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Is misogyny misleading the response to Africa’s HIV/AIDS epidemics?

Everyone has prejudices. Trying to overcome them can be like playing the arcade game whack-a-mole. See it, whack it. It pops up again, whack it again. The AIDS epidemic energizes a lot of prejudices. Unfortunately, the international AIDS industry – organizations and individuals getting money to do something about AIDS, including aid agencies, researchers, and others – has not been alert to see and reject common prejudices.

For example, even though careful surveys show that heterosexual behavior in Africa is similar to behavior in the US and Europe, most AIDS experts say that sexual behavior explains Africa’s terrible epidemics. Because the AIDS industry has not yet whacked racial stereotypes of sexual behavior, it has not yet been compelled to look for something other than sex that is different in Africa, and that could help to explain how HIV can infect 5%-26% of adults (50-260 out of 1,000 adults) in 15 countries in Africa compared to only 0.3% of adults (3 in 1,000) outside Africa.

But it’s not only racism that misdirects the AIDS industry’s response to Africa’s epidemics. Another prejudice – misogyny – seems to do so as well. Features of two prominent health aid programs in Africa – circumcising men, and extending birth control to women – suggest that misogyny is a hidden influence.

Circumcision: During 2005-07, studies in Africa reported that circumcising HIV-negative men reduced their risk to get HIV by 53% (median result from three studies), but that circumcising HIV-positive men increased transmission to their wives by 49% (result from one study). Based on these studies, donors initiated crash programs to circumcise millions of African men. Critics point out that circumcised men will still have to use condoms to be safe (not just safer). But since we’re focusing on women, let’s leave aside arguments that mass circumcision is not a good way to protect men.

Let’s focus instead on what was done with the evidence that circumcising HIV-positive men increased their partners’ risk to get HIV by 49%. Notably, in the study that reported that statistic, wives of circumcised men were at especially high risk if they resumed sex before their husbands’ circumcision wound healed – 5 (28%) of 18 who did so got HIV in the 6 months after their husbands were circumcised.

Programs offering subsidized circumcisions could protect wives by requiring that men asking to be circumcised be tested for HIV, and if found to be infected bring their wives for couple counseling before proceeding with the circumcision. Instead, the Joint United Nations Programme on AIDS (UNAIDS) recommends: “The offer of male circumcision should neither depend on a person undergoing an HIV test, nor on a person being…HIV-negative” (quote from page 7 of this link). As mass circumcision programs got underway, as many as 1/3rd of men resumed sex before wound healing. Lack of care to protect women suggests misogyny – or is it just careless incompetence that happens to hurt women?

Hormone injections for birth control: During the last several decades, many studies in Africa and Asia found that women taking hormone (progesterone) injections for birth control were more likely to get HIV compared to women using other birth control methods. A similar risk is found with monkeys: As early as 1996, scientists studying SIV (simian HIV) in monkeys found that progesterone implants multiplied by 8 times their risk to get SIV. Progesterone thinned the monkey’s vaginal wall and enhanced virus replication. Another HIV risk with hormone injections is that careless providers might reuse unsterilized syringes and needles, transmitting HIV from one woman to another.

Despite the evidence, WHO continues to say hormone injections are safe for all women, and donors continue to push hormone injections for birth control – especially in Africa. Outside Africa, 3% of women (partnered women aged 15-49 years) use hormone injections. In contrast, in Kenya, Lesotho, Malawi, Namibia, South Africa, and Swaziland, the percentage of women using hormone injections increased from 6%-20% in 1996 to 17%-29% in 2009. In these same countries, 6%-26% of adults are HIV-positive.

Compare what the AIDS industry does to protect men vs. women: In 2011,  a study among discordant couples (in which only one partner is HIV-positive) in Africa reported that women taking hormone injections for birth control were more than twice as likely to acquire HIV from their husbands compared to women using non-hormone methods. From this data, helping women shift from hormone injections to safer methods would cut their risk for HIV by 54% — as much as circumcision seemed to protect men in several recent studies. How did donors respond? Donors budget hundreds of millions of dollars to circumcise African men, but no donor has committed even one dollar to shift women from hormone injections to safer birth control methods. As of late 2011, the aid-for-family-planning industry, including notably USAID, continues to push hormone injections in Africa.

Other signs of misogyny: Outside Africa, HIV infects mostly men. Where that’s the case, researchers have identified all important risks – most infections come from anal sex among men or from sharing syringes and needles to inject illegal drugs. Knowing their risks helps men to avoid infection and thereby limits the extent of HIV epidemics. Outside Africa, only 0.3% of adults are infected.

In Africa, HIV infects more women than men. In Swaziland, for example, HIV infects 31% of women vs. 20% of men. In the 28 years after AIDS was recognized in Africa in 1983, researchers have failed to do the simple research required to identify important risks for women – that is, to trace the source of their infections.

We know some women get HIV from their husbands. But we also know that in most African countries married women with HIV are more likely to have HIV-negative than HIV-positive husbands. We know that many self-reported virgin women are HIV-positive. We know that reuse of unsterilized medical instruments is common in Africa. So we know some things. But we don’t know enough. Failure to identify women’s risks may well be the key to failure to control Africa’s epidemics.

Other evidence of misogyny comes from the AIDS industry’s frequent  claims that prostitutes drive Africa’s epidemics. Throughout history, societies have blamed promiscuous women — especially prostitutes — for spreading sexually transmitted disease. Some studies in Africa have found a lot of prostitutes with HIV — but how did they get it? Notably, in most countries outside Africa, HIV is rare in prostitutes who do not inject illegal drugs. Few prostitutes in Africa inject illegal drugs, but they get other injections, such as antibiotics to treat sexually transmitted disease. Nevertheless, building on a long tradition, the AIDS industry finds it easy to blame prostitutes’ HIV infections on sex, rather than to investigate to see how much unsafe health care not only infects prostitutes, but also spreads HIV from prostitutes to others.

Finally, consider the different attention paid to sterilization of medical instruments in the Expanded Programme on Immunization (EPI), which began in 1974 and which treats mostly children, compared to what has been done in safe motherhood and family planning programs for women. During the 1980s and later, EPI’s donors arranged dozens of surveys of injection practices in immunization programs. These surveys found lots of unsafe injections. In 1999 a WHO committee acknowledged that 30% of vaccination injections were unsafe. To address the problem, EPI’s donors belatedly shifted vaccination injections to auto-disable syringes, which break after one use.

Unlike EPI, programs promoting health care for women have not arranged surveys to see if health care is safe – e.g., how often are gloves, specula, and syringes reused without sterilization? Even so, there is a lot of evidence that women’s health care in many hospitals and clinics in Africa is not only unreliably sterile but has also infected women with HIV. For example, a 2005 national survey in Ethiopia found that 9.9% of women who gave birth in the last 3 years with delivery care from a health professional were HIV-positive vs. only 1.2% of women who gave birth but did not get such care. We don’t know where all those infections came from. Not knowing shows that no one has cared enough about women to do the simple studies to find the risks – tracing infections to their source – so that women can be warned and thereby protected. Donors’ head-in-the-sand approach to women’s exposures to unsterile instruments in health care mocks the “safe motherhood” slogan.

More than money is required to stop Africa’s AIDS epidemic – it also needs clear thinking.  That is hard to do when common prejudices are not recognized and whacked. If we see and whack racial stereotypes of African sexual behavior, we’re more open to evidence pointing to other explanations. If we’re alert to whack misogyny, we’re forced to take a good look at all the ways the AIDS industry harms and stigmatizes African women. Clear thinking can help to translate good intentions into protecting and healing actions.