HIV Workshop (written Oct 5 - yes, I was busy Oct 5!)

Last weekend I attended a truly excellent workshop put on by one of Peace Corps/The Gambia's volunteer committees, the HIV Task Force. It was a three-day workshop and the format was: Day 1 - Technical HIV information, including the science of HIV, transmission and risk, and the state of HIV in The Gambia; Day 2 - Presentations by Gambian health educators, on topics including culturally appropriate ways to talk about sexual and reproductive health (and HIV specifically) and HIV support groups in The Gambia; Day 3 - Teaching about HIV in school, including the use of drama and a run-through of the draft curriculum for the HIV Bike Tour we will be doing in November (more to come on that in a later post).

Like I said, the workshop was incredibly well done and there are many things I could share, but I thought the information about the state of HIV in The Gambia would be particularly interesting for all of your at home. Here are some key facts, in no particular order:

1) The best estimate of the HIV prevalence in the Gambia is around 1%. (For comparison, the prevalence in the US is about half a percent, while South Africa is 18%. See this link for data on other countries if you're curious: http://en.wikipedia.org/wiki/List_of_countries_by_HIV/AIDS_adult_prevalence_rate.) My understanding, however is that that value, is calculated almost solely based on pregnant women reporting for antenatal care and agreeing to testing. Gambian statisticians assume one infected man for every infected woman, and go from there. This strategy for estimating the prevalence, while the simplest and most straightforward, has a some potential flaws, the most concerning being overlooking more difficult groups to capture such as sex workers, anyone who is not sexually active, children, young unwed mothers who are often unlikely to seek antenatal care, women who can't or aren't getting pregnant, either by choice or due to infertility or old age. All of this may result in an underestimation of the official rate, while ignoring polygamy may result in an overestimation of the official rate (since they are assuming one man for each infected woman and one man can actually infect up to four wives without even looking at fidelity issue). All these factors may cancel each other out, but it is really hard to know.

2) Contrary to popular belief, 80% of HIV transmission in The Gambia is estimated to occur through heterosexual sex (we don't have stats on what percentage of that is intra-marital, but anecdotal evidence suggests it is quite high). This is a common theme throughout Africa.

3) While the HIV prevalence in The Gambia is (supposedly) quite low compared to many other countries, particularly in Southern Africa, The Gambia has a LOT of risk factors that are serious reasons for concern, including: polygamy (concurrent relationships); the practice of wife inheritance (brothers marrying their deceased brother's widows); pressure to have a lot of children soon after marriage; early marriage of girls (young girls generally have not finished their education and have very minimal decision making power, while their older husbands have had more time to contract HIV); the practice of female circumcision (razors are often shared during ceremonies and circumcised women are at an increased risk of traumatic sex and childbirth, which carry huge risks of HIV transmission); resistance to condom use (sex outside of marriage is condemned by Islam and inside of marriage everyone wants to have a lot of children, so the only logical conclusion is people using condoms must be participating in un-Islamic activities); and The Gambia's small size, highly mobile and transient population, and location at the intersection of several major African highways.

A few important protective factors against all these risks include: free and widespread voluntary testing and counseling and support groups; free and readily available anti-retroviral drug therapy; a high level of social and cultural cohesion, and widespread male circumcision, which most health authorities believe reduces HIV transmission rates (dearest reader Mark - kindly keep your comments on this to yourself - you've already said your piece on a previous post - point taken).

4) One additional reason for concern relates to the two strains of HIV. For those you who many not be aware, there are two strains of HIV - HIV1 and HIV2. There are several differences between the two strains, but the most important one is that HIV1 is significantly more virulent (i.e., aggressive). For more information on the differences between HIV1 and HIV2, visit: http://en.wikipedia.org/wiki/HIV. HIV2 is thought to have originated in West Africa and until recently, it accounted for most of the cases in The Gambia. Since HIV2 is comparably "better" (50% of people with HIV2 never progress to AIDS at all), that was a good thing. However, in recent years, for reasons not completely understood, the cases of HIV2 have been declining here, while the cases of HIV1 have been rising. Bad news.

5) In The Gambia, in addition to biological risk factors such as women being twice as likely as men to contract HIV through heterosexual sex, women are at a particularly increased risk from HIV because of a lack of decision-making power, economic dependence on men, early marriage, and the prevalence of transactional relationships such as sex for grades or school fees between students and teachers and "sugar daddy" relationships. On the topic of early marriage, which sometimes happens as early as 13 for girls, we learned that in some tribes, a girls marriage can be triggered by one of two things: ability to carry a pounding mortar (signifying she is strong enough to carry a man) or debut of sexual activity (which means she is at risk of shaming her family by becoming pregnant). The same triggers do not apply for boys, who are rarely married before 17, and often much later.

6) This isn't Gambia-specific, but it is something I didn't know and found interesting (and important to know): An infected person is more likely to pass on the virus during their initial spike in viral load, which occurs during the first three months after contracting the virus. The scary thing about that is that many HIV positive people do not test positive until they have had the virus for 3-6 months...so that means that people are most likely to infect others during the time period when they often do not have any symptoms and, even if they were tested, they probably would test negative. Yikes. That is one of the many things that makes the spread of HIV so difficult to combat.

Ok, that's enough for now. Keep the feedback coming guys - let me know if I'm getting too techy or you'd rather read posts on other topics...