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Unaddressed elements of the developing world epidemic

    I’ve had a couple of fairly interesting
conversations of late with an epidemiologist working for an NGO here
in the Boston area, and he’s got a bit of a hobby horse about the way
policy is being implemented.

    In short, much of HIV prevention policy in Africa
focuses on the transmission aspects of the disease that are of
proportionately less risk because they are more socially acceptable to
talk about than what he contends are real causes. J. points out that
transmission via sources such as saliva, vaginal fluids, and other
bodily fluids are much less likely than transmission by blood and
semen.  True. 

    So it seems much less likely that HIV in
SSAfrica is spread by heterosexual contact of men with prostitutes,
especially if we’re talking about vaginal intercourse.  The most
effective way to transmit the virus is through anal sex, especially
anal sex between men.  But most HIV prevention programs, outside
of the gay community in the West, do not discuss anal sex as a form of
sex putting people at greater risk, instead focusing on the prevention
of the quite proportionately lower unprotected vaginal heterosexual
intercourse.  Based on statistical probabilities, such policy
might be problematic because it does not actually address the more
likely methods of HIV transmission.  So we could be focusing on a
method of transmission that is much less likely than an unaddressed

    He also points out that transmission of the virus
has occurred most quickly and broadly in the context of homosocial
environments.  The traditional story now is that HIV became
widespread in these great gathering places far from home, where men
were away from their wives and resorted to the use of prostitutes and
mistresses.  So along the Kinshasa highway, in mining camps, in
other work situations where there are high concentrations of men, and
in prisons, men have taken to using female prostitutes, spreading and
acquiring the virus from them.  But as he points out, these are
environments where there are lots of men in close and consistent
contact with one another and with a general lack of women.  We
know from other situations that men who want to have sex and lack the
opposite sex will very often turn to other men for that same sex. 
The proposition boils down to this: if men want sex and the majority of
their social environment is made of men, then they will have sex with
those men (and from what I have seen this is fairly well-verified where
it has been assessed).  If the foregoing is the case, then it
stands to reason that a large part of the African epidemic (and perhaps
that in other countries) is driven by male-male sexual contact.

    But that element of the epidemic is definitely not
addressed in the African context, where HIV is regarded as an (almost)
entirely male-female sexual intercourse disease.  Male-male sexual
contact is not spoken of in most of Africa, and so we perhaps ignore a
large driver of the epidemic there.

    If this is the case, what effect might this have on
our efforts at prevention in SSAfrica?  And how would we address
such in a political manner?  One could shift to a further
discussion of behaviors, emphasizing avoidance of anal intercourse of any sort, I guess.  But I can see problems with that.

    Just seemed an interesting idea worth some consideration.

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3 Responses to “Unaddressed elements of the developing world epidemic”

  1. Very interesting and provocative possibility. Have not seen anything on this. Another interesting thing is that there appear to be much lower rates of disease incidence in West Africa from what I hear which is attributed to a higher incidence of male circumcision. Relating this to your post, are those environments in West Africa also less likely to have men far away from home on truck and trade routes where there are few women around?

    I think one point against your post is that there are so many heterosexual, married women infected with the disease in Africa. Even if this is a less likely pathway for disease transmission than anal sex, it appears to happen enough that it’s unclear if they got it from partners who slept with prostitutes, other women or with men.

    Certainly an interesting avenue for further research.

  2. I was at a World AIDS day discussion last night and Helen Epstein from Princeton noted that there appears to be a much higher proportion of people having multiple long-term partners in Africa than other parts of the world. What this means is that AIDS travels quickly through the network, much faster than in places with serial monogamy. She had some charts that looked like applications of network theory to the transmission of HIV. One study that documented this was Cleland, Ferry 1995.

  3. That’s interesting. It seems that one of the necessary conditions for the disease getting off the ground is that you have to have multiple partners in the same time period. not that transmission can’t occur under conditions of serial monogamy, but it’s obviously faster to have multiple partners.

    And it seems like that might be something necessary to have a real epidemic of high population prevalence. Africa’s got it. But Latin America? Do people tend to have multiple long terms or serial monogamy there?