UGANDA / HEALTH
Fighting HIV and AIDS
African fisherfolk suffering from HIV are subject to stigma, denigration and disempowerment, all of which weaken their voice in civil society
This article is by David Gisselquist (david_gisselquist@yahoo.com), an independent consultant on HIV and AIDS in Africa
Titled Deadly Catch: Uganda’s fishermen seeking sex workers prompt HIV surge’, an April 2014 article in The Guardian reports 43 per cent of adults have been infected in Kasensero, a Ugandan fishing community bordering Lake Victoria. According to the article, Once their catch is sold most head for Kasensero’s bars and the sex workers who hang out there. This, and many other similar reports in the media,echo multiple studies in the medical literature linking HIV to stigmatized sexual behaviour.
For example, a recent review of 44 articles about HIV among fishermen considers heterosexual sex to be responsible for most infections. According to the review, as many as 30 per cent of fishermen are HIV-positive, while 42 per cent engage in transactional sex (that is, they hire prostitutes). The review, by Smolak in AIDS Care, 2014, included studies on fishermeninternationally as well as in specific Asian, Africa and European countries. Similarly, a recent publication by the World Fish Center, titled HIV/AIDS in the Fisheries Sector in Africa’, generalizes a number of lifestyle factors suggest that heterosexual sex is the prevalent channel [for HIV infection] in fishing communities.
For fisherfolk, as well as for all adults, the specific risks that account for most HIV infections as well as the numbers infected, differ between Africa and the rest of the world. Outside Africa, the percentage of adults with HIV is much less than in Africa, and the two risks that drive HIV epidemics are anal intercourse among men and sharing unsterilized syringes and needles to inject recreational drugs. Since only a minority of adults have these risks, the percentage of adults with HIV outside Africaas well as the percentage of fisherfolkis almost always low.
However, the situation is different in Africa, where 5 per cent25 per cent of adults are infected in more than a dozen countries, and where injecting illegal drugs and malemale sex account for only a minority of HIV infections. But how are so many adultsand fisherfolk getting HIV in Africa? The common view that almost all HIV infections among all adults in Africa come from sex is not based on evidence. No studies among fishermen in Africa have looked at all risks, including blood exposures through unsterilized syringes, needles, razors, and other skin-piercing equipment used for healthcare and cosmetic services.
Conflicting evidence
Similarly, researchers have only rarely traced infections in African adults to sexual partnersinstead, researchers have routinely assumed that an HIV infection in an African adult came from sex, without showing that is so. At the same time, researchers routinely ignore abundant conflicting evidencesuch as people with HIV who deny sexual risks, and HIV in children with HIV-negative mothers.
The characterization of Africans, in general, and fisherfolk, in particular, ason averagemore willfully and thoughtlessly promiscuous than other adults is denigrating, stigmatizing and disempowering, weakening their voice in civil society. Even worse, the emphasis on sexual risks distracts from what has to be doneand can be doneto help prevent HIV infections in fishing communities.
Avoidance of sexual risks is not enough to protect someone from HIV. In African countries with a lot of HIV infections, fisherfolk, like all other residents, are at risk to get HIV from minor blood contacts. The Joint United Nations’ Programme on HIV/AIDS (UNAIDS) warns UN employees in much of Africa that unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. To address this risk, UNAIDS assures UN employees: Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of healthcare. UNAIDSand other public health organizations and initiativesdo not similarly warn local populations or assure safe care.
In countries with a lot of HIV infections, fisherfolk have many of the same risks as other residents. They go to barbers who may reuse razors and electric shavers without sterilization. They go to doctors who may reuse needles and syringes for injections or needles, tubes or bags of saline for infusions. Because of their profession, fisherfolk have some special blood-borne risks. On board a fishing boat, tools in a first aid kit may be reused without sterilization from one person to another. Reliably killing HIV requires boiling instruments, not just rinsing in chlorine or alcohol; boiling may be difficult on a boat.
While staff of UNAIDS and other public health organizations are aware of the risks of getting HIV from blood exposures in Africa, public health agencies have not alerted the public to these risks. It is understandable that people delivering healthcare do not want to warn people about risks of getting HIV during healthcare. But this is an ethical failurein not telling people about all risks, public health staff are not respecting their responsibility according to the World Medical Association’s Declaration of Lisbon on the Rights of the Patient, including: Every person has the right to health education that will assist him/her in making informed choices about personal health and about the available health services.
With healthcare professionals not wanting to talk about blood exposures, HIV prevention programmes and messages designed by public health professionals are incomplete. This failure to warn leaves all adults including fisherfolkunaware of what they need to know to avoid HIV. As long as health professionals are not willing to craft a complete message about risks, it is up to others to do so. For example, civil society organizations that are not controlled by public health professionals, such as churches and unions, could revise their HIV prevention programmes to warn people about blood exposures as well as sex.
Formal organizations representing fisherfolk could revise HIV prevention programmes to warn fisherfolk not only about sex but also about blood exposures. Fishing communities could spread the message through crews and fish markets. Despite decades of failure on the part of health experts to warn Africans about HIV from blood exposures, one can always hope that experts will wake up to their ethical responsibility to deliver this. But since lives are at stake, multiple strategies may be considered to ensure change.
Good evidence shows that Africans aware of risks to get HIV from blood exposures have less HIV. During 200307, national surveys in 16 African countries asked people how to prevent HIV. In these surveys, the percent of adults who mentioned avoid sharing razors/blades as a way to prevent HIV ranged from 10 per cent in Swaziland to almost 50 per cent in Niger and Ethiopia. In five countries where less than 15 per cent of adults recognized contaminated razors or blades as risks for HIV (Kenya, Lesotho, Swaziland, Tanzania and Zimbabwe), the percentages of adults with HIV ranged from 5.6 to 26. On the other hand, in six countries where at least 30 per cent mentioned razors or blades (Democratic Republic of Congo [DRC], Ethiopia, Ghana, Niger, Rwanda and Senegal), only 0.8 per cent to 2.9 per cent of adults were HIV-positive.
On the other hand, good evidence shows that warnings about sexual risks alone have almost no impact on the rate at which people get HIV. Ten trials of HIV prevention in Africa tested what happens when some adults (in the intervention arm of the trial) get special education and warnings to avoid sexual risks while other adults (in the control arm) do not get such education or warnings. What was the result? Educating and warning people about sexual risks had virtually no impact on the rate at which they acquired HIV infections (see http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999).
Changing the messagewarning about blood as well as sexnot only gives fisherfolk the information they need to avoid HIV and to protect their loved ones, it also reduces the blame and stigma that have been linked to HIV. If a husband or wife has HIV, the other spouse should not assume it came from sex outside marriage. But on a larger scale, recognizing blood-borne risks arms African fisherfolk to fight back against the demeaning and weakening stereotype that they are unusually and thoughtlessly promiscuous.
For more
data.unaids.org/Publications/IRC-pub06/jc975-livinginworldaids_en.pdf
Living in a World with HIV and AIDS, UNAIDS
papers.ssrn.com/sol3/papers.cfm?abstract_id=1940999
Randomized Controlled Trials for HIV/AIDS Prevention among Men and Women in Africa: Untraced Infections, Unasked Questions, and Unreported Data
