Premier Zille: wrong again

Premier Helen Zille. Photo source: City of Cape Town website.

Francois Venter

4 September 2014

DA leader and Western Cape premier Helen Zille has again entered the HIV prevention arena, telling us we are failing to deal with HIV because we don’t have the right approach to taking personal responsibility for sexual behaviours.

In an article on the DA website, she argues that HIV continues to spread because no one talks about ‘sugar daddies’ and ‘multiple concurrent partnerships’, and she suggests that we need to criminalise HIV transmission.

Her previous foray three years ago famously led to her referring to the HIV treatment activist community as the ‘AIDS Gestapo’ when she was challenged.

Unfortunately, her piece is a confused mess of poor science, incorrect history, moralising, and an appeal to what seems to her to be ‘common sense’, despite good scientific evidence to the contrary. It’s hard to believe that anyone with an interest in AIDS for the past ten years hasn’t heard repeated discussions about sugar daddies and multiple concurrent partnerships, and hasn’t seen failed behaviour change initiatives attempting to respond to these now largely discredited theories.

It appears Zille hasn’t looked on the web for freely and widely available data. Nor has she asked some of the world’s experts living in her town. A good start would be Brian Honerman’s superb The Boogeymen of HIV that Never Were, but let’s unpick some of the article’s claims.

Her call to specifically criminalise deliberate transmission of HIV is a discredited health and legal position. South Africa, like most countries, has legislation in place to allow for the prosecution of people who try to harm people, including the deliberate spread of HIV (she even mentions this in her article). She says “Every time I raise this question there is an outcry.” Well, I haven’t heard an outcry, but yes, it’s a dumb idea, because the law is a dreadful way to police sexual behaviours, even in places with well-functioning legal systems. Further, there is no evidence to suggest that HIV is being spread by people who know that they are positive and are reckless.

On the contrary, all the evidence is that people who know their status are careful. This measure would further stigmatise HIV, allocate responsibility unfairly (people who have sex without knowing their HIV status are, arguably, just as responsible), but not reduce the spread of infection.

Uganda’s ‘success story’: Many people contest the very rosy HIV history that she portrays for Uganda. But even assuming this history is right, the rise in new HIV incidence predates antiretrovirals (ARVs), so she is wrong that the introduction of ARVs led to increased risk taking behaviour.

This then raises the issue of ‘disinhibition’: she asserts that access to ARVs leads to more sexual risk taking. This is a legitimate concern, and was raised in regard to male circumcision programmes. However, multiple studies have shown either no change or actual improvement in sexual risk taking, after ARVs are started (we see the same after circumcision, and when someone tests positive for HIV). I have yet to see a properly done study demonstrating anything to the contrary.

She rightly is concerned about the billions of rands allocated to HIV. But the scale of the epidemic remains vast, and it’s an appropriate allocation considering the sickness and death extracted by the condition, when you look at the overall health budget. People on ARVs don’t get sick or die nearly as young, and they avoid expensive medical care.

In addition, she completely ignores the fact that people on ARVs taking their treatment will not transmit the virus. Treatment is by far the most effective form of prevention, and the money spent is an investment not just in personal health, but in prevention.

Her assertion that multiple concurrent sexual partnerships drive the epidemic: This has pretty much fallen off the prevention radar after a well-done study in KZN showed that there was no correlation between concurrency (a hazy concept at the best of times, where it includes faithful polygamists and excludes someone with a new sexual partner every night). Even her assertion around age discordant relationships is contested after a recent study found that ‘sugar daddies’ don’t seem to add risk, and may even be protective.

She says that people are not willing to discuss this for fear of being called racist (and by inference, that she is being brave by doing so), and says “no-one dares confront the stigma of talking openly about the health crisis occasioned by multiple, concurrent sexual partners and inter-generational sex”. I don’t know where she’s been hiding, but the HIV prevention field has talked of little else for the last few years, and I haven’t heard accusations of racism. The literature is full of the debates, conferences discuss it, and I alone have been on umpteen radio shows to discuss these issues.

She again engages in ad hominem attacks on the ‘AIDS industry’ which is presumably the activist community, researchers, health workers and pharmaceutical companies. This is the ‘industry’ that got us one of the most miraculous medical interventions to the poorest areas of the globe, raised South Africa’s life expectancy by a decade, led a human rights revolution for everyone from gays to sex workers, and has had a positive knock on effect on the rest of the health system. AIDS activism has spawned movements of people being arrested for demanding access to basic health care in the Free State, the campaign for text books in Mpumalanga, and sanitation in the Western Cape. It’s by no means perfect, but it’s an índustry that has had an extraordinary impact, and one I’m proud to be a part of. Calling us an industry is as cynical and unhelpful as me calling her out for being part of the ‘politician industry’.

There are dozens of medical conditions which are so-called ‘personal choices’, ranging from obesity to drug addiction to violence to sports injuries, where we often have a poor understanding of the causation, allowing for unhelpful moralising and bad public health interventions. In HIV, we still don’t know why a young black KZN woman’s risk of contracting HIV is several thousand-fold greater than her contemporary in London, Rio or Delhi despite similar kinds and amounts of sex. We’re not clear why South Africans are so overweight, why South Africans have so many car accidents, or why Cape Town has so much TB. While behaviours may drive these, it’s not always clear what these behaviours are or what makes people do them, and one of the failures of the HIV prevention science community is explaining the incredible.

I share Zille’s frustration with HIV prevention failure. Science has a lot to do to explain the disproportionate burden of HIV in our region, and many public health specialists were irresponsible in confidently assigning behaviours as high risk. and allowing these assumptions to determine subsequent programmes.

The premier laments that too much responsibility is being placed on the state and too little on individuals. But yet she thinks the state has the power to dictate to people how to run their sexual lives. She should know that it has been tried, with the ABC campaign, with what charitably can be called very limited success.

We certainly could be doing more. Some things worth trying are ensuring that all schools have condoms and that there is a much better defined life-skills curriculum (and let’s call it sex-education, damn it) that teaches accurate information about how to avoid contracting sexually transmitted infections and about having sex for pleasure. We could change the laws around sex workers to make it easier to provide health services to them, because recent data suggests this has a major beneficial impact on new HIV infections. Yet, these straightforward measures are ones that moralising politicians continue to avoid implementing.

When she says ‘take responsibility’ at the end of her article, the main responsibility that needs taking is politicians too lazy to get the facts, unfortunately something that seems to happen intermittently across South African political parties. If politicians want to enter the arena, they should take the time to meaningfully engage with the science. We deserve a better level of debate.

Professor Venter is an HIV clinician and scientist, and the former president of the Southern African HIV Clinicians Society. He is the Deputy Executive Director of the Wits Reproductive Health Institute.

Editor’s note (published 7 September 2014)

Several readers requested links to the evidence Francois Venter refers to. He has therefore provided several. The remainder of this editor’s note is a summary of correspondence with him.

Brian Honermann’s article, linked to in the article, has references on sugar daddies and concurrency, as well as the references on risk taking, and the transmission risk reductions on antiretrovirals:

For Uganda, the Wikipedia page on the AIDS response actually has many inaccuracies, but the ”Criticism” section gives some of the controversy:

The latest UNAIDS report (page 26) documents the rise in Uganda:…

For the role of antiretroviral treatment in HIV prevention:

Encouraging people to find out HIV status reduces risky behaviour:

Professor Venter writes, “This one from Uganda suggests a return to pre-treatment levels of risk taking behaviour in men, not in women. The title is a bad one, as there is no evidence of ‘disinhibition’ to my mind, just a return to pre-treatment behaviour levels; but does not support Premier Zille’s position:

Professor Venter concludes, “The data isn’t always consistent, but Premier Zille makes a hopelessly unsubstantiated claim.”