Global Health

Sex Work and HIV - like peanut butter and jelly?

Published January 09, 2009 @ 08:26PM PT

Amanda wrote about HIV and sex trafficking today in the end human trafficking blog, so I thought I'd toss out my two cents.

People really like to pin HIV transmission on sex work. I think it's comforting to think of AIDS as something that belongs to risk groups like sex workers and drug users, and not something that can happen to regular people.

The truth, as always, is more complicated. While AIDS has a devastating impact on commercial sex workers, prostitution is not synonymous with the spread of HIV. Sex workers are at a very high risk for getting AIDS, pretty much globally. But they are not necessarily a major driver of AIDS epidemics. In some places they are, especially Southeast Asia and Central Asia. In other places, like Western Europe, not so much. There is an awful lot of conflicting writing out there about HIV and commercial sex workers. Some of it is good, and some of it is based on very shoddy research.

The best paper I have seen on the topic argues that there are two important numbers that determine whether sex work is an important drive of an AIDS epidemic. The first is the percentage of the total country population made up by sex workers. The second number is the percentage of sex workers infected with HIV. Together, they represent the role of commercial sex workers in the epidemic.

This means that global organizations like PEPFAR and the Global Fund don't get far trying to set general policies on reducing HIV in commercial sex workers. Effective responses will be planned country by country, and adapted to local circumstances within a nation.

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Sometimes it’s good to be wrong

by Alanna Shaikh

Published January 08, 2009 @ 09:21PM PT

PEPFAR logo

Astute commenter Evelyn Garland pointed out that I got it wrong about the President's Emergency Fund for AIDS Relief (PEPFAR). There is no longer a required 7% of funding for abstinence-only education.

The Abstain, Be faithful, use a Condom (ABC) approach remains, but in a less directive way. Instead of a mandatory 7% level of funding, implementers have to write an explanatory report if they spend less than 50% of their prevention budget on abstinence and fidelity. It's still a lame attempt to force a useless activity into places where it won't work, but now it has leeway. That's a huge improvement. (In my own defense, I was keeping track of the PEPFAR reauthorization process, but I somehow missed the shift from a hard budget earmark to this gentler language.)

The change in prevention requirements is not the only interesting thing about the new PEPFAR.It now allows funding for tuberculosis vaccine development, and formally authorizes assistance to develop microbicides against HIV. It also mentions medications for opportunistic infections like thrush and pneumonia. Since opportunistic infections often end up killing people with HIV, being able to use PEPFAR money to fight them is a big deal.

So, in conclusion - I was wrong about the PEPFAR legislation, and I am very glad to know that.

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Five Global Health Problems that are much worse than they sound

by Alanna Shaikh

Published January 08, 2009 @ 09:04PM PT

Vintage ad for iodized salt

(image credit: jbcurio)

When I ask people about global health, they usually mention HIV or bird flu. Sometimes tuberculosis. But there are some really destructive problems that people hardly think about at all. Here are five:

1. Diarrhea

In the developed world, diarrhea is an inconvenience. It's embarrassing and you probably have to go buy some Imodium. To children in the developing world, diarrhea is often a death sentence. Diarrhea and dehydration resulting from it kills more children under five than malaria, AIDS and tuberculosis combined. The worst part is that there is good treatment for diarrhea, if we can make it available - oral rehydration salts, and IV hydration if necessary.

2. Respiratory infections

In a child who is already malnourished or sick, respiratory infections go from mild colds to pneumonia very quickly. Influenza is always dangerous for children. 20% of the children who die in the developing world die of respiratory infections; mostly from pneumonia.

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Abstinence only education needs to be stopped

by Alanna Shaikh

Published January 07, 2009 @ 07:41PM PT

(photo credit: hdptcar)

So, we finally have conclusive proof that abstinence-only education doesn't work in the US. In fact, it's worse than just not working. Abstinence-only education is worse for teenagers than doing nothing at all. Young people who go through an abstinence-only education program are just as likely to have sex and they are more likely to do so without protection. And let me tell you, most public health types have known this for years. Abstinence-only education is a useless, damaging load of hooey.

For those unfamiliar with sex ed - abstinence-only education is exactly what it sounds like. It is an educational principle that young people should be taught to abstain from sex and why abstinence is important. It does not provide information about contraception or about sex and sexuality. The curricular focus is solely on why sex must be postponed.

Now, I am not one to ignore the role of culture in educational interventions. Every situation is unique. It seems to me though that if we can't get fundamentalist Christian teenagers in Southern Mississippi to abstain from sex, it's not a huge leap to argue that we also can't get people from historically polygamous cultures to abstain from sex. In other words -

It's time to abandon Abstain, Be faithful, use a Condom. This is the mantra of PEPFAR, the US-funded President's Emergency Fund for AIDS Relief. All PEPFAR-funded HIV education efforts must follow that formula, and include all three points. 33% of all HIV prevention funds - 20% of the PEPFAR budget - must be - according to the organization's congressional mandate- spent on abstinence only education.

Yes, that's right. We are requiring that 7% of our HIV budget be spent on programs that have been scientifically proven not to work. Oops! Sure, nine out of ten Americans have sex before marriage. But we expect the developing world to do better at that kind of thing, right?

PEPFAR is a good idea. More money for AIDS prevention and treatment is a good thing. Wasting limited PEPFAR funds is not. It's time to free the PEPFAR budget from loony congressional restrictions on what can be funded. PEPFAR should be funding the efforts that will do the most good for the least money. End of discussion.

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Preventing Brain Drain

by Alanna Shaikh

Published January 06, 2009 @ 09:00PM PT

(image credit: Spierzchala)

In the comments on my last post, Rani P. asked about health care provider training. "I wonder if you had any thoughts about the challenge of retention. I remember reading that due to the shortage of health care workers globally, workers were often hired away after they had completed more advanced training."

She's got an excellent point. The heart of building the capacity of a health care system is its providers. Doctors, nurses, radiologists, medical techs...these people are the core of your system. Building its capacity mostly means training them. But one you've trained them, they never stay where they are. It's all well and good to build up a rural clinic by training its doctors, but what do you do when they use that training to get better paying jobs in the capital? Or you spend a year training a nurse-midwife in perinatal care, after which she gets married, gets pregnant and promptly leaves the workforce. And then, of course, there is brain drain, in which qualified medical professionals leave their home countries in the developing world for high-paying jobs in wealthy countries. It is a much-reported phenomenon.

Any time you trade health care providers, you've got to take turnover into account. Your impact will erode very, very fast if you don't. Your training gives people a valuable new skill. You'd like them to use it for the public good; very often they want to use it for their own good. (and who can blame them?)

In my experience, there are four ways you can deal with provider turnover after training:

Incentives - you can find ways to keep the health care worker in their job after training. The most obvious way to do it is to increase salaries for trained workers. This makes their income more competitive with whatever is luring them away. The downside is that it (obviously) costs money in a long-term way, and often you can't afford to pay enough to be really competitive with the private sector or the glitz of the capital.

There are other incentives besides money. If you can build a culture of respect for health care providers, they may feel loyalty which keeps them from leaving despite salary disparities. Additional responsibility and a more senior title may also encourage people to stay. Even little things like employer-provided uniforms, t-shirts, or knapsacks can have a surprising effect on staff loyalty.

Coercion - you can force people to stay. This is more common than you'd think. Ministries of health often require people to sign multi-year contracts before they are eligible for training. NGOs use voluntary commitment documents, where people promise to stay in their jobs, or at one location, for a specified amount of time after education. These are non-binding, but people tend to take them seriously.

Extremely selective process when choosing trainees and training subjects- this may mean choosing your individuals with great care, or training only certain kinds of health workers. If you train village health nurses, for example, they are unlikely to leave for other jobs. Even a well-trained village health nurse is unlikely to have skills for anything but village health programs. There are a number of basic primary health care jobs that fit that criteria - vaccination personnel, clinic helpers, and so on. Training these people will improve health care almost as much as training physicians, with less risk of brain drain.

And even higher level personnel, such as doctors, are going to find some kinds of training more marketable than others. Train a physician in the diagnosis and treatment of sexually transmitted infections, or tuberculosis, and she'll be off to a high-paying private sector job in the blink of an eye. Train a doctor in the integrated management of childhood illness, though, and it's not going to net them anywhere near as much money.

You can also choose individual trainees to try to limit turnover. If there is an application process for the training, you can screen out people who seem likely to leave. This can be very effective, but it can also turn into discrimination. One program I read about didn't take any unmarried women for training, because they assumed women would leave the profession once they were married. That's not exactly good for gender equity.

Let it happen, and work around it. This may mean allowing providers to work nights for private pay at the same public clinic they staff during the day. Or it could involve letting them charge an extra fee for each patient that goes directly to the provider. This is a very tricky option; it's highly effective but it can easily lead to patient exploitation.

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Female Condoms, a Mea Culpa

by Alanna Shaikh

Published January 06, 2009 @ 09:22AM PT

(photo credit: wikipedia France)

It’s been accepted wisdom in global health for quite a while that nobody likes the female condom. It’s bulky. It makes a squeaky noise while in use, and you can still see it after it has been inserted. It’s expensive. It’s difficult to put in. It is, all in all, profoundly unsexy. (admit it - you even find that picture up there vaguely icky)

And despite all that, it looks like accepted wisdom has been wrong. Here’s the thing we forgot – for a huge slice of the female population, sex has nothing to do with “sexy.” Sex is paid work, coerced work, a form of slavery, or an unpleasant duty for one’s husband. In those circumstances, a little insertion effort in return for protection from HIV or Herpes is well worth it.

Which makes those of us who scoffed (And yes, I was one of them. I bought a female condom, found its looks and feel hideous, and never thought about it again except as a very bad idea.) look like insensitive jerks that can’t get past our own experience.

I was put in my place by a recent Oxfam paper that someone recommended to me on Twitter. Called “Failing Women, Withholding Protection,” it thoroughly debunks the idea that the female condom is hated by users. It says that the reasons for neglecting female condoms “mirror the common reasons for not using a male condom: responses formed by ignorance, culture, denial, ‘poverty’, and conservatism. Added to this are overarching errors of a lack of leadership, a huge funding bias against existing forms of primary HIV prevention, failure to scale up programming, and failure to invest in strategies to lower the cost of female condoms.” Ouch.

South Africa’s Mail & Guardian online was way ahead of me on this discovery. It was already making this point in 2005, when it said that “Sniggering at the (female condom), it seemed, was a privilege only for those lucky enough to have a choice about whether to sleep with a man who wouldn’t wear protection.”

It’s pretty clear at this point that neglecting the female condom is a public health embarrassment. A commenter on the From Poverty to Power blog pointed out that it really doesn’t matter if most people hate the female condom. Most contraceptive methods have trouble with acceptance. The question is – even if it is hated – why has no one supported efforts to improve the design? It could make a major difference in female empowerment, and yet it hasn’t been pursued.

If you want to do something about this neglect, you can join Prevention Now, a global anti-AIDS campaign that promotes the female condom.

About the female condom
The female condom was developed by a Danish physician named Lasse Hessel, who is really pretty eccentric. He also invented two kinds of diet pills, and used MRI technology to determine how women could better experience sex.

It consists of two rings, connected by a polyurethane or latex sheath. One ring is inserted into the vagina, while the other remains outside. It serves as a barrier method against HIV and sexually transmitted infections. It is less effective than the male condom, but far more effective than using no protection. You can find more information about female condom effectiveness here, and instructions for use here.