Low HIV Prevalence Countries: Things Policy Makers Should Keep in Mind
Sub-Saharan Africa has the highest rates of HIV prevalence in the world with some countries reaching as high as 30% prevalence in the general population. Given the pervasiveness of the infections among the population, services to prevent new infections and care for those already infected are scaled up so to be made universal. After all any young person or adult in Southern Africa is susceptible to becoming infected. This is not the case in other countries where a combination of societal factors and practices has made the epidemic among the general population very low while concentrating it among specific groups. Despite this epidemic profile the majority of these low prevalence countries has chosen to either look the other way or to toe the African approach. The “HIV is not my problem” or “the copy and paste from the Africa” approaches are both misplaced and potentially harmful. Any policy makers in countries with low prevalence rate should keep two things in mind.
Low prevalence does not mean low risk. Low prevalence among the general population leads many governments to think that HIV is not their problem: after all sex is taboo in many societies, people do not have many sexual partners and most of the men are circumcised which reduces their likelihood of getting infected even in the case where they assume more inhibited sexual practices. Yet such simplistic analysis keeps out of the picture groups which do have high chances to get infected: people who inject drugs, who engage in anal sex and who sell sex to make a living. Some of them can engage in one or more of these practices: they do not fit neat boxes. If you underestimate this risk you could find yourself facing a concentrated epidemic overnight. And this happens because once the virus enters this circle its spread is made very rapid by the risky practices. The case of Nepal in the early 1990s is instructive in this sense. Injecting drug users were believed not to share needles, a practice which increases the risk of being infected, while showing zero prevalence, as surveys showed. For this reason IDUs were written off the agenda of groups to monitor and they were officially forgotten. But as this forgetfulness translated into an interruption of data collection during the 1990s one-half of the IDUs population was getting infected. When in 1999 a national study was conducted 40% of IDUs nationally were found to have the HIV virus.
(Not) Everyone is at risk. Once you realize that HIV is also your business the first thing to do is to know the patterns of sexual relationships: they define your epidemic. Men in Asia and the Middle East who wants to have sex outside their marriage are unlikely to find any willing partners: women are very loyal to their husbands. For that reason, they resort to buying sex from sex workers. The chance to get infected depends on whether the sex worker is infected: this likelihood increases with the number of clients she has. If she has a lot of clients there is the chance that the virus is spread heterosexually. If the client turnover is low and the majority of the men are circumcised then three things are likely to spread the virus: unprotected anal sex, buy and selling homosexual sex and needle sharing. The majority of the population does not engage in these practices: so if you want to reduce the risk of HIV infections you need to make condoms and needles available for those groups and make sure that those who need them understand why to use them. Awareness raising campaigns for the general population will not do the job, simply because the general population is not the most likely of getting the virus: targeting thus becomes imperative.
In sum, HIV in the majority of the world is not a public health priority: yet there are some groups within societies that are exposed to HIV. As such, they also have the right to receive the necessary services. So if you are a policy maker in a low HIV prevalence country remember that low prevalence does not mean low risk, keep monitoring at risk population, and target the most at risk groups because not everyone is at risk.
 “HIV/AIDS in MENA. The Costs of Inaction” by C. Jenkins and D. Robalino, World Bank