The Revolutionary Nature of HIV/AIDS Prevention.

HIV/AIDS is a social decease. No matter what kind of societal, psychosocial, psychological or economic factor you choose to test for correlation with, the correlation seems to be there. In consequence, HIV prevention can only be of a society changing and challenging nature if it is to be in any way effective.

Gender Inequity

 Redressing gender inequality and ensuring that men and women were truly equal in all senses of the word would act as a protective barrier against new infections.

As far back as in 1995, Hortensia Amaro of Boston University wrote an article for American Psychologist about gender and HIV vulnerability. Among the findings of the articles quoted are the following:

Gender based roles do play a part in the vulnerability to HIV infection: The more “traditionalist” and macho the males in a given community are, the more dangerous they are to their female partners in terms of passing on HIV infection. This is caused by several factors:

  1. Impregnating women is seen a sign of masculinity,  which has an adverse effect on the men’s willingness to use condoms.
  2. More “traditionalist” males tend to have more different sexual partners in looser and less affectionate relationships
  3. They regard the relationship between men and women as essentially adversarial, meaning that a relationship is not something to be cooperated and agreed on and which should accommodate the needs and wishes of all involved parties, but rather something to be achieved through lies, manipulation, use or abuse of power and possibly incentives such as material or economical support of the women
  4. “Traditionalist” males tend to have multiple concurrent relationships. It is still not scientifically established exactly how or if this is a driver of the epidemics, but the fact is that the prevalence rates are higher in countries in which concurrent relationships are a common practise
  5. “Traditionalist” males regard deceases and the transfer of them as well as caring for the sick as a “women’s area”. In many African countries, HIV infection is always blamed on the women, no matter of she was actually a virgin by the time she instigated her sexual relationship and never slept with anybody but the man in question.
  6. Because of the above, “traditionalist” men are also less willing to admit to a positive HIV status and take responsibility for their own health and that of their sexual partners

Most behavioural HIV Prevention programmes have not managed to distinguish between men using condoms and women making their sexual partners use condoms, though this is in no way the same matter. The weaker the position of a women, be it because of economical dependence, low societal or legal status or the way she was raised, the smaller her chances of successfully negotiating use of condoms or refusing to have sex in case her male sexual partner refuses to use one.

In consequence, gender, as viewed as the societal construction of behaviour, norms, expectations and freedoms of a specific sex, is very strongly correlated with vulnerability to HIV infection as well. Research into the understanding of the self suggest that women tend to see themselves in relation to their peers, meaning effectively that running the risk of conflict with your peers is the same as running the risk of loosing your footing in your understanding of your place and role in life. men do not to the same degree see themselves in relation to their peers. It is not clear whether this difference in perception is a biochemical or societal construct.

Even though women in more developed countries tend to have more casual sexual partners, they do not have the high prevalence rates that their sisters in underdeveloped countries have. There are many suggestions as to why this might be, such as:

  1. Regarding themselves as more equal, women of western societies have less trouble negotiating use of condoms
  2. Intimate partner violence is not an accepted practise in the western world, meaning that women do not face the threat of being beaten up if they insist on the use of condoms
  3. Being economically and materially independent of them men they sleep with, women in western societies have a leverage with which to bargain that their sisters from underdeveloped countries do not
  4. Use of condoms in casual relationships is an accepted practise in most of the western world

There’s much interest in developing female controlled effective means of HIV protection that can be used without the knowledge of the male sexual partner. This reflects an accept of the fact that men in many contexts are not willing to protect their female sexual partners. This is further accentuated by the fact that many “normal” African men that I have had the chance to discuss male circumcision with, thinks that the whole problem is solved by circumcising all men. They disregard the fact that though he’s circumcised, an infected man can still transfer virus to an unprotected partner.

Interpersonal Inequity

 Redressing situations in which a person’s sense of self-esteem and self-efficacy are threatened, no matter whether it is a caste system as in India, bullying as in schools or job situations in Europe, racism as in many countries in Africa or open hatred of groups that are defined by drug use, sexual or religious orientation, could act as a protective barrier against new infections with HIV.

Studies suggest that the development of a feeling of self-efficacy or the belief in your own ability to successfully achieve the things you set out to achieve, is one of the stronger protections against vulnerability to HIV infection. In other words, having a sense of self-esteem protects you from running risks in terms of unsafe sexual practises. On the flip-side, bad personal experiences such as bullying, intimate partner violence, violent attacks or other traumatic experiences work adversely on one’s ability to negotiate safer practices.

I would very much like to develop a framework for testing if the building of self-esteem in itself – as isolated from the income generating activities or microfinance loans of traditional studies into this area – act as a protective measure in terms of HIV infection.

However, this would entail an in-depth knowledge of the cultural contexts of the countries in which to run the studies, as most Western tools of changing your relationship with yourself, no matter whether it is cognitive therapy, neo-linguistic programming, traditional psycho-analysis or any other school of psychological treatment, is based on a reflective and self-searching aspect of our personalities that is not generally part of the traits that make up a personality in most developing countries, e.g. countries in Africa, which is why these methods would have limited if any affect if used without being adapted to the context in which they are attempted to be sued in.

This is a very interesting facet of HIV prevention, as there normally is little if any interest in people who hold a position of power in terms of societal status, sex, association with a specific community group or societal class or belonging to some other privileged group to sustain the development of a sense of self and of a right to equity in those who they gain their position of power from being in an unequal relationship with. Quite simply, because that would be a threat to their position of privilege and power.

Economic Inequity

 Ensuring a more equal access to health services, education, employment, choice of line of work and ability to affect government decisions would work as a protective barrier to more HIV infections.

The need to redress power relations is a trait of HIV prevention that permeates societies at all levels, right from the unequal relationship behind the walls of single households to the differences between societal classes and those in power, be it a government or, as is the case of Swaziland, the country with the highest HIV prevalence rate in the world, the immensely privileged royal family, who hold both the power of owning most of the country’s riches and industries and the right to appoint the members of parliament.

This leads on to the next controversial trait of HIV prevention – namely, the strong correlation between poverty and vulnerability to HIV infection. Most of the world’s HIV infections occur in the poorest countries, though the correlation seems to be associated with the with the gap between poor and rich as well as with the relative riches of the country in comparison to others. Swaziland, again, is actually a middle income country, but still more than 2/3 of the population live on less than a dollar a day.

Poverty leads to many desperate measures such as prostitution or the common phenomenon of sugar daddies. When you have no means of supporting yourself, you have no leverage for negotiating the terms of the services rendered for money or materials. These days, you see sugar mommies too, no doubt with the same mitigating effects on the epidemics as the sugar daddies have been having for decades. There’s a (growing ?) European sex tourism taking place in Africa, with as yet unknown potential for exacerbating the situation in both Africa and Europe.

People are poor as a consequence of other people’s access to depleting their resources without adequate compensation, underpaying them for their labour, putting up trade barriers to protect own market interests, concentrating the wealth on few hands in stead of many, privatising social security and possibility of development such as health services and education, and this is very much one of the power concentration structures that the people privileged by it have no interest in changing or allowing others access to.

On the other hand side, vulnerability to almost any decease, not just HIV, is inversely correlated to level of education and access to effective and affordable means of health care. Poor countries, in which the epidemics rage most uncontrolledly, lack these basic services, and with the SAP's (Structural Adaptation Programmes) and other conditions on loans from the IMF or the World Bank or similar instances, they are asked to further exacerbate this situation by privatising and charging for services such as health care and education. The SAP's have been called genocide by the UN in the face of hyperendemic epidemics.

I have always wanted to test for correlation between access to participation in a country’s democratic structures and HIV prevalence rate, but it is not clear what “participation in a democratic structure” entails or how I should get the relevant data to test this thesis. However, the strong correlation between self-efficacy and ability to protect oneself from infection would suggest – assuming that active participation in a democracy and in the governance of structures that affect one’s life builds a sense of self-esteem – that better access to democratic control of one’s own conditions would decrease vulnerability to HIV infection. This seems to be sustained by the unusually successful Avahan programme by the Bill and Melinda Gates foundation, in which a very high level of participation and self-determination was used to ensure that the programme addressed the problems identified by the communities and not by some distal donor.

This, of course, is also highly controversial, as concentrating power on few hands as in dictatorships or even the power structures in countries suffering from corruption and other symptoms of democratic deficiency are mutually exclusive to allowing the people of the country in question democratic control of the people governing their country.

Facing Taboo 

Enabling effective HIV prevention programmes to be implemented means admitting to the existence of drug injecting communities or sexual orientations other then heterosexuals or other potentially tabooed issues.

The last controversy that I am going to write about now is the fact that HIV prevention efforts in order to be effective must target communities that in many countries are illegal or tabooed to the point of a direct refusal to acknowledge their existence.

The most typical example of this is men having sex with men. In many countries this is outlawed, and it is possibly a serious threat to one’s personal health to disclose a sexual preference for one’s own sex. Other examples are prostitutes and injecting drug users.

In order to target the most vulnerable communities, you must first acknowledge that they even exist. This in itself has a society changing potential, but less drastic taboos exist, such as talking openly about sex – it is still common practise never to mention the consequences of having unprotected sex and yet kicking your girl children out if they fall pregnant – or the women’s right to decide about their own sexuality.

Conclusion: Dealing effectively with HIV prevention means changing societies in a more progressive direction.