Bloodborne HIV: Don't Get Stuck!

Winnie Byanyima, head of UNAIDS, wrings her hands about racism and stigma, and the title of the article points the finger at ‘Big pharma’. But that’s not quite accurate. Big pharma will take money from anyone, not just people in sub-Saharan Africa (SSA). The characterization of HIV as a primarily sexually transmitted virus in sub-Saharan Africa is one of the main sources of stigma. The consequent grouping of HIV positive people according to their assumed or alleged sexual behavior is one of the main sources of racism and sexism. The source of the prejudice is institutions, the UN, development finance, academia and others. 

The executive summary of the 2022 Global Aids Update claims (in a pie chart, page 15) that 97% of all HIV positive people in SSA were infected through sexual contact. Over 40% are said to be infected through sex work, either because they are (alleged) sex workers or (alleged) clients of sex workers. And a whopping 49% are part of the ‘remaining population’. Which means, if they were infected sexually, they must engage in extraordinary levels of ‘risky’ sex (although it looks as if UNAIDS can’t convincingly explain how they were infected, they just publish data attributing it to some kind of sex). 

The population of HIV positive people in SSA is 1.94%, overall (23,500,000 people living with HIV; 1.21b people). Many HIV positive people are either not sexually active, not engaging in any kind of sexual contact with a HIV positive person, or only engage in ‘safe’ sex. A relatively difficult to transmit virus, at least sexually, infects about 23,500,000 people, mostly in a few parts of several countries, the vast majority of those being in about 10 countries in eastern and southern Africa. So why target the entire 1.18b people in SSA when you could target these ‘hyperendemic’ hotspots? (Of course, 1.18b is a much bigger market than just 2% of that, so that’s a good reason.) 

But UNAIDS (and therefore Big pharma, BINGOs, funding, healthcare, and anyone else with a share in the industry) target those who are infected with HIV, regardless of whether they are ‘key populations’. (In case this is beginning to sound like a circular argument, I can assure you that it is.) Being HIV positive is used as a proxy for ‘engaging in some kind of risky sex’; and engaging in sex of any kind, or being assumed to do so, attracts the blanket behavior change communications and other finger-wagging interventions that many people in SSA have grown up with. That means the entire sexually active population of SSA is considered to be ‘at risk’. 

When Big pharma came up with their ‘Pre-exposure prophylaxis’, (PrEP, the use of antiretrovirals by HIV negative people to reduce the risk of being infected), they targeted anyone engaging in sex, or alleged to be engaging in sex. PrEP was designed for people who identified themselves as belonging to a group that faced a higher risk of HIV transmission. It was developed in wealthy countries, where the behaviors involved are not as deeply stigmatized as they are in many parts of SSA. Big healthcare came up with mass male circumcision because the US believes it is ‘hygienic’ (with all the racist overtones of that word). Big NGOs were already deeply involved in ‘behavior change’ programs, which date back to a time when eugenics was openly referred to as science. 

But there is something very simple that Byanyima, UNAIDS and others in the industry can do: they can target the places or broader environments where all the bigger sub-epidemics can be found. They can consider the circumstances in which people live that may make them more susceptible to infection with HIV or other serious diseases. HIV positive people in the worst hit hotspots have things in common that have nothing to do with their individual sexual behavior. Cities, places with relatively good infrastructure, accessible and widely accessed healthcare facilities, high population density areas, big employers and various other factors have been closely associated with some of the highest rates of HIV transmission. 

In contrast, most people in most countries engage in some kind of sexual behavior, some in high levels of sexual behavior, and some in high levels of ‘risky’ sexual behavior. But there is little evidence that sexual behavior patterns are unprecedented in SSA, even less so in HIV hotspots. Pointing the finger at sex and implying that being HIV positive strongly suggests that people’s HIV status is a result of their individual sexual behavior is the source of the stigma associated with HIV. Big pharma and other players in the industry merely adopted UNAIDS’s and academia’s scattergun approach. If you brand the entire population of a sub-continent as promiscuous, you can’t then qualify your actions by adding that you do so in a completely non-stigmatizing way. 

More women than men are infected with HIV in SSA (although far more men than women are infected outside SSA). So, the pie chart claiming that 97% of HIV positive people were infected through their own individual sexual behavior reflects the anti-woman and institutionally sexist strategy of UNAIDS and the industry. African men are stigmatized as predatory. Some men may be, but predatory behavior is not confined to SSA, nor to high HIV prevalence hotspots. UNAIDS and the rest of the industry, including academia, and legacy media who depict HIV as a predominantly sexually transmitted virus, but only in SSA, are upholders of this stigma, institutionalized sexism and racism. 

UNAIDS has been around for nearly thirty years and was set up by people who had already worked with HIV for the 10 years since it was identified. The groups most affected by HIV in the 1980s in SSA were often self-identified as sex workers, sex worker clients, and the like. These are groups that had been targeted by healthcare practitioners for decades to address sexually transmitted infection and contraception. Other groups that were infected with HIV early on include women giving birth in healthcare facilities, antenatal care clinics and similar. Some of the biggest outbreaks of the mid to late 80s and early 90s are the hyperendemic hotspots of today. 

UNAIDS and other institutions that have been working with HIV in SSA from early on, or from the very beginning, know better than anyone how misplaced the stigma is. They know more than most about the conditions people live in, and what their health determinants are. They collect the figures showing that individual sexual behavior cannot account for any of the massive rates of HIV transmission that occurred after HIV was identified (not before). If anyone knows what happened, UNAIDS and all the other institutions working in the epicenters of HIV in SSA should, because they were there. A lot of these epicenters are healthcare facilities. They are still operating and can still be investigated.