Somebody else’s problem



A short letter in the correspondence section of this week’s Lancet describes the difficulties faced by a campaign to promote HIV testing among school children in South Africa. The campaign is part of a broader push to get people to know their HIV status in South Africa, a country where 5.6 million people are HIV positive.  The national campaign aims to get 15 million people tested by June 2011.

The letter describes the results of work in a rural district, during which 758 people aged under 21 received and HIV test over the course of 14 months, but none of the seven who tested HIV positive had been enrolled in care at the end of the period.  It appears that  efforts were made to ensure that those testing positive accessed care; however the authors suggest that even more needs to be done before testing, to ensure that people know and understand what it means and what to do in case of a positive result.  Just testing people is not good enough.

They’re not wrong there.

This may just be an anecdote, but it is an anecdote I hear often.  In the past few months someone I met during a programme evaluation died very shortly after: he knew he was HIV positive, but when he got sick he was turned away by several doctors, most probably because was homosexual.  I’ve just been reviewing national programme data from another country which suggests that only 90% of people who get tested ever find out their results, and where the numbers of people newly placed on treatment is a fraction of the number testing positive.  I’ve heard several accounts from antenatal clinics working on preventing mother-to-child transmission of HIV, losing track of HIV-positive pregnant women and not being able to give them the appropriate assistance as a result.  As for sex workers, there are so many reports of mandatory testing that it sometimes seems like HIV prevention programmes around the world are doing it just for fun.  This recently published article describes the atrocious rates of follow up for HIV positive sex workers in Senegal.

HIV testing has, for many years, been at the heart of the misjudged split between HIV prevention and HIV treatment efforts.  Long before treatment was widely available, there were testing campaigns, based on the premise that people who know their HIV status are better motivated to adopt preventive behaviours.  The key UNAIDS publication on testing, published in 1999 was called Knowledge is Power, and outlined the power of testing as a preventive intervention.  And perhaps because testing was therefore seen to have an inherent value, lots of organisations have got involved.  It has also been a major push from the major donors supporting HIV prevention.  As well as testing being introduced in existing health facilities, a lot of energy has also been expended on specialist testing approaches such as mobile testing campaigns and setting up stand alone testing clinics, like the one pictured above which, when it was brand spanking new, was in marked contrast to the run-down hospital down the road.

The problem with this is that there isn’t that much evidence that HIV testing does make such a major contribution to prevention after all.  There has been one randomised control trial of voluntary counselling and testing with HIV incidence as an outcome; and a systematic review of the impact of testing on sexual behaviour submitted to Cochrane in 1998 is still at protocol stage.  The previous review, covering the period up to 1999, suggested the preventive benefit of HIV testing was clear among HIV positive people but among HIV negative people.  Other analyses of the behavioural impact of testing suggest mixed evidence on the impact of testing on risky behaviours.  It’s not a disaster: it’s just not particularly clear-cut, and it’s hard to tell why it is a useful approach in some situations but not others.

None of this is to say there’s anything wrong with HIV testing, as part of a comprehensive response to HIV.  But unlike care and treatment, HIV testing is a clinical intervention that it is fairly easy for non-clinically specialised organisations to take on.  Many organisations specialising in HIV prevention also provide testing.  To be sure, people testing positive are referred to or advised to go for treatment, but once that referral has been made?  Well then, the question of whether they get treatment or not becomes Somebody Else’s Problem.  “But we do prevention, not treatment”, was the answer I got last time I asked an organisation if they followed up on the HIV-positive cases they referred out.  Treatment outcomes for positive people just aren’t among the things that organisations with “prevention” funding get judged against.

If we want to make progress on HIV prevention – or any other critical public health issue for that matter – the Somebody Else’s Problem problem is going to have to be dealt with.  These days in HIV prevention programming we talk about “combination prevention” which thankfully includes HIV treatment but also other issues such as reproductive and sexual health.  Most organisations delivering services can’t, and won’t ever be able to deliver every single component of combination prevention, so to be effective they have to collaborate; to plan and deliver services together.  Calling a testing or peer education programme “prevention” is no longer accurate because we know that just doing those things is never going to be enough.  You can’t just say “somebody else will get the condoms, do the treatment, make sure people aren’t persecuted for their sexual behaviour” – it’s your problem as much as it is anyone else’s.

Recent research showing the huge impact of antiretroviral treatment on reducing onward transmission of HIV helps to further undermine the false division between prevention and treatment.  Hopefully it will also sharpen minds about the need for a greater sense of responsibility toward the people that programmes are there to serve.

* The image is of the stand alone testing facility in Toamasina Madagascar, established in 2003.


Rude pictures



My brother once pointed out to me that I was doing for a living what he and pretty much every schoolboy does for fun in the back of their schoolbooks: drawing pictures of genitals.

These days I don’t get many opportunities to get paid for rude pictures, but I was reminded of it when I spotted the pavement art pictured above.  It’s probably safe to assume that the adult footprint and the dog’s paw-print were accidental but whoever drew the penis probably couldn’t resist the temptation that the wet cement provided to repeat what might be one of the oldest visual gags in the world.

Notwithstanding by brother’s comment, drawing is actually very useful in sex education work, for a variety of reasons.  The early proponents of participatory methods in aid work used drawing a lot as a way of levelling the playing field when working with people with low-literacy or with groups of socially unequal people: it shifted the emphasis away from the written word and technology, since you can draw with anything, and you can represent complex things very easily with a few lines, some pebbles and some leaves.  One of the participation mantras is to “hand over the stick”, which can literally mean handing a stick to community members to draw maps, or human bodies, or timelines, on the ground, and to take over the process rather than just listening to an expert lecture them. 

Lots of types of images are used in sexual health work, including photographs of severe sexually transmitted infections that aim to shock people into being more aware of the risks of unprotected sex.  But whether scare tactics work or not, in my experience this sort of image is particularly informative.  The point at which you want to get yourself checked for STIs is when you have barely perceptible visible symptoms or even none at all, whereas the images you find in a lot of sexual health leaflets show STIs at very advanced stages: conditions that most doctors are unlikely to have seen.  On the other hand, using even very basic anatomical drawings can help to communicate ideas that a photograph can’t show, for instance by asking people to describe what some internal symptoms like pain urinating or lower abdominal pain feel like and where on their bodies they can feel them.  This leads to a broader point, which is that sexual health isn’t just about diseases and symptoms – it’s just as much about pleasure and knowing your body.  Exercises like body mapping as a way of exploring all sorts of issues such as safe sex, STIs, and sexual pleasure can be done using drawing, and can be a good way of generating discussions in group work.

The other good thing about drawings is that they can help show things in an abstract way that most people can relate to.  Because a line drawing or diagram is obviously not real I don’t think people are as tempted to compare themselves as they might with photos, and to wonder if they are “normal” or not (though it is worth remembering that some people can look very different, either because they were born that way, or because of practices like female genital mutilation).  This is why I really like the mix of images on materials developed by Bish Training, such as this one on sexual anatomy: on the one hand the drawn images shows the different parts and what they are but is clearly just a diagram; on the other hand there is a set of photographs showing lots of different photos of the same thing, another way of showing readers how diverse human bodies are.  And the “don’t compare” message is even clearer in this resource on porn.


Drawing isn’t necessarily better than any other approach – it largely depends how it is being used, and whether the overall approach of the trainer or educator is right.  But as I continue to come across limited sex education, based largely on the distribution of scary photos, I find myself returning to flexibility and potential of the time-honoured practice of drawing rude pictures.

Thanks to @sexedukation for a handy chat about this blog post.