A sour business

The number of new HIV infections continue to rise, particularly in sub-Saharan Africa, but also in south-east Asia and elsewhere in developing countries. Condom promotion has not stemmed the tide, nor abstinence, nor faithfulness. There is no HIV vaccine in the immediate future. So there is understandably a great deal of interest in novel approaches to HIV prevention.

One interesting line of research leads to ... lemons. For some time, lemon juice -- applied to the female genitalia -- has been used as a relatively cheap, natural contraceptive. Sex workers in Nigeria and elsewhere in Africa use lemon juice as a way of killing potential HIV virus in the semen of their male clients, particularly those who pay more for the privilege of not using a condom. The safety and efficacy of lemon juice for this particular purpose is unknown: for the moment it seems that the concentration of lemon juice that might be effective may be unsafe for women. Findings presented at this month's Microbicides 2006 Conference in Cape Town may provide more answers. Those trading in lemons should take note.

Intimate surgery in Guatemala

This week’s Lancet reports on a troubling development in Guatemala. Approximately 2% of Guatemalan women undergo reconstructive surgery of the hymen to be able to claim themselves as virgins before marriage. This raises ethical issues at a number of different levels. Given that the surgery involves risks without compensating medical benefits, ‘intimate surgery’ conflicts with the Hippocratic injunction of ‘doing no harm.’ What doctor, in good conscience, ought to participate in this cultural practice? And in the Guatemalan context, the surgical risks are elevated: most of the surgeons performing the interventions are not fully qualified, many clinics operate under the regulatory radar, and the women are typically not informed of the potential side-effects of the surgery, including infections, hemorrhaging, fistulas and extreme pain during sexual intercourse. And this is among the women ‘lucky enough’ to afford the $1000 procedure; one can only imagine the social repercussions for those that cannot. (As usual, there is no corresponding community pressure concerning male virginity.)

As Hannah Roberts, the author of the article points out, intimate surgery and the cult of virginity is only a symptom of a larger biopolitical struggle in Guatemala for women’s reproductive rights. A new law backed by a parliamentary majority on family planning and reproductive health could improve the dismal levels of maternal and infant mortality, and women’s knowledge of and access to contraceptive choice. But the new law is opposed by the Guatemalan president, Oscar Berger, and by his influential supporters within the Catholic Church. The Church is unhappy about the prospect of programs give women the power to control their own pregnancies -- only roughly 40% of women had ever used any conceptive technique at all. Promoting contraception, they claim, is like promoting bullets: it creates a ‘culture of death.’

HIV? Nothing a little soap and water can't handle

Last week, I neglected to mention a detail of the Zuma rape trial in South Africa that is getting a lot of play in the African media.

During questioning in the trial, ex-Deputy President Jacob Zuma not only admitted having had sex with an HIV-positive woman (other than his many wives) without a condom, but that he felt that his post-coital shower would 'minimize his risk of contracting the disease.'

This false statement from a high ranking government official has further dismayed the AIDS community in southern Africa, already waging an uphill battle to send clear messages to people on how to protect themselves and others from getting and transmitting HIV. The National AIDS Hotline of South Africa is already being flooded with callers asking whether showers can wash that pesky virus away, and that whether it is ok not use a condom if that is the case.

Update on free health care in Zambia

Proving once again that no good deed goes unpunished, rural Zambian hospitals have already been hit by waves of patients looking for the free treatment promised last week by the national government. Perhaps the announcement should have been made after some of the 4 billion dollars received from debt relief was first invested in health infrastructure in rural areas. After all, it is all fine and well to promise free health care in a country where there is only one doctor per 14,000 people. But for the moment, it seems the Zambian rural health care system is not yet overwhelmed, if only because the rural population has not yet caught wind of the news that free health care is available. So the Zambian health system now finds itself in a race against time, having to scale up stocks of medicines, hire more health care staff and invest in new medical equipment. Still, it is a better situation than before, where the poorest in Zambia would not even bother trying to access the most basic health services.

The Zuma trial: new insights into HIV

The American media has understandably been closely following the court proceedings of Zacarias Moussaoui, the only person indicted in the September 11th attacks. Southern Africa, however, has been riveted by another legal case lately: the trial of Jacob Zuma, former South African Deputy President. The 62 year old politician, once regarded as a future Presidential candidate for the African National Congress, is accused of raping a 31 year old AIDS activist.

As with anything to do with AIDS and politics in South Africa, there is no shortage of weirdness. Before the trial started, Zuma’s followers already deemed the rape accusation a political conspiracy, a vile attempt to discredit a leader described as a ‘man of the people’ and ‘Mr. Nice Guy.’ Supporters of Zuma have jeered and heckled his female accuser every time she has arrived at Johannesburg High Court. During the time leading up to the trial, the otherwise happily married Mr. Zuma has vigorously denied the rape charge, taking the moral high road by claiming that he and the woman in question merely had consensual sex. Or rather: knowingly had consensual sex with an HIV positive woman. Or rather: knowingly had consensual sex with an HIV positive woman without a condom.

Yesterday saw Zuma take the stand to be questioned by the state prosecutor. The prosecutor asked a simple question independent of the rape charge. Why, the prosecutor asked, would the previous head of the South African AIDS Council and the Moral Regeneration Movement have unprotected sex with a woman he knew to have HIV? His answer was noteworthy: the risk of acquiring HIV through unprotected sex with a woman, he stated, is small for a healthy man. “I had the knowledge that …chances were very slim that you could get the disease.” As for his own HIV status, Zuma stated that he knew he was HIV negative, and besides, he ‘had a way of having sex that protected him from infection.’ Not wanting to give the wrong impression at this point, Mr. Zuma told the court that he regularly uses condoms, a piece of information that may be reassuring to both the nation and his four wives.

Mr. Zuma’s statement offers a peek into the understanding of HIV/AIDS among the highest political circles in the country with the most HIV positive persons in the world. As is well-known, South Africa has a President with a soft spot for rogue scientists who deny that HIV causes AIDS, and a Health Minister who is convinced that garlic and local herbs are just as good at controlling clinical AIDS as antiretroviral drugs. Now South Africa has a political leader with a bold new vision of HIV prevention: just be a healthy guy, and do it in a special way, and you’ll be fine. The trial is ongoing, so stay tuned for lurid revelations and creative approaches to HIV/AIDS.

No, it’s not April Fool’s: free health care in Zambia

The G8 summit in Gleneagles last July released $4 billion dollars for Zambia via debt relief and increased aid, and the Zambians plan to do something rather exceptional with the money: make health care free in rural areas of the country.

The background to the story runs roughly like this. In the 1980’s, many African countries were facing an economic crisis in the primary health care sector, during a period in which the World Bank and IMF sought to alleviate the economic plight of low-income countries through structural adjustment policies and conditional loan agreements – where the conditions were privatization, deregulation and lower expenditure in the ‘social’ sectors such as health care and education. It was in this general atmosphere of social improvement via liberal economic reform that the WHO and UNICEF drew up a proposal to raise the quality and accessibility of primary health care in Africa – focusing particularly infant and maternal health – and one part of the proposal involved the introduction of users fees for health services. The proposal was called the Bamako Initiative, and it was adopted in 1988 by the health ministers of the WHO Africa Region. The basic idea was that if people paid for health services, the user fees would act as revenue that could then be used to improve services and health care access for all; at the same time, the health sector could reduce its expenditures to comply with international loan agreements. It would be economically efficient and socially equitable. Everyone would be happy.

Or perhaps not: someone in the Washington or Geneva think-tanks forgot that low-income countries are low-income. Many Africans could not pay the user’s fees or could only pay if they sacrificed food, transport or school fees. The payment of user’s fees, for some, led to personal bankruptcy. Predictably, the use of primary health services plummeted in nearly every African country in which the policy was implemented. Basic indicators like vaccination coverage show that user fees discourages the poor from seeking health services, and now even WHO and UNICEF have admitted this, albeit more than 15 years after the fact.

So the Zambian government is now using debt relief and aid to eliminate user’s fees for the most vulnerable in their society. But this admirable gesture raises ethical questions too. Is this a sustainable system? What happens when the money runs dry? What about the urban poor in Zambia? What level of health care is being offered for free, anyway?