I wouldn't have wanted to give the impression in my last blog post that misogyny is something rare in the fields of HIV and public health, or that it is confined to Uganda, high HIV prevalence countries or even Africa. A good deal of HIV programming in African countries over the years has been noticeably racist, particularly in the assumption, overt or covert, that HIV is almost always heterosexually transmitted. But a lot is also misogynistic, and little effort is made to conceal this.
Mass male circumcision campaigns are ostensibly aimed at reducing HIV transmission from females to males. It is unlikely to achieve this aim; the extent to which circumcision could possibly influence transmission is almost certainly very low and would be rendered lower still if sexual behavior were to change as a result of circumcision. For example, men, and even more so women, think circumcised men are unlikely to be HIV positive. Circumcision is even being offered to HIV positive men; and many HIV positive men happen to be circumcised already.
People behaving as if circumcision reduces HIV transmission, whether through dishonesty or ignorance, will result in risks for women increasing. Yet, African women are a lot more likely to be infected with HIV than men. The recent Aids Indicator Survey which found that HIV prevalence is increasing in Uganda also showed that prevalence is a lot higher in women. This is also the case in other African countries; in some tribes, female prevalence can be manytimes higher than male prevalence.
There has been a lot of discussion recently about Depo Provera and other injectable hormonal contraceptives which, research has suggested, may increase transmission from males to females and also from females to males. WHO did some well publicized humming and hawing, though those doing the discussing were sworn to secrecy. But it was decided that women in high HIV prevalence countries should continue using Depo Provera and the like (curiously, women in low HIV prevalence don't tend to use injectable Depo Provera), as long as they use condoms at the same time. Yet, such contraceptive methods were originally sold to people in developing countries on the grounds that condoms were unlikely to be used.
Some of the excuses for continuing to use injectable hormonal contaceptives included worries about women having unplanned pregnancies, suffering injury or death during childbirth, or concerns that the infant will be injured or die. However, increasing contraceptive use does not, on its own, improve maternal or infant health. Only improvements in health facility conditions, increases in the numbers of trained and well-equipped health professionals and greater accessibility to safe health services will reduce maternal and infant morbidity and mortality.
One of the most affected groups in the history of the HIV pandemic in Africa has been sex workers, or those thought to be involved in sex work. But it is still unclear how such high rates of HIV transmission seen in the 80s and 90s ever came about. Sex workers in non-African countries don't appear to face anywhere near the same risks unless they are also intravenous drug users. As sex workers have been systematically rounded up for testing and treatment for sexually transmitted infections since long before HIV was identified, it is even possible that HIV was inadvertently spread through the reuse of unsterile equipment. After all, up until some time in the 1980s, reuse of unsterile equipment was common in many countries. It is still not known how common it is in very poor countries today.
In their paper on how Uganda 'reversed' its HIV epidemic, the authors make scant reference to non-sexual HIV transmission. But they must have known from their own experience, or found out from their research, how much things changed in health facilities and, indeed, how some things may not have changed that much at all.
Another group that has suffered, and continues to suffer shockingly high HIV transmission rates is pregnant women. But they may, like sex workers, also face what could be serious non-sexual risks. Pregnant women in urban areas (prevalence, like health facility attendance, are low in rural areas) tend to receive a lot of medical care, such as vaccinations and various other services. Instead of wondering how so many women, often with only one HIV negative partner, become infected with HIV during their second or third trimester, or even in a few weeks or months after giving birth, it is assumed that they continue to have unprotected sex, and not just with their main partner, either.
In addition to showing that women are more likely to be HIV positive than men, these surveys carried out regularly in African countries always show that some men have far more sex than most women and that men are far more likely to engage in 'unsafe' sex than women. However susceptible women may be to HIV compared to men, it is even clearer that HIV transmission is unlikely to be mainly heterosexually transmitted. It's time to look more closely at the non-sexual risks people face, especially those routinely faced by many women. In fact, if you remove men infected through male to male sex and intravenous drug use (the latter being more likely to affect men than women), the ratio of female to male HIV prevalence is even more stark.
So where does the misogyny come in? Well, stories about half empty soda bottles without caps, snakes in holes, cows in fields and much of the rhetoric associated with HIV transmission seems to find willing, though uncritical recipients. 'Targeting' women and groups that are all or mostly made up of females may reinforce the belief that HIV affects women more than men, especially given higher prevalence figures among women. Moralizing accounts of HIV and 'explanations' of transmission also seem to point the finger at women who tempt men, who get pregnant, who spread diseases; while certain male groups are also targeted, one can often get the impression that sex, and therefore HIV, are primarily the preserve of women.
Moritz Hunsmann has looked at the issue of politicization of spending priorities for HIV prevention programs in Tanzania in a paper soon to be published. He notes that programs aiming to influence sexual behavior tend to be supported but those aiming to change 'structural factors' are rarely implemented. While HIV is often approached vertically, in isolation from health more broadly, structural interventions "try to address the broader legal, political and socio-economic contexts in which individuals make behavioural decisions".
Hunsmann's research was carried out at a time when there was a lot of HIV money coming into the country. But contrary to what one may have expected, cost-effectiveness of interventions was not a high priority. And it was assumed that structural interventions were not cost-effective, without there being much evidence for this. Different groups carved out their chosen niches and lobbied for continued funding, but structural interventions were not among those concerns.
The facts that structural interventions may be longer term and have an impact that goes way beyond HIV alone may sound like advantages; but they don't tend to attract money that feeds short term interests and concentrates on something as worthy of public attention as sex and sexually transmitted diseases. Structural interventions that might address gender inequities, access to health services, less fashionable health and other issues, many of which long pre-date HIV, have not attracted much attention or funding and they continue to be ignored now that funding is becoming more scarce.
The obsession with sexually transmitted HIV often highlights some of the background structural factors involved in HIV epidemics. But those structural factors do not attract anything like the attention or funding that many relatively ineffective interventions receive. Western HIV funding has tended to be highest where HIV has been presented as a matter of sexual behavior, often with the implication that women play a more significant role in transmitting the virus. And funding has been lowest for interventions that may most successfully address such prejudices. Western backed programs may draw attention to these issues, but far from addressing them, they may be exacerbating some of the more acute pre-existing problems rather than alleviating them.