HIV loves those who are most left out by David Harrison

HIV loves those who are most left out by David Harrison

Any of us could get HIV, and some of us do. Whether rich or poor, unprotected sex can lead to HIV infection and we all have a personal responsibility to avoid getting infected and to protect other people. But HIV loves some of us more than others.
 
If you lived in the United States, your odds of HIV would be 35 times lower than in South Africa. If you lived in Angola or West Africa, your odds of infection would be 5 times lower than here. If you are a white South African, you’re 10 times less likely to have HIV. If you’ve dropped out of school or live in a squatter settlement, you’re twice as likely to have HIV. If you’re orphaned, you’re 1.5 times more likely to have HIV.
 
In South Africa, HIV is increasingly concentrated among the most marginalised – those who drop out of school, can’t get work, lose their parents, and live in informal settlements. This applies as much to men as it does to women. Black people are at far higher risk – and we know that’s not the result of ‘ethnic culture’; there are ethnic groups that have far lower rates of infection. Clearly, there are psychological aspects of social and economic marginalisation that are not captured by survey data. Based on the best evidence available, we can say that these factors include a sense of social isolation, a lack of choice in life, and the lack of a sense of imminent possibility in life. It’s a ‘culture’ of risk-taking shaped by life circumstance.
 
In other words, we don’t all fall into the same risk distribution curve – those of us who have jobs, live in nice houses, feel included in society and have a strong sense of future are in a lower risk distribution curve than people who are marginalised. So even if marginalised people do respond and move to a lower risk-taking position, they will on aggregate still be at higher risk. 
 
If the roots of persistent HIV infection in South Africa lie in the shape of our society, what can we do about it? There’s a tendency to want to punish the individual, and particularly men. But we know that an increasing proportion of new infections (maybe 40% now) are occurring among monogamous couples (where one partner came into the relationship already infected).  Many of these couples want children – and sperm-washing (which gets rid of the virus) is only for the rich. So we could end up criminalising the desire to have children. We know that most women are economically reliant on men. What would happen to them if they reported their partners? Often, they would be beaten up and kicked out of the house with their children. 
 
Neither is jailing men the answer. We know that 17% of 16–24-year-old men in prison are HIV positive. That proportion rises to 45% among 25–34-year-old men – twice as high as in the general population. A quarter of the prison population is released every year, and I suspect this is a major source of new infection in communities. So we’ll just make that cycle worse.
 
The rate of new infection in South Africa has come down sharply in the past six years, from 2.4% to 1.5% per year. Among 15–24-year-olds, the decline is even more dramatic and, as best we understand it, is associated with an increase in the use of condoms. We need to build on the good news. We should be telling men and women to protect themselves and their partners.  Even more vitally, we should be giving them real reasons to do so – reasons that don’t punish the poor, but give them a reason for living.

David Harrison