The Ethics of Deliberate Obfuscation
The March 16, 2018 Wall Street Journal reported on the increase of HIV infection in young South Africa women. “Slowdown in HIV/AIDS Progress Puts Focus on Young Women.” 1 It was a particularly disturbing report considering the more than three decades that have elapsed since the discovery of AIDS and the remarkable progress that has been made in wealthy countries to prevent the spread of HIV.
But the subtitle bothered me even more. “Experts say the booming population of young women in sub-Saharan Africa means global infections could start rising”. Unintentionally perhaps, the implication was that young women will be responsible for a future worldwide escalation of HIV infections.
The report raises worrisome questions about the portrayal of marginalized and vulnerable populations as somehow being at fault for public health and government failures. When obfuscation leads to the wrong conclusion it becomes an ethical issue. It imputes blame for a self-gain at the expense of others.
Historically, women have been blamed for causing the spread of other sexually transmitted infections. In the last century women were arrested as prostitutes for spreading syphilis—but not the men. The global HIV epidemic followed a similar pattern. Women were (are) blamed for being HIV infected even though they acquire their infection without their knowledge or consent. (HIV infection is not consensual sex.) Because of stigma and discrimination they fail to get the protection they need from public health, political and legal agencies—as a woman in South Africa once told me, “Why do you keep testing us women for HIV? Don’t you know we are infected by men.”
Multiple studies in South Africa and elsewhere document the association of sexual violence and HIV. Indeed, HIV is yet another manifestation of violence against women. Tragically HIV ranks as one of the most devastating forms of violence against women resulting, without recognition and treatment, in death. More than 50% of women who are HIV-infected come from circumstances of intimate partner violence. It is also true that women who report intimate partner violence are more likely to become HIV-infected. South Africa has one of the highest rates of intimate partner violence as well as HIV.2,3
While the “spin” relayed to the Wall Street Journal by the South African physicians and researchers suggested that more research was needed, it was far from the truth. The reality is that implementation of already existing and inexpensive solutions for prevention and treatment are not being provided to young women.4,5
Young women, in South Africa and elsewhere, receive little protection from acquiring HIV infection — they are not notified that they are being exposed to a potentially lethal infection and are therefore unable to protect themselves. If already infected, they are unable to access life-saving antiretroviral drugs until HIV has advanced to often irreversible forms of AIDS.
A just analysis of the issue of young women and the spread of HIV should conclude that the issue does not lie with the young women as incorrectly implied, but in the failure of the public health, political, and legal institutions of South Africa to protect young women from HIV and violence. (It is intuitive that you cant spread an infection if you’re not infected.)
Many of the quotes in the Wall Street Journal report were disheartening.
From young women—
“It has become normal — you test, you test positive.” “Because I give you money, you can’t dictate whether I use a condom.”
From South African healthcare leaders—
“They [young women] are the key to global epidemic control of HIV,” [suggesting they are to blame for the continued HIV epidemic].
“Scientists are developing and testing new prevention methods that women can control.”
The truth is that further research will not bring HIV under control without protecting women from the violence associated with HIV infection and that will not happen unless women are accorded the dignity that they deserve – to be free from coercive sex and HIV.
I believe that the continued high rate of HIV infection in South African women is the result of the failure of South African healthcare professionals, and healthcare professionals elsewhere to protect women from violence. No amount of medical research in HIV prevention will control the epidemic of violence and HIV infection in women.4,5 Research on unaffordable, unrealistic, and inaccessible prevention methods are not needed — rather, it is providing young women with the dignity they deserve by protecting them from violence and HIV.
2- Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Jewkes RK, Dunkle K, Nduna M, Shai N. Lancet. 2010 Jul 3;376(9734):41-8.
3- Prevalence of consensual male-male sex and sexual violence, and associations with HIV in South Africa: a population-based cross-sectional study. Dunkle KL, Jewkes RK, Murdock DW, Sikweyiya Y, Morrell R. PLoS Med. 2013;10(6):e1001472.