing about their problems but the ones I have met, over a period of nearly three years, believe what 'foreign experts' say, much of which is untrue. African countries, especially Uganda, are dependent on foreign funding for their HIV work and this may explain why, although they 'understand' their problems, they don't target them very directly.

I would imagine every HIV positive Ugandan has a good idea about how they did or did not become infected with HIV. UNAIDS thinks otherwise, assuming that almost all Africans are infected sexually. They ignore African cases of non-sexual HIV transmission.

I do not just criticize without suggesting an alternative. I am constantly advocating that the 'behavioral paradigm', the view that almost all HIV is sexually transmitted (in African countries) be reexamined and that non-sexual HIV transmission be investigated.

I don't know any Africans who are questioning the behavioral paradigm or advocating for an investigation of and reduction in medical and cosmetic HIV transmission.

I am the sort of 'expert' who openly publishes what I think in a blog, that anyone, such as yourself, can reply to. UNAIDS is completely closed shop, unless you are part of the mainstream HIV industry. You can not easily challenge their view, for example, in peer reviewed journals. They are peer reviewed by mainstream people, who brook no opposition.

As for discussing HIV in Uganda on a blog called 'HIV in Kenya', there are distinct connections between Uganda and Kenya, as you will notice if you study their respective epidemics. There are even overlaps in tribes, customs, economic circumstances, geographical terrain, political practices, history (of colonialism), etc. They are not separate from the point of view of disease transmission and spread.

Thank you again for your comments, though I think they are somewhat misdirected. But at least you can comment on my blog. Try telling UNAIDS that they treat Africans as if they are all the same, uneducated, unhealthy and sexually promiscuous. let me know if you get a response.