Thursday, April 11, 2019

Antimicrobial Resistance and PrEP: Medical Disasters

Here are two antimicrobial resistance (AMR) scenarios, one rapidly spiraling out of control, and the other (arguably) incipient:

The AMR scenario that is spiraling out of control is described in an article in The New York Times. The development of AMR is blamed on overuse and misuse of cheap antibiotics, usually without prescription. Ever-increasing use and misuse of antibiotics results in ever-increasing development of resistant strains of pathogens.

The NYT article describes the appalling conditions that an estimated one billion people live in; slums where waterborne, foodborne and airborne pathogens thrive. Unable to escape the risks, people try to treat the symptoms with antibiotics, inevitably leading to resistance to most or all available treatments.

The scenario described is a loop: widespread disease leads to overuse of antimicrobials; this leads to development of resistance; people with resistant conditions, if they survive, are taken to healthcare facilities, which also overuse antimicrobials, amplifying resistance and transmission of resistant strains; this loops back to the slum, resulting in an even higher disease burden, and greater levels of resistance.

The loop could be broken by: 1) improving the environment, including water, sanitation, habitation, food, etc and 2) improving conditions in healthcare facilities, infection control, safety, hygiene, etc. This will reduce antimicrobial use and, therefore, resistance.

The approach suggested by the Global AMR R&D Hub, on the other hand, risks speeding up the loop leading to AMR. They aim to “tackle the threat of resistant pathogens” by developing “new antibiotics and treatments against infections.” Producing antimicrobials of ever-increasing power, without addressing 1 and 2, above, only continues the cycle of ever-increasing resistance.

The other scenario is described on websites such as iwantprepnow.co.uk (and prepster.info and others). They advise on the use of PrEP (pre-exposure prophylaxis), antiretrovirals taken by HIV negative people to reduce the risk of HIV infection. For example, if "you have sex in a variety of situations where condoms are not easily used or not always used", PrEP, if properly used, can reduce risk of infection with HIV by more than 90%.

There are (at least) two problems with this. Firstly, overuse or incorrect use of antiretrovirals can give rise to a resistant strain of HIV developing in an infected person, and that resistant strain can also be transmitted to others.

Secondly, the advice from iwantprepnow.co.uk (and other similar sites, such as PrEPster.info) is aimed at people who frequently have sex without protection from other sexually transmitted infections (STIs). Exposing yourself repeatedly to infection with STIs increases the development of resistant strains of, for example, gonorrhea, shigella and Mycoplasma genitalium.

Use of PrEP without condoms also increases transmission of hepatitis C virus: “Incidence of acute hepatitis C virus (HCV) among men who have sex with men who use PrEP in Lyon increased tenfold between 2016 and 2017”. HCV has doubled among HIV positive people.

The Center for Strategic and International Studies spectacularly fail to notice the positive feedback mechanism, whereby improper use of PrEP could increase transmission of STIs and the development of resistance in countries where HIV prevalence is highest, sub-Saharan African countries:

"In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a prevention lynchpin." The same article even acknowledges that "High rates of sexually transmitted infections (STIs) increase the risk of HIV acquisition", without noticing how PrEP will increase STIs and resistance!

According to The WHO, health is a "State of complete physical, mental, and social well being, and not merely the absence of disease or infirmity." In the two AMR scenarios described above, producing stronger antimicrobials and PrEP are examples of medicalization of health, viewing it as merely the absence of disease or infirmity. These kinds of medicalization will radically increase AMR.

allvoices

Tuesday, April 9, 2019

Cherie Blair and ‘Rape in Africa’ Stereotypes

Cherie Blair was accused of perpetuating and reinforcing stereotypes and usurping African voices with her comment that “most African ladies’ first sexual experience is rape”. The English Guardian and NPR both weigh in, with a number of reasons why Blair’s remarks were met with outrage.

Critics of Blair are not wrong in calling her out on these comments. But they don’t go far enough. Yes, Blair should have acknowledged, for example, that rape and gender based violence are faced by women everywhere, not just in African countries. But Blair is only repeating stereotypes she would find throughout the mainstream media, and in a lot of specialized published sources.

Blair is far from being alone in perpetuating and reinforcing stereotypes, such as those of the ‘promiscuous African’, ‘the violent African male’, ‘the widespread exchange of sex for money’, ‘the disempowered African female’, etc. Most of these stereotypes are a lot older than Blair, and date back to colonial times, at least.

Nor have the long-held stereotypes mellowed with age. The bulk of HIV programming (and spending) is based on the very assumption that “sexual transmission [is] the major mode of spread of HIV-1 in Africa”, with some estimates suggesting that sex accounts for 80-90% of all transmissions in high prevalence countries (which are all in sub-Saharan Africa).

On the subject of rape, the Center for Strategic and International Studies (CSIS) claims that: “Girls and women [in South Africa] also face an epidemic of rape and gender-based violence; many young women express more concerns about getting raped or getting pregnant than getting HIV. At one site we visited, the girls stated that getting raped was their number one fear.”

CSIS was commenting on the fact that in some parts of South Africa, 60% of women are HIV positive. Many new infections are among girls 15-24 years old. However, the entire CSIS article assumes, without ever arguing for it, that all HIV transmission is sexual. This assumption may suggest that stereotypes such as those above are based on empirical findings, rather than being rank prejudice.

Far from being based on research, stereotypes about ‘African’ sexual behavior are flatly contradicted by vast quantities of data collected by Demographic and Health Surveys, every five years, about sexual behavior in African countries. Just select any sub-Saharan country; rates of ‘unsafe’ sexual behavior are low, and there is little or no correlation with HIV prevalence.

Cherie Blair is unlikely to have come across views that diverge from the mainstream prejudices about HIV in SSA, and that challenge those prejudices. But many of those challenges can be found, for example, in a paper by John Potterat, and in the bibliography for that paper. One of the main suspects in high rates of HIV transmission is unsafe healthcare; others are unsafe cosmetic and traditional practices.

If Blair would like to reconsider the sort of stereotypes about sexual behavior and violence also expressed in the CSIS article, this is a good time to do so. Those outraged by her comments about ‘Africans’ and their alleged sexual behavior may wish to avail of the same research. Otherwise they all risk reinforcing and perpetuating stereotypes.

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Thursday, April 4, 2019

Ebola: A Strategy of Misinformation?

In an article in The New England Journal of Medicine entitled ‘An Epidemic of Suspicion — Ebola and Violence in the DRC’ Vinh-Kim Nguyen writes about violent attacks on Ebola treatment units and other health facilities. Nguyen argues that: "Epidemics thrive on fear — when they are frightened, patients flee hospitals, sick people stay away to begin with, and affected communities distrust groups trying to respond to the epidemic."

But there's an important sense in which the opposite may be true. When people fear something that has proven dangerous in the past, avoiding that something may be the only rational response, the only way to avoid the danger. After all, several well-documented epidemics have been shown to thrive on unsafe healthcare. Examples are Ebola Virus Disease (EVD), hepatitis C (HCV), extensively drug resistant tuberculosis (XDR TB) and MRSA (Methicillin-resistant Staphylococcus aureus).

The second ever outbreak of EBV, which occurred in Yambuku (in Zaire) in 1976, was a result of unsafe healthcare: "Peter Piot...concluded that it was inadvertently caused by the Sisters of Yambuku Mission Hospital, who had given unnecessary vitamin injections to pregnant women in their prenatal clinic without sterilizing the needles and syringes."

WHO has recently announced that "The outbreak [of EBD] in Katwa and Butembo health zones [in DRC] is partly being driven by nosocomial [=originating in a hospital] transmission events in private and public health centres. Since 1 December 2018, 86% (125/145) of cases in these areas had visited or worked in a health care facility before or after their onset of illness. Of those, 21% (30/145) reported contact with a health care facility before their onset of illness, suggesting possible nosocomial transmission."

Globally, hepatitis C virus (HCV) has infected an estimated 130 million people.... [T]he wave of increased HCV-related morbidity and mortality that we are now facing is the result of an unprecedented increase in the spread of HCV during the 20th century. Two 20th century events appear to be responsible for this increase; the widespread availability of injectable therapies and the illicit use of injectable drugs. A significant healthcare associated outbreak occurred in  Egypt in the 1970s.

Associated with poor infection control in health facilities, one of the first outbreaks of XDR-TB was discovered in Tugela Ferry Hospital, KZN, South Africa, in 2005. And a significant proportion of healthcare associated infections are resistant to methicillin (ie, MRSA).

Nguyen goes on: “In areas where the epidemic response has not involved security forces...people ask to be vaccinated.”

But rolling out vaccinations in environments where infection control is inadequate (for example, healthcare facilities) might increase the risk of viral strains developing resistance (for example, among healthcare practitioners). Going to a healthcare facility during an outbreak of Ebola may be the worst thing a person can do. When people didn’t go to health facilities during earlier outbreaks, case numbers were limited, and the outbreak didn’t last long.

Nguyen has also highlighted the importance of trust, and the consequences of mistrust of authority, experts and science. But if people are right to question the safety of healthcare facilities, as it would appear from above considerations, how can the trust of people at risk of exposure to ebola and other pathogens be regained?

As long as continued Ebola transmission is blamed on what is depicted as an irrational fear of healthcare and vaccinations, people will stay away from healthcare. Because their fear is far from irrational, it is supported by scholarly research, expert opinion and even communications from the WHO. XDR TB, MRSA, HCV and other outbreaks have been shown to be healthcare associated outbreaks. Healthcare facilities also contribute the lion’s share to anti-microbial resistance (AMR).

Modern healthcare facilities are potentially dangerous places. If patients were informed about the dangers, they would know better how to avoid them, and healthcare facilities would be compelled to address those dangers. Some of the earliest EBV outbreaks occurred when people came together around healthcare facilities, and died out when healthcare facilities closed, often because healthcare staff had been wiped out by Ebola.

Trust in healthcare in developing countries may be regained, slowly, if people are adequately informed about the greatest risks they face, such as poor infection control, lack of hygiene, AMR, etc. Trust will not be regained by dreaming up new misinformation, nor by reinforcing old misinformation.

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Tuesday, February 12, 2019

Guardian: Another Fine Press Excess Mess

If I wrote that health facilities may be contributing to the spread of diseases, such as Ebola (or HIV), I'd be accused of spreading scare stories. But because it's the English Guardian, and it's about sex in an African country, they can publish with impunity a story with the title 'Ebola vaccine offered in exchange for sex, say women in Congo'.

A quick read through the article shows that the title is wholly unmerited. And even the WHO has acknowledged that 86% of people infected with ebola in several hotspots have worked at or visited health centers recently. So the "deep mistrust of health workers" in the DRC may not be as misguided as the Guardian seems to suggest.

The Guardian continues: "Suspicion of authorities and health agencies has further hampered efforts to contain the response". The Guardian tends to avoid suggestions that suspicion of health agencies is ever justified. They prefer to point the finger at gender based violence, sex, bats, women, corpse touchers, anything to avoid the admission that ebola outbreaks cannot possibly be a simple matter of individual behavior, traditional practices, etc.

The article is not an isolated example of the Guardian's fantasies about exotic sexual behavior, occult practices, primitive people, violent men and hapless female and child victims, without power or agency. Another in the series had the title 'Women in sub-Saharan Africa forced into sex to pay hospital bills', based on research that did not warrant anything so salacious.

A third article in the Guardian screams "Girls are literally selling their bodies to get sanitary pads", which is a quote from a researcher more anxious to get publicity for her work than to address some very serious issues in developing countries. Read the research in question and you will not come away with the impressions that the Guardian would have us believe.

And a fourth claims that dating apps in Pakistan (a very low HIV prevalence developing country, where several outbreaks of healthcare associated HIV have been described) are leading to an increase in transmission rates (there is no evidence of any correlation, let alone a causal connection, it’s just speculation).

It's not just the English Guardian that plumbs the depths of tabloid journalism when it comes to 'Africa', nor are all the bizarre, not too credible and very badly researched issues always about sex. For example, some may remember reading articles about people on ARVs eating cow dung because they had no other food, in the BBC and elsewhere.

This story was repeated in a few other countries. Less attention was given to a woman who said she made up the story because she was told she would have to come up with something good in order to get money to buy food.

Other stories that seem belittling and (often obviously) untrue include one about men who have anal sex having to use adult diapers, people renting out used condoms and washing them before renting them out again, assumptions about 'African' sexuality (which can also be found on the BBC site, for example), etc.

Other news outlets that seem unable to resist trivial, belittling and often simply untrue stories about some African countries include IRIN (condom recycling), and Reuters, whose articles, like the BBC's, are often used to back up newspaper articles, or are syndicated in African newspapers.

Aside from being insulting and demeaning, especially to people from African countries and women, these stories deflect attention from extremely serious risks that people in developing countries face, such as unsafe healthcare (which has been shown to contribute to outbreaks of HIV, Ebola, TB, hepatitis C and others), lack of sanitary and reproductive health services and supplies, misuse of medicines and many others.

The consequences of such irresponsible reporting by some of the most trusted news outlets go far beyond the often trivial gossip that purports to be news. If healthcare facilities are unsafe, people should avoid them, especially if authorities (and the press) try to cover up and lie about the risks, at least until healthcare associated outbreaks of deadly conditions are investigated and addressed adequately.

But if unsafe healthcare is deadly, so is the press that lies about it, the press that slings muck at anyone who dares to suggest that ‘professionals’ don't always know best, the press that loves to brand people as 'denialists' if they don't fall in with whatever is currently fashionable in 'expert opinion'.

allvoices

Saturday, August 11, 2018

Tanzania: Some Alternatives to Orphanages

In a previous blog I concluded that “Long-term residential accommodation will not provide the child with the conditions they need to develop”, and this view is shared by many people and organizations working in child protection in Tanzania. But it would be a mistake to conclude that current practices can cease without being certain of which alternative strategies can be developed to care for vulnerable children, and avoid separating them from their families.

I don’t claim to be an expert in the field of child protection, and what I have written below is based on a relatively small amount of research and inquiry. I make it available in case it is useful to others doing similar or overlapping work.

I briefly outline a number of alternatives, in no particular order. Some of these activities are already being carried out by NGOs in Tanzania or elsewhere; others are in need of further inquiry; some of them may be practiced but I have not found any details yet (this is just informal research!). The list is by no means exhaustive:

1. Child protection monitoring is lacking in the Tanzanian social welfare system; there are probably too few social welfare officers, with too few skills; more importantly, residential care seems to be one of the few options they consider whenever child protection is involved; many social services are provided by private bodies and there is little that is available nationally
2. Mental health issues in mothers and other family members need to be addressed, especially post natal depression; mental health issues are a common reason cited for children being in institutions, and other research shows that post natal depression is rarely diagnosed, let alone treated
3. Maternal health issues: health problems during pregnancy, delivery and in the months after giving birth are numerous; maternal morbidity and mortality rates are very high in Tanzania; care for the mother must not exclude appropriate care for the child, especially if they are separated; care for the child must involve continued contact with their family
4. Newborn health issues: birth defects, disabilities, developmental problems and doubtless many preventable and/or treatable conditions are common; infant and under 5 mortality very high in Tanzania; where this results in the child being separated from the mother or carer the care must be monitored so that the child is reunited as quickly as possible, and does not lose touch with the family at any time
5. Infant feeding and support for mother/carer/family is an important intervention that has been implemented in various forms in Tanzania for a long time, both large and small scale programs; but this needs to be available to all children, if required; timely programs have prevented a lot of separations of children from their mother/carer, and continue to do so
6. Support and acknowledgement for carers; sometimes the nominated carer has a very low status (social status, legal status, etc) in the family and is not considered to have an integral connection with the child’s welfare; there’s little point in the child bonding with a carer who will soon disappear, to be replaced by another carer, who may have a similarly low status
7. Home support for children with special needs; rare in Tanzania to find any kind of support for children with special needs or their carers; what is available is generally provided by NGOs and other private providers
8. Respite care for carers; such care may be provided by some NGOs but it is rare; informal respite care can be provided by relatives and friends/neighbors but this can carry serious risks, and many carers are completely isolated and without support of any kind
9. Daycare facilities; several NGOs are providing daycare facilities but these are mainly ‘supply driven’, and arise when there is a provider willing to build and run them; being able to send young children to daycare facilities would allow mothers/carers to work without having to worry about leaving their children in riskier circumstances, or leaving them with young siblings, who will then have to miss school
10. Foster care, formal, informal, long and short term; informal foster care is and has been common in Tanzania for a long time, although there is little recognition of the word or concept; there is legislation covering formal foster care but it doesn’t seem to be used much; social welfare tend to be reluctant to try out ‘new’ things
11. Family centered support in the home, eg, financial support, especially where there are indications of poverty, neglect, abuse; families are expected to provide care for children, even children of relatives, also old people, people with special needs, etc; yet many families live in poverty and isolation from healthcare, education and infrastructure; nothing is free when you have no income, so ‘free’ school and healthcare, for example, still involve costs that families struggle to meet, or fail to meet
12. Facilities that care for couples, infant/child and mother/carer, when required; rather than separating infants from mothers or carers in the event of sickness or death, providing facilities that allow them to remain together would significantly increase the child’s chances of thriving and even surviving, and also reduce the risk of separation
13. Specialist facilities for children who can't be at home; special needs often cannot be addressed adequately at home; sometimes a child has so many needs that the family can’t provide that they must spend some time in a specialist facility; but there needs to be better provision for keeping children in touch with their family if they are separated; at present, maintaining contact between children and families is down to the individual provider
14. Support for childless families, those who have experienced loss, stillbirths, etc; fostering and adoption by Tanzania families should be addressed and those who have lost a child, or families who are childless, are often interested in considering caring for a child who has been separated from their family and cannot return
15. Support for facilities reuniting children with families; generally, once a child has been placed in a facility, little effort is made to consider reuniting them with their family; often, families don’t even visit children once they are in a facility; reuniting them with their families can involve a lot of negotiation and logistics that facilities cannot afford, but reuniting them should always be the first concern for facilities and others working with child protection
16. Working with fathers/birthing partners, to encourage women to consider not being alone during delivery and the days after birth; programs that focus on infants, children or women can effectively exclude men, even antagonize them; working with fathers during pregnancy and birth is only one way of including them and could have a significant impact on the tendency to place children in orphanages; working with fathers to understand and negotiate how they can support their partner through pregnancy and delivery and the early months (putting it prosaically, mothers are often afraid of healthcare professionals, but healthcare professionals are often afraid of fathers who turn up to support their partners!)
17. Investigate cases of 'abandonment' and other instances of children being separated; this is a legal/administrative issue that can be very vague when cited as a reason for referring a child to an orphanage; it’s difficult to ‘abandon’ a child without a lot of people knowing about it, so claims of abandonment should be treated with greater caution
18. Investigate cases attributed to 'alcoholism', as some of them may be something entirely different, or something treatable, but that drives the alcoholism; the term ‘alcoholic’ can be applied to anyone who drinks, especially when applied to a woman; some residential facilities are funded by churches that preach against even the slightest association with alcohol
19. Follow up HIV and TB infected children to find out why they are in facilities, where they often cannot benefit from funded programs that are available for those conditions; chronic conditions can prove difficult for families to deal with, but many children are successfully cared for at home, given the right support
20. Investigate cases attributed to 'abuse' to ensure that there is not some other treatable cause that has been categorized as abuse; families are generally reluctant to discuss abuse openly, so it must be questioned when it is used as a reason for admitting a child to an orphanage; of course, abuse does occur, and there are legitimate reasons for children to be separated from their family, and possibly referred to a facility, a foster family, etc
21. Investigate children for whom there is no identifiable reason for their being in a facility, no problem with the child, no problem with the mother/carer/parents/family; if a child is in a facility and no one is visiting them, they can be left without anyone considering their future care; facilities often don’t have the resources to regularly review children’s care plan and social welfare tend to leave such matters to the facility
22. Promotion of Early Childhood Education where this is not available; many children go to school late for various reasons and this can make it difficult for them to catch up; sending children to appropriate education institutions must become the norm; being in daycare or early schooling is preferable to being at home alone, in the care of young siblings or in the care of people who are neither trained nor motivated to look after the child
23. Promotion of inclusive education in public schools; sometimes the smallest reason can be used for delaying a child’s start at school, such as a very minor impairment or disability; for example, there’s no reason for most children with albinism to stay at home; some children out of school have special needs that can be met at state schools, preferably with appropriate measures where the special needs are more acute; waiting until an institution that can provide for special needs is identified, or until the child is older and can more easily access such an institution, leads to long delays
24. There are tools such as the 'Child Development and Monitoring Tool' (from the Suryakanti Foundation), which can help identify, treat and even prevent some conditions that give rise to children having special needs; special needs can include developmental, behavioral, learning, impairments, etc, so it’s important to accurately identify what needs a child has as early as possible

There are many alternatives to ‘orphanages’ and ways of preventing separation of children from their family. But it will be a harder job to assess the needs of every child currently in an institution and reunite them with their family, or care for them more appropriately, than it was to refer them to the institution in the first place. The challenge is to follow Tanzania’s Law of the Child Act to the letter: an orphanage should always be a last resort, and it should not be seen as a permanent solution.

The majority of Tanzanian families are poor, a lot are living below the poverty line, unemployed, unskilled and isolated from services they need to change things for themselves. Orphanages and NGOs, donors and sponsors have long been seen as a lifeline, a way of getting one or more children cared for and educated, perhaps so that they can do more for their family later. If resources and funding are to be reduced in one area of child protection, they must be redeployed elsewhere.

But the proliferation of orphanages in a region such as Arusha has merely led to the expectation that more and more orphanage places will be provided. And children will continue to be referred to orphanages as long as a justification that is acceptable to social welfare can be found. Support, funding and sponsorship need be redeployed in ways that avoid separating families.

This is a working document and it will continue to be developed if people make contributions, comments, criticisms, etc. Thank you in advance!

allvoices

Friday, August 3, 2018

Why Watoto Kicheko Orphanage is now closed

Supporters and followers of Watoto Kicheko Orphanage will have heard that we are now closed, and we are not admitting any more children. Although there were some big challenges over the four years Watoto Kicheko was open there was only one reason why we closed: the children all had somewhere else to go; most of them (about three quarters) were reunited with their own families. A small number were adopted (4), or were placed in facilities that can best provide for their specific circumstances (3).

Out of 36 children admitted over a four year period, only about 19 probably needed to spend some time in a residential facility. About 7 of them probably needed to stay for a year or more. But about 17 had no convincing reason for being in a residential facility. About 29 out of 36 should have left the facility sooner than they did, and some of them should have left far sooner. Sadly, three of the children died while under the care of the orphanage. No child was ever admitted on the grounds that both parents had died.

A number of children were admitted because they were in urgent need of care, sometimes medium to longer term care. And a few would certainly not be alive today if they had not received the treatment and care they got while they were staying at Watoto Kicheko. For this, we owe a debt of gratitude to the staff of Watoto Kicheko, specialists and staff at Selian Hospital (ALMC), staff from a number of other facilities and a whole host of others who visited, gave advice and assistance, supported us in various ways, sent money, gifts and the like.

The Tanzanian Law of the Child Act is clear that orphanages should be a last resort, once every other option has been considered. For a long time now, orphanages seem to have been treated as the go to place for children. Many of the children, and sometimes their parents or carers, have needs that can be provided without the child being separated from their family. Once a child has been separated, for whatever reason, it can be difficult to reunite them. Being separated from their family is a significant harm in itself, aside from the many risks children in care face. The practice of placing children in orphanages when they have no need to be separated from their family must stop.

Of course, there are situations when a child may need to be separated from a parent, carer, or even their family. Sometimes it is not possible for a child to return to a family member, or even to the family. Caring for children in such circumstances is difficult, as anyone involved in child protection knows. But even urgent measures that need to be taken, emergencies, situations where there are clear risks for the child, etc, must also include a strategy for keeping the child in contact with a carer, someone who will stay close to the child, at least until their future is clear.

Long-term residential accommodation will not provide the child with the conditions they need to develop. Neither disability nor poverty are valid reasons for denying children a family life. If you are involved in researching or working with forms of non-residential care for children, reuniting children who have been in care, alternatives to orphanages and strategies for keeping families together in Tanzania, I would love to hear from you: Simon Collery – collery [at] gmail.com


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Tuesday, June 12, 2018

A Minor Revelation Short of a Pulitzer

Steven Thrasher has made the fascinating discovery that many of the HIV positive, gay men in the US are not white, and he regularly reveals this to "incredulous audiences".

If he enjoys sharing this so much, perhaps he'd be interested to know that most HIV positive people in some of the country's southern states are heterosexual and female, as well as black.

Indeed, the majority of HIV positive people in the world are black and heterosexual; and a majority of those black HIV positive heterosexuals are female.

Even though the majority of new HIV infections are among men who have sex with men in the US, HIV prevalence is 7 times higher among African Americans than it is among white Americans.

So HIV among men who have sex with men is, to a large extent, a result of sexual behavior. And HIV among people who inject druts is, to a large extent, a result of reusing injecting equipment.

But HIV among heterosexuals is much less likely to be a result of unsafe sex. Even among men who have sex with men, it's receptive anal sex that carries the highest risk.

Thrasher laments American art imagining Aids as white and in the past. Yet, imagining it as black, gay, western and in the present fails to include the vast majority of HIV positive people: they are black, heterosexual females, from developing countries; and sexual behavior is unlikely to conform to the common stereotypes of 'African' sexuality, either.

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