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Wednesday, 28 May 2008

Fighting HIV....the Angolan proposal

Angola is proposing reforms to the Penal Code which would make HIV-positive people who intentionally infect others with the virus to be punished. The law calls for a sentence of between three and tens years in prison for those who knowingly pass on infectious diseases, including HIV. Proponents argue that the law will act as a strong deterrent against willful infection. NGOs disagree saying that criminalisation would increase the disincentive for people to admit their status.


  1. That's quite a bad and unefficient proposal, not surprising though..

  2. I have serious questions about the specificity of HIV tests in Africa. Especially the way tests are used in surveys (single test, no independent confirmation).

    Remember that the AIDS industry is a multi-billion dollar industry.

  3. Random, why are you not suprised? lol!

    MrK, are you saying the tests are largely inaccurate? is HIV overstimated in Africa?

  4. because it's Angola.

    It's not like they have a record of smart policies or even minimal care for their people.

  5. I see you don't subscribe to a progress a forward looking Angola?

    Their past record of course is marred by external forces and internal strife...

    But the government appears to be very forward looking...we can't argue with the highest growth rate in Africa right?

  6. But the government appears to be very forward looking...we can't argue with the highest growth rate in Africa right?

    Yes we can.

    The high growth rate is the result of two things: high oil prices and peace (which allow some pre-war activities to restart) and it's high because it was so low not so long ago.

    When I look at their literacy rates, when I look at inequality, when I remember that Angolans travel to Congo to get medical treatment, I can't help thinking that their government does not care at all. And the fact that they're (former) marxists makes it even worse.

    So no, I don't think they have any record of doing anything good.

    is HIV overstimated in Africa?

    Actually it is.
    Not because of the test though. Everytime they actually tested people and didn't use estimate and unjustified allocations, the number was lower.

    Basically, there's a tendency to put every death of things like TB or other infections on HIV.

  7. Cho,

    MrK, are you saying the tests are largely inaccurate? is HIV overstimated in Africa?

    Absolutely. The way the tests and surveys are used, are designed to overestimate whatever HIV/AIDS epidemic there is.

    In Africa, there are a lot of factors that cause a false positive on the single ELISA screening test, especially if there is no confirmation test used, as is the standard in diagnosis (as opposed to surveys).

    The specificity is bad, in Africa generally, but especially in pregnant women in Africa. For instance, one of the screening tests that tests for HIV 1 gp120, crossreacts with gp135 of CAEV as well as env gap95 of FIV, directly undermining any claims about these test's specificity.

    In pregnant women, there are a lot of false positives, which can only be cleared up by confirmation by for instance Western Blot.

    And yet, until very recently, most surveys depended on the blood of pregnant women collected at antenatal clinics. These surveys are called 'Antenatal Clinic Surveys'. By contrast, population based surveys, usally the Demographic and Health Surveys or DHS, look at samples from population that are representative for the general population, even though they too only depend on a single ELISA test.

    However, as a result, population based surveys have led to drastic reductions in the estimates of national HIV prevalence rates. Most dramatically, Sierra Leone went from 7% (ANC) to under 1% (DHS). See this article in the Washington Post, which is a follow up to this 2004 article in the Boston Globe.

    My guess is that if the DHS also used a Western Blot as confirmation test in addition to the ELISA screening test (less expensive that the opponents claim), national HIV estimates would be reduced even further.

    Also, it needs to be said that none of the predictions of depopulation of entire regions of Africa never took place. For instance, there was a Ugandan article on AllAfrica, which basically stated that the fight against the deadly HIV/AIDS epidemic was undermined by Uganda's rapid population growth. No irony in that at all, I guess.

    Uganda: 'Population Pressure Affecting Aids Fight'

    Even 10 years ago, even though it was supposed to be the epicenter of AIDS in Africa, there was no discernable impact on population growth:

    (1997) " It is concluded that for the district overall, an estimated 27% of all deaths would be averted in the absence of HIV infection. However, the increase in annual mortality which has occurred as a result of the HIV epidemic has not reversed population growth. "

    (1998) District State of Environment Report, August 1998

    In Rakai District, the high population growth of 3.04 is putting intensive pressure on the economy and the natural environment for basic needs like social services, water, energy, food and shelter. This is leading to land degradation, deforestation; depletion of soil and other natural resources and above all it is cost the district much in term of economic development.

    This is the same region about which 10 years before that, people said the following:

    " As one prominent California AIDS expert says, "We're going to see a significant depopulation of entire portions of Africa."

    (AIDS AT 25 Fear of Epidemic In the Mud Huts by Randy Shilts

    Needless to say, this depopulation never occurred.

    I don't have the population data for Rakai town or district, but for a few towns very near to it:

    Mbarara 41,031 (1991) 69,363 (2002)
    Masaka 49,585 (1991) 67,768 (2002)


  8. I was listening to the Brain Drain programme on BlogTalkRadio, from Dec 27th I think, and at one point a religious leader (no matter which one, my comment is general and he is quite entitled to his views) came on and said that he was against the distribution of condoms as a part of the battle against HIV/AIDS and other STDs. I understood his stated position to be that without adultery, diseases would not be sexually transmitted, therefore condoms are only preventing disease when used in the course of adultery, therefore encouraging condom use is tantamount to encouraging adultery, which is expressly held by most religions to be a sin.

    This seemed like a good thread in which to argue that this view of sin is too narrowly focused, in that the sin of adultery and the sin of transmitting diseases contracted thereby to innocent family members subsequently are equal in as much as all sins are equal. A person who commits adultery and contracts an STD may be said to have brought it upon themselves, however the disease is earthly in nature, and therefore not the ultimate spiritual judgment on the sin of adultery. Are we to think that by contracting the disease the adulterer is automatically forgiven? Since the disease will then pass to others through marriage or birth, does their earthbound suffering add to the cleansing of the adulterer's soul? I suggest that this thinking of the evil of disease as the product of sin is false.

    I think that the initial stated position is correct only in the sense that without transmission, you cannot have sexually transmitted diseases. Doesn't that imply that if the disease is the product of evil, then the transmission is in and of itself a sin? I see no justification for absolving adulterers of the additional sin of disease transmission to their unborn children simply because you have already chided them for the adultery. The failure to protect others even in the act of sinning is a separate act that individuals will have to account for separately.

  9. Yakima,

    Whoa! That is a deep theological thought process there!

    I have to say that thinking about the issue limited theological understanding is that when faced with two UNAVOIDABLE sins the great sin must be avoided...[Unavoidable seems to be the operative word in theological circles]

    The example usually quoted in theological seminaries is Rahab the Harlot who hide the Israelites and lied to save them...and God rewarded her for it. Lying was a sin but a greater sin would have to hand the men over to be killed.

    Within the context of the current discussion its a little more complicated because of this "unavoidable requirement". But I would probably say that the important thing is to preach abstinence but also make condoms available inorder to save lives (assuming condoms would save lives - there are bizarre outcomes I have read about where condoms have actually made things worse because of the pervese incentive for more promiscuity).

    I have always tended to see this issue through "economic lenses".

    Unfortunately, this blog is very thin on health topics!! I am sure you have diggging through the archives, I remember doing something on ARVs versus Prevention Revisted ...and how the evidence pointed to prevention being more cost effective. So on purely economic grounds, I am all for prevention rather than wasting money on ARVs...

  10. Cho,

    The argument of unavoidability seems flawed to me when applied to condoms (though in Rahab's case I can see the theological dilemma!), as is the perverse incentive argument. Condoms are a piece of medical equipment, such as gauze bandages. There is no more moral hazard in giving a condom to a person who may use it in sin, than to give bandages to a person who may have been injured in the course of a robbery. I don't think that the presence of the gauze encourages theft. One important aspect of condom use is for persons who are already infected with an STD, whose partner is not yet infected. Given the incurable nature of many STDs, a single act of unprotected adultery can result in decades of responsible condom use within marriage thereafter. A person can kill with a scalpel, but we do not associate the tool with murder. I argue that the current association between condoms and promiscuity is likewise improper. Indeed, rather than condemning condom use, I believe that those who confess to adultery should be encouraged to use condoms at least until their disease status can be confirmed.

  11. Cho,

    Let me say that if Zambia weren't officially declared to be a Christian Nation, then I am not certain that it would be appropriate to discuss such theological issues in this forum. However the formal status of Christianity makes the statements of Church officials on public policies such as medical delivery politically significant and arguably morally binding. It is in this context that I take umbrage with stated objections to disease prevention measures on moral grounds, and not as an assertion of my superior ability to interpret theological precedent. My view is that failure to use condoms during, or failing that, following an act of adultery as defined by the official churches is itself sinful, and should be treated as such by the churches, however nobody is confessing to me, and I have no real conception of what it takes to be that person, so I would like my position to be taken as a suggestion in spite of my personal vehement certainty.

  12. Yakima,

    "There is no more moral hazard in giving a condom to a person who may use it in sin, than to give bandages to a person who may have been injured in the course of a robbery. I don't think that the presence of the gauze encourages theft.

    The two sentences don't sit easily together. I suspect the "than" really is your point. We cannot deny moral hazard exists, surely the issue is simply one of scale?

    "I argue that the current association between condoms and promiscuity is likewise improper. Indeed, rather than condemning condom use, I believe that those who confess to adultery should be encouraged to use condoms at least until their disease status can be confirmed."

    I wonder whether there's a broader question here - an empirical question : What message has succeeded better prevention or abstinence. I am told the ABC campaign worked quite well...with its emphasis on Abstinence for the youth, encouraging Being tested and for Condoms for those who don't follow the path of righteousness so to speak..Most churches are advocates of the ABC....

    But purely focusing on condoms apparently has not had the desired effects...compared to ABC..

    "Let me say that if Zambia weren't officially declared to be a Christian Nation, then I am not certain that it would be appropriate to discuss such theological issues in this forum."

    Oh would still be appropriate..regardless of declaration, we cannot ignore that the historic importance of the Church in Zambia....also the Church remains a significant agent for change.....I am actually planning to do a series on Religion and Zambian Development...after we complete the on-going series on Chiefs...

    Its very difficult to do anything in Zambia without the blessing of the Church...declaration or no historic processes its just there, and I think one of the traversities of our approach to development is the failure to deal with institutions as they are..

    It is true that we have very few topics on religion, though a tag cloud exists for it, its a failure of finding something meaningful to say as opposed to it be a topic to be avoided.

    I am a believer in the tripod - effective development requires strong markets, strong democracy and strong religious and cultural institutions.

    Without the strong religious and cultural institutions I think markets and societies would collapse. They would no really basis for developing crucial ingredients like "virtue" or "trust".

  13. Cho,

    I agree with your tripod analogy, I guess I just get more nervous advocating a position about sin than I am about public policy, and I am certainly not a biblical scholar. As a layman however, I think that in this one instance I need to speak up in theological terms, I think that I see an error, and at the very least, if it is I who is in error, then I should be able to achieve enlightenment as to the wisdom behind the current position of the churches in Zambia.

    My objections to ABC programs has to do with the insistence that somehow universal condom distribution is mutually exclusive from support for abstinence. This is an entirely false dichotomy. I should clarify from my earlier comment, I see zero moral hazard in binding the wounds of an injured person, no matter how they came to be injured. I likewise see zero moral hazard in distributing condoms to people who may or may not use them, inside of wedlock or not. As for the empirical side, I do not have precise figures for the US, but my recollection of the last annual report on teenaged pregnancies and STDs under state programs or private schools using ABC instead of universal distribution was pretty dismal. It was touted as a fatal blow to Bush administration efforts to push abstinence only programs through the Education Department and Surgeon General's Office. I can try and hunt up precise figures for you if you like, the result was pretty much what I had expected when the programs were announced from talking to health professionals.

    Some people don't accept the analogy to medical equipment such as gauze or scalpels, arguing that they have nothing to do with sexual activity. I suppose that I can go with that, though I am not certain what makes sinful sexual activity so much more contagious to inanimate objects than other sins such as theft or murder. So I will use a very modern example which also involves STDs, it perhaps is a bit trickier because it involves a one-time vaccine and the effects are not gender neutral, but like a condom, it only prevents the disease from being transmitted initially, it cannot treat the causes or symptoms of disease. Specifically, vaccines against the Human Papilloma Virus, 2 strains of which are believed to be responsible for around 70% of all cervical cancer and its precursors. Before I go on I should say that I do not agree with some advocates of mandatory vaccination, however I think that it is something that most parents should have no difficulty with providing for their daughters.

    There are many people in the US however that are objecting to the inclusion of the vaccine for girls on the grounds that it will encourage promiscuity, citing the fact that it must be administered at an age before the girl becomes sexually active in order to be effective. I fail to see the connection. They seem to be arguing that the only thing which will keep their daughters from sex before marriage is the fear of disease, and that to remove that fear is to encourage adultery. I suppose that they plan to withhold the vaccine until her wedding day, perhaps the bride and groom can exchange syringes instead of rings? I argue that to rely upon fear of disease as a barrier against sinful behaviour is to surrender the fight before it has begun. If a person refrains from adultery solely because they have no condom, or no vaccine in their bloodstream, then it clearly is not heavenly judgment of the adultery in the afterlife that bothers them.

    Now I suspect that many church officials are concerned when they hear language such as, "At least you used a condom," or, "It's okay, we used a condom." I think that identification of condom use as separate from the sin of adultery might actually help in this case, and in that sense I agree very much that condoms should not be the focus. Besides, most people don't much like using condoms, so if they must be connected, why not consider them penance rather than proximate cause?

  14. Cho,

    I am intrigued by your adherence to the tripod as a core referent in your personal triangulation. I am reminded of studying the "Medicine Wheel" as taught within various north american Tribal Custom. Often mis-classified as either religion or astronomy, the ceremonies and physical artifacts of the wheel are in fact quite introverted and philosophical in nature, while at the same time being a common experience and referent for cultural adherence (i.e. you have either undergone certain rituals, or you have not). Because the philosophical grounding and vocabulary derived therefrom was common throughout the North American Continent, even peoples who traditionally warred with one another nevertheless shared the wheel and respected the rites thereof (which leads to the misunderstanding as religion, when in fact is more akin to primary school).

    The wheel has been around for a very very long time, and in fact it is widely accepted that the Iberian crucifixes carried by Spanish conquistadores (consisting as they did at the time of a cross encompassed by a circle within a circle) were often mistaken by Native americans as manifestations of the wheel. The fact that I did not grow up with the wheel has been no barrier to acceptance and equality amongst those who did. I find my experience similar to my sister's in training to be a yoga instructor, a very morally sound yet religiously neutral activity. I am going slow because it is a nervous thing to attempt to translate someone else's culture, thanks for bearing with me.

    In its most basic, shared form, the wheel is divided into four parts, designated by the four basic magnetic points on the compass for universal compatibility (The source of many of the astronomical misunderstandings, star position is coincidental, not causative.) In order to not overly associate any one quadrant with any one thing, quadrants are also assigned seasons, colours (often based on local seasonal colours, therefore variable by region), representative animals (highly variable by region, yet not by characteristic), and very loose "traditional societal roles" which while often identified by stereotype that could be viewed as pejorative after translation, in fact represents necessarily diametric opposites which are as arbitrary as animal choices (i.e. traditional feminine/masculine role, short/longsighted role).

    The point of the whole thing is to come to the wheel with an internal dilemma, some question you need to ask yourself (and/or God) and get an honest answer in order to proceed with confidence. Oh, a HUGE part of all this is that while Native americans developed the wheel ages ago, the only thing on either continent that could pull anything and be domesticated was the llama, and that never got further north than the Panamanian jungles until recently. For them wheels were almost universally horizontal (e.g. pottery wheels, belt driven gearing, gyroscopes, etc.), and representative of the benefits of cycles in general, therefore nature, the universe, everything (except transport).

    So one is expected to "walk the whole wheel" several times before making a decision. This involves viewing the available options from many different viewpoints, as if the problem itself lay at the centre of the wheel, and the East represented the long view, the South represented the good of the whole, the West represented the immediate need, and the North represented the unique ability of the individual, which necessarily feeds back into the East to identify the best use, and so on. As one takes the walk, passing through the various shades of value and emphasis, thinking about one's options, it is encouraged to think of the whole wheel as balanced upon the head of a pin, capable of tilting this way or that without any other impetus than the weight you bring to it. Any place you find yourself naturally lingering, any option which seems naturally attractive, paths which rely on those abilities within yourself which are most tested and reliable, those are to be avoided, at least at first, in favour of balance. The goal being to reach a feeling within yourself whereby you can move from the "rim" to the "hub", where all options are equally accessible, and the best course most clear.

    For those who walk the wheel, it is said that one's greatest strength is always the greatest weakness, because it leads us to the folly of relying upon that which we know when only that which we do not yet know will serve. Yet one cannot easily cast aside one's natural strengths or inclinations, which is why all are encouraged to walk through the South (summer) and appreciate the growth of the whole people, to walk through the West and assess the resource within your grasp, to walk through the North and aspire to do what others can or will not, to walk through the East filled with concern for generations to come, and again back to appreciation for those who travel with you. Each turning of the wheel leads to a new vision of each direction as it applies to your problem, the experience can be much like an inward spiral, or a lump of clay being shaped on a wheel for sculptors like myself, with pressure from various directions that gradually form a functional whole.

    I wonder if your tripod is amenable to similar application to a cyclical arrangement? (btw I have encountered both "clockwise" and "counterclockwise" Tribes, though I don't know of it even leading to much conflict.) Perhaps as a lens through which policy could be viewed, i.e. How does this strengthen the economy? How does this strengthen public institutions? How does this strengthen cultural tradition? Followed by the cycles of, Why do I think that is good? Is it really good, or is it just comfortable? What if I had a different definition of good, would I still like it? And so on, until you feel in balance, and then you decide.

    Personally I think it is a wonderful gift to the world that has been drowned in newage (rhymes with sewage) for the most part outside of Indian Reservations themselves. I find it necessary to include that last part in order to accurately portray the sentiments of those who taught me this skill which I find so personally valuable.

  15. Yakima,

    Very fascinating indeed.

    In some sense the tripod is similar to the wheel in so far as the aim is to ensure that each of the conclusions or policy initiatives are perfectly anchored to reach a more cohesive and stable outcome. Crucially, within the tripod framework I see no conflicts as such.

    In many ways the three aspects democracy, strong markets and strong religious or cultural institutions acts as limits on each other ensuring the whole remains stable but dynamic. More importantly you remove one, the all thing comes crumbling down.

    I think having a “system of thought” or some framework of “reference” is crucial in developing policies. I sometimes wonder what our government’s framework of reference is. What are they balancing the different things against? What is the whole on which the various particulars hold?


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