HIV Could be as Much About what we Do as What we Don’t Do

17 Feb

There are many things to agree with in Jason Hickel’s article in Pambazuka.org about AIDS and global capitalism. But there are also many things to disagree with. I’ll concentrate on two. The first is that Hickel believes that HIV is almost always transmitted sexually, but he argues that there are reasons for the high levels of unsafe sexual behavior that result in HIV epidemics. I don’t disagree that people are poor, starving, unhealthy, unemployed, exploited and the like. But I disagree that all these necessarily result in the massive rates of HIV transmission that are found in Southern African countries; at least, not for the reasons Hickel says or implies.

Many of these conditions exist in other countries, such as Cambodia, where HIV prevalence is very low, lower than it is in the US. You can’t point the finger at corruption either, because corruption is said to be more acute in several Asian countries, including Cambodia, than it is in many African countries. All the circumstances that Hickel describes surrounding people’s behavior, sexual or otherwise, are real and terrible; they all need to be addressed, whether HIV is involved or not. But even the circular migration that is so common in South Africa, and that has often been blamed for high HIV transmission rates, is not enough to explain high transmission rates in areas where incidence is also high, but where circular migration is really not an issue.

Yes, all epidemics are different, not just between countries, but also within countries. There’s a huge epidemic among one of the three major tribes in Kenya’s Nyanza province, another huge one among women in the major tribe in the Western province; medium epidemics among most tribes in the country’s other provinces and less than 1% prevalence among the Somalis of the Northern parts of the country. But I am suggesting that differences in health seeking behavior may have as much to add to the picture as sexual behavior, perhaps more. This is not to say that all HIV is transmitted through unsafe healthcare and none is transmitted through sexual behavior (that’s the mistake many commentators make, that it’s all down to one factor, when that factor is clearly not relevant in many epidemics or subepidemics).

The second thing I disagree with is pinning the blame on structural adjustment policies (SAP) or other neoliberal movements, capitalism, globalization, urbanization or whatever else. These do not explain why entire populations of certain areas should suddenly change their sexual behavior, and sometimes even change back again from time to time (such as Uganda). SAPs were destructive and whatever more cuddly, touchy-feely name they now have doesn’t make them any better. But there were two especially interesting outcomes of SAPs in the 1980s in Kenya and some other East African countries, and later on in some Southern African countries: for some people, healthcare became a luxury they could no longer afford; this may have protected them against HIV (eg, Kenya, Uganda, Tanzania, where prevalence reached medium levels and stabilized at medium levels); for others, the healthcare they were used to was becoming less safe, as well as less accessible, and this may have increase their risk of being infected with HIV (eg, South Africa and Zimbabwe).

If HIV is all about sex, why does Hickel think that it is more likely among wealthier people, both male and female (before he wheels out the old chestnut about wealthier men having sex with more paid partners)? Why is HIV more common among urban dwelling people? Why is it more common among employed than unemployed people? Why is it more common among the better educated? Why is it more common among those who live close to and have good access to health facilities?

In the big mines in South Africa and other countries, the mine owners provide little enough, but they are obliged to provide basic healthcare, at least so they can send home people who are no longer healthy enough to ensure productivity levels required by their employer. But there is no obligation to provide safe healthcare. Even big development players in healthcare rarely mention safety as a priority. It’s almost as if they feel HIV can not be transmitted in African hospitals because, rather than despite the fact that, there are so many HIV positive people in some populations.

SAPs are a reminder that denying people healthcare results in high levels of disease and death. But providing substandard healthcare can spread disease far more quickly than no healthcare at all. HIV prevalence has often reached the highest levels among sex workers (yes, some people have sex for money/goods/services, etc), pregnant women and very mobile men. But these groups often avail of health services far more frequently than people who live in more isolated areas or people who have not specifically been targeted by sexual health, reproductive health or HIV related services. Those providing healthcare in high HIV prevalence countries may be far too careful to ever risk transmitting HIV by accident, but it is worth finding out. After all, no one would accuse hospitals in high HIV prevalence of being well resourced, well run or particularly desirable. The UN routinely warns its own employes to avoid them.

HIV is not always transmitted sexually; knowing about people’s sexual behavior does not allow you to predict their HIV status; and knowing their HIV status does not tell you anything about their sexual behavior. Sometimes HIV is transmitted sexually, sometimes it is not. In addition, the majority of people, African, Asian, European, etc, do not engage in transactional sex. Survey after survey shows that most people have one long-term partner and a minority have many partners, the same as would be found in Western countries. As long as Hickel and others view HIV as being mainly sexually transmitted, they will always fail to understand HIV epidemics.

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

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