A perfect storm of poor

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Diane Abbott is on the warpath. The shadow health minister responded to the findings of the latest Health Survey for England (HSE), which show that 27% of women aged 16-24 reported having had sex before they reached the age of consent (16 years old). Says Abbott, in an interview with the Guardian:

“The underlying cause must be the ‘pornification’ of the culture and the increasing sexualisation of pre-adolescent girls. Too many young girls are absorbing from the popular culture around them that they only have value as sex objects. Inevitably, they act this notion out.

“The government needs to respond to spiralling underage sex, not with pointless schemes to teach abstinence, but with better PSHE [personal, social, health and economic] teaching in schools for both girls and boys.”

In so doing she rehearses an increasingly popular and nuance-free moral panic about sexualisation and underage sex, which the findings of the research really don’t support.  Abbott also perpetuates a damaging perception that in matters of sex, girls and women are always the victims, with boys and men at best invisible and at worst the perpetrators of abuse.  

The problems around how the media and politicians deal with underage sex are explored in this blog post by Petra Boynton.  Elsewhere, Petra also provides a critical take on contemporary discussions of sexualisation (also here) and pornification.

The more you look into this story, however, the more the plot thickens.  Abbott was interviewed by Sarah Boseley, the Guardian’s health correspondent.  Her article begins:

More than a quarter of young women today say that they first had sex when they were below the age of 16, a greater proportion than in any previous generation asked about underage sex in an official annual health survey.

Around 27% of women aged between 16 and 24 said they had sex before they reached 16, according to the Health Survey for England. Fewer men in the same age bracket – 22% – said they were under 16 when they first had sex.

A greater proportion than in any previous generation asked about underage sex in an official annual health survey“.  I’m pretty sure there is only one way to interpret this: the implication is that the 27% in the 2010 HSE is higher than in any previous survey.  Now that is odd, since the seminal survey on sexual behaviour was the NATSAL (National Survey of Sexual Attitudes and Lifestyles) which, in 2000, showed that something in the range of 27.2% of girls aged 16-24 reported having initiated sex before the age of 16*.  For boys, the result was around 27.8%, pretty much the same as it was for girls.

(*I say something in the range of because the table reports the results for 16-19 year olds and 20-24 year olds separately, so I’ve had to go back and work out the percentage for both groups).

To be sure, the NATSAL was sampled in a different way and it covered the whole of Britain (as opposed to just England), but nonetheless how can the 2010 HSE results for girls be reported as being higher than any other national survey?  Especially given that each of these estimates comes with a degree of uncertainty – the NATSAL estimate for girls, for instance, has a 95% confidence interval of (again, roughly) 24.9%-27.2%.  Given that the sample size for the HSE was smaller, the uncertainty of the HSE estimate is likely to be greater.

It’s not ideal, then, that the news article doesn’t explore the context of the figures.  Perhaps, though, the press release for the HSE was misleading? Here’s how it starts:

Some 27 per cent of women aged between 16 and 24 reported having sex when they were below 16 – a greater proportion than women in any previous generation covered by the survey.

Now that’s different from the Guardian article, in an interesting way. What does “any previous generation covered by the survey” mean? It could mean any generation covered in a previous HSE survey, but from what I can tell previous HSEs have not systematically asked the same question.  I can’t find them in the trend tables that compare HSE results year on year.  In any case if they had, the press office – and the Guardian article – ought to have reported these previous figures.  Note that just like the Guardian and Diane Abbott, the press release focuses on women and girls.  

The press release can be interpreted in another way: what it means is that the proportion of women aged 16-24 reporting having started sex before the age of 16 in the 2010 HSE is greater than the proportion of women in any other age group in the 2010 HSE.  In other words the comparison that is being made is between cohorts of different age groups within the same study.  This is fair enough, providing the risk of response and recall biases for the older cohorts is acknowledged.  I thought it would be interesting to check the proportion among women in the 2010 HSE report who would have been 16-24 at the time of the NATSAL (2000): the 25-34 year olds.  In this group, 18% of the women reported having had sex before the age of 16, and 25% of the men.  Even accounting for confidence intervals, the discrepancy between the 18% of women reported by HSE respondents casting their minds back to what they got up to in the 1990s, and the 27% of women reported by what ought to have been respondents of a similar profile back in 2000, is large.  It’s also strange that the NATSAL found similar proportions for boys and girls, but the HSE results, for 25-34 year olds, finds a much higher proportion of boys reporting having had sex before the age of 16.  The studies can’t both be right.  Moreover, one might ask: if girls are starting to have sex earlier but boys are increasingly waiting, does that mean girls are increasingly having sex with older men?  That seems to be the implication but where are the data to back that up?  The press release, the Guardian article, and by association Diane Abbott’s comments are all misleading.

What of the HSE survey itself?  The report (sexual health section) and the methods can be viewed and deserve to be examined closely.  One or two things immediately leap out, however: the report states that people were asked at what age they had first “had sex”.  If President Clinton taught us anything it is that not everyone means the same thing by “had sex”.  The question that participants were actually asked was more nuanced, fortunately: “How old were you when you first had sexual intercourse?”, but even then I’m not sure how clear it is.  What is harder to understand is that when this question was put to women, they were asked specifically about intercourse with a man; and men were asked about intercourse with women.  So the figures for first sexual intercourse below the age of 16 only relate to sex with someone of the opposite sex.  This leaves no room for different identities or even ambiguities about gender, and while relationships with people of the same sex is explored later in the survey, it seems odd that it is left out here. 

So, we end up with a story that is very hard to interpret: uncertainty about the survey approach, the press release, the media coverage and the political opportunism that it has generates. A perfect storm of poor.

There are many good sources of information on young people and sexual health in the UK.  If you wish to investigate further, look at the links provided on the blogs of sexedukation and Brook, and the resources that the amazing Bish Training produces, including his resource on porn and young people.

H/T Petra Boynton for the subject matter of this post, and also for the title.

Why can’t they just concede?

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Earlier this year I went to a meeting on sex work in the global AIDS epidemic. The purpose was to look at the current information on HIV in populations and among sex workers and assess the relationship, and to look at how effective different types of intervention and programme in reducing the risk of HIV among sex workers. Most of the best quality evidence comes from a fairly narrow set of interventions, that have been shown (or not, as the case may be) to have a direct impact on HIV transmission or acquisition. Things like vaginal microbicides, presumptive STI testing and treatment, HIV testing, peer education, and condom distribution and counselling.  Things that, to all intents and purposes, “look” like HIV interventions.

Of course, for an intervention to be discussed as part of the evidence base, there has to be decent evidence – whether it is evidence of positive effects or of negative ones.  So some things didn’t come up in the discussion, despite being widely implemented in the context of HIV programmes, because there is no evidence of their impact. Things like microfinance and income generating projects aimed at reducing numbers of sex workers, which I began to review a few years ago and never properly finished… but take my word for it, there isn’t much in the way of quality research or good theory for this approach. Although the approach does not feature prominently in the current UNAIDS guidance on sex work and HIV, it remains a central pillar of the US government’s strategy on HIV and sex work.

Untested approaches are at best a waste of money and at worst actually harmful.  It is certainly the case that economic programmes such as these only reach a fraction of the numbers reached by “classic” HIV programmes, for the same amount of money.

But what is more alarming is the things that don’t come up in the discussion of the programme evidence base, despite there being a pretty strong association between them and HIV.  On Saturday December 17th, it is the International Day to End Violence Against Sex Workers, and I am talking about violence.  Time and again, sex workers tell us that the criminalised nature of sex work, and in particular the role played by law enforcement agents and health care workers in committing violence and in failing to address it properly, mean that violence is one of the biggest risks they face, and is a far more immediate threat than HIV.  The epidemiological association between violence and HIV has also been documented in a number of observational studies: in Bangladesh, in Cambodia, in India and in Kenya, for instance.  Other reviews can be found here (disclosure: I wrote that one), and here.

But as with income generation strategies, because hardly any well designed intervention studies have looked at how best to tackle violence, fighting violence against sex workers as a means of tackling HIV doesn’t come up in many systematic reviews on HIV prevention with sex workers.  To be sure, many HIV programmes acknowledge that it is an issue but they generally don’t do much to tackle it – and of course there is hardly any commitment to tackling the laws and attitudes that make it so easy for the perpetrators of violence to get away with it.  When tackling violence does appear in programme plans, it is often something along the lines of “training police officers to refrain from violence”.  Or, as Cheryl Overs would put it, sending them to workshops with a nice buffet lunch and a perdiem for the purpose of telling them something they already know, rather than handing them a ticket to a jail cell. “Sure, there is a role for the carrot, but justice demands some stick too sometimes”.

Funding proposals that do attempt to tackle violence are required to demonstrate and justify how their efforts will directly impact HIV transmission.  When it comes to sex workers, violence is not seen as something worth tackling in its own right.  

Sure enough, during the meeting I talked about at the top, someone pointed out that tackling violence against sex workers was unlikely to appear in any evidence-based guidelines on how to design HIV programmes for sex workers because the evidence base is so weak.  But the thing is, when the discussion is about young women, or men who have sex with men, or children, building efforts that tackle violence into HIV programmes irrespective of the evidence for a link between violence and HIV is a no-brainer; and rightly so.

Which explains the angrily scrawled note which I passed to the person sat next to me and which you saw at the start of this post.

Not all about the money, or the technology

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Another World AIDS Day comes round, and while the main players can’t seem to decide what the theme is for 2011 (“be an activist” according to UNAIDS; “getting to zero” according to the World AIDS Campaign; “leading with science, uniting for action” according to the US government), it is clear that there are two issues that are dominating all of the current discussions about the fight against the pandemic: the major advances in the technologies used to fight HIV transmission, and the abrupt and significant decrease in the funding being made available to pay for them.  

Secretaty Clinton talked, a few weeks ago, about the US government’s commitment to a “combination” approach to HIV prevention based on proven technologies to prevent mother-to-child transmission, on male circumcision, and on making the most of the now-proven fact that putting people on treatment significantly reduces the chances they will transmit the virus onwards.  In her speech she stated that creating an AIDS-free generation was now official US policy.

More recently still the Global Fund to fight AIDS, TB and Malaria, set up only ten years ago to channel funding to efforts to fight these three diseases, announced that because most of its donors have failed to commit enough funding, and indeed because many haven’t even paid what they promised, it is suspending funding for new grants and proposing a new model which will take account of the reduction in funds available.

Much of the commentary on World AIDS Day 2011 is likely to focus on the disconnect between the optimism of knowing “what works” and the failure of donor governments to keep their promises.  I think this article from the Instute of Development Studies sums up the ambivalence very well.  But it also talks about some of the other challenges: the challenges of implementation.

I’ve been trying to sum up how I think my year as a freelancer working to support AIDS programmes has gone.  Earlier today I sent a few tweets:

World AIDS Day, I met a MSM* peer educator in Madagascar in March; he died of AIDS 2 weeks after I met him because docs didn’t want to know.

(“men who have sex with men” – actually, he identified as gay but its hard to explain this in 140 characters)

World AIDS Day, also thinking about many people with HIV in Benin who said they often default on treatment bcs drugs don’t arrive on time.

World AIDS Day, also thinking abt sex workers in Namibia, struggling to convince donors that they need more than just condoms and HIV tests.

World AIDS Day, also thinking of the month I wasted helping an NGO write proposal it was incapable of implementing. Luckily it wasn’t funded.

I wasn’t going to say anything else, but then it occurred to me that, with the exception of the last one, none of these issues has much to do with either the lack of money or the existence of new technologies. These problems were happening irrespective of whether men have foreskins or not, and irrespective of the preventive effect of ARV treatment.  Madagascar has plenty of money for ARVs and only has to keep a few hundred people on treatment, and yet there are failures when it comes to stigmatised populations.  Benin is a small country, with reasonable grants for HIV treatment, but somehow many people with HIV still face problems getting their drugs regularly.  The situation faced by sex workers in Namibia is faced by sex workers around the world. Despite explaining how badly they get treated by health care workers, or how often they get beaten up and extorted by cops, the default mode for HIV programmes seems to be to give them leaflets and condoms.

As for the last tweet… well, that is about the money, and about what happens when big institutions end up searching high and low for ways of justifying their existence.

As we move into the fourth decade of the fight against HIV and AIDS, promoting the amazing new tools at our disposal and demanding the funds to pay for them, I hope we won’t lose sight of the fact that there’s an awful lot of other stuff the AIDS response needs to start fixing and doing better if the technology and the money is going to make a difference.