Sunday, August 2, 2015
Offering money to young girls in return for an undertaking by them to have less sex, or to take precautions against infection with sexually transmitted infections and unplanned pregnancy, strikes me as inherently contradictory. If you want to make money out of your body, what difference does it make whether you achieve that by agreeing to have sex, or by agreeing not to have sex?
Imagine you wish to make money in these ways: you have clients who pay you to have sex; and you have clients who pay you not to. The two types of client are perfectly compatible. Instead of making eight dollars a day (100 Rand), week or month, you can make sixteen, or you can use the payment as leverage to charge some clients more, or as a subsidy to charge some less.
These 'conditional cash transfers' seem to be based on a number of assumptions. For a start, they seem to assume that HIV is almost always a result of sex, generally extra-marital sex, and generally 'unsafe' sex. They also seem to assume that protecting themselves against being infected with HIV is within the control of the recipient of the money.
What about non-sexually transmitted HIV, through unsafe healthcare, cosmetic or traditional practices? Don't people infected in that way need money too? Shouldn't they be encouraged to avoid health facilities where conditions are dangerous, also practitioners who have a poor record for safety?
By the way, the recipient of money is always female. Therefore, it is further assumed that the male with whom the female has sexual intercourse is usually the 'index case', the one more likely to be HIV positive. (All men are sexual predators and all women are sexual victims, at least in the world of HIV.)
But, as it turns out, most young males in South Africa and other sub-Saharan African countries tend to be HIV negative. Far more females than males become infected, some in their teens, but far more in their twenties, and many in their thirties. So who is doing all this infecting?
This requires another assumption: the girls/women are having sex with men who are older than them, often much older. There are several problems with this attempt at rescuing current HIV 'policy' and thinking: many females do not have sex with men who are much older than themselves; many 'older' men are not HIV positive; and many females are infected even though their sexual partners are roughly the same age as themselves.
Worse still, some girls/women are infected even though they either have not had sex, or they have always taken precautions. In fact, using condoms is more strongly associated with higher HIV prevalence than not using condoms. Those trying to dig themselves out of this hole claim that people who know they are HIV positive are more likely to use condoms. But this claim is not well supported by evidence.
'Intergenerational' marriage and sex, where one partner (usually the male) is older than the other, used to be the darling of the anti-sex brigade. But very little research was carried out into whether it really resulted in higher rates of HIV transmission. When some research was carried out it was found that it may be associated with lower rates of transmission.
Back to the drawing board? Well, no, actually. As well as persuading girls/women not to have sex (or the wrong kind of sex, or sex with the wrong kind of person, etc), there are conditional cash transfers for men who agree to be circumcised. It works, too. Not very well. Not many men will agree to be circumcised for a few dollars.
Unsurprisingly, more men will agree to be circumcised if they are paid more money, and fewer if they are paid less. But most of the men who agree to the operation would have already agreed to it without the payment; they were already convinced that circumcision would be the answer to their prayers (or what they thought were their prayers).
There is cash to stay in school, even though this is not associated with lower HIV incidence. The payments may continue because school is a good thing. But didn't we know that already? Didn't we already know that all children should go to school and that there should be equal access for all children, regardless of their gender, tribe, religion, etc?
There is cash to support prevention of transmission of HIV from mother to child. What about reducing infection in mothers? Many are infected when they are already pregnant, even late in their pregnancy, or just after giving birth. Many infected have husbands who are negative. These women are unlikely to have been infected through sexual intercourse, despite the constant pompous and racist prognostications of the HIV industry.
Sometimes the payment, or some of it, goes to the family. Great, so poverty is a bad thing; and another thing we just wouldn't have known if it hadn't been for this research? The World Bank made a big hoo hah recently about how wonderful eradicating human parasites is, how much better off children are, with improvements in health, academic achievement, etc.
But human parasites are debilitating and result from appalling living conditions. They are also easily and cheaply treated. Aside from the clever medications, provision of water and food of a quality appropriate for human consumption can also significantly reduce the problem. Why so much research to tell us what we already know? Why so much research telling us that a lot of what we are doing are wrong, yet the research, and much of what we are doing, both continue.
Something all of the above failed approaches have in common is that they show that HIV is not very closely related to sexual behavior. It is not just that attempting to influence someone's sexual behavior often fails; successfully influencing someone's sexual behavior also fails to reduce HIV transmission.
Conditional cash transfers that assume HIV is almost always a result of sexual behavior don't just frequently fail to influence sexual behavior, they fail to prevent HIV transmission. Mass male circumcision has been shown to reduce HIV transmission from females to males, only slightly, and only under certain conditions; but it increases transmission from males to females.
These same researchers have been working on the same unpromising initiatives for many years, even decades: Karim, Pettifor, Jukes, Thirumurthy, etc. However, their racist bilge doesn't fail because it is racist, it fails because it is based on assumptions that are not borne out by their own findings. Except in the minds of journalists, there is no 'money, sex, HIV' triad in Africa; HIV is also transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices. Let's try dealing with that.
Posted by Simon at 5:50 PM