Wednesday, October 11, 2017

UNAIDS: Still Spanking the Chimp

How are we to make sense of a HIV epidemic such as the one in Uganda? We are told that it is mostly a result of ‘unsafe’ sex. But data about sexual behavior in Uganda is unremarkable; most people don’t engage in high levels of unsafe sex, and types of sexual behavior considered unsafe appear not to be so unsafe after all.

In 2007, it was estimated that there were almost one million people living with HIV, 135,000 newly infected with HIV in that year, and 77,000 deaths from Aids. The Demographic and Health Survey for Uganda in 2011 concluded that “Differences in HIV infection according to higher risk sexual activity are minor”.

In fact, the vast majority of the 18,000 people surveyed did not engage in sexual behavior considered to be risky. Most people had a maximum of one partner in the last 12 months, most who had more than one partner did not have concurrent (overlapping) partnerships, most did not report large numbers of lifetime partners, most didn’t pay for sex and most didn’t engage in ‘higher risk’ sex in the past 12 months.

So it’s hard to believe that the table appearing on page 15 of the Modes of Transmission Survey (MoT) for Uganda, for 2009, can be anything but fiction. It claims that almost 90% of HIV incidence is a result of multiple partnerships, partners of multiple partnerships and people engaged in mutually monogamous heterosexual relationships.

Even incidence attributed to sex workers doesn’t reach 1%, nor does that attributed to men who have sex with men, plus their female partners. Injecting drug use doesn’t play a big part in most of the epidemics in sub-Saharan Africa either.

The DHS figures for Uganda clearly do not support the MoT figures. They do not support the contention that high HIV prevalence indicates high rates of ‘unsafe’ sexual activity; HIV prevalence is high in Uganda, but sexual activity is not exceptional, nor is it closely associated with HIV transmission.

DHS continues: “HIV prevalence by the number of sexual partners in the 12 months before the survey does not show the expected patterns”. It is noted that “HIV prevalence shows the expected relationship with the number of lifetime sexual partners” but the author doesn’t mention that the numbers of people involved is very small. So they conclude that “it is important to remember that responses about sexual risk behaviours may be subject to reporting bias”.

Uganda was one of the first countries to expose itself to the scrutiny of the rapidly developing HIV industry, from the 1980s. As a result, a lot more studies took place there, a lot more papers were published about Uganda and tens of millions more dollars were spent there than in any other African country, even countries that later turned out to have far worse epidemics.

It takes more than a bit of fluffing to get from the Demographic and Health Survey’s flaccid data on sexual behavior to the conclusion that almost 90% of HIV transmission is a result of unsafe heterosexual sex. But if the industry doesn’t come clean about where the bulk of new infections are coming from, resources targeted at those thought to or claimed to engage in ‘unsafe’ sex will continue to be wasted.

allvoices

Thursday, September 28, 2017

HIV: A Rich Seam in a Long Abandoned Mine?

Here's a stomach-churning quote from The Eugenics Review, 1932: "East Africa [has] a heavily syphilized native population", where tests suggest that "not less than 60 per cent. to 70 per cent. of the general native population" have some kind of sexually transmitted disease.

At that time, several conditions were mistaken for syphilis (or other STIs). For example, yaws and endemic syphilis, neither of which are sexually transmitted. Prejudices about 'African' sexual behavior were used to prop up beliefs about prevalence of STIs (and prejudices about STIs proped up beliefs about sexual behavior).

You might think that things would have moved on a bit, what with eugenics no longer having the cache it had in the thirties, right? But the received view of HIV in high prevalence countries is that 80-90% of transmission is a result of sexual behavior, mostly heterosexual behavior.

From this 'expert’ opinion about ‘Africa’, it is assumed that high HIV prevalence indicates high rates of 'unsafe' sexual behavior, and that high rates of 'unsafe' sexual behavior (or rates that are assumed to be high) indicates high HIV prevalence, or that prevalence will reach high levels in the foreseeable. It’s pretty easy to spot the pig-headed circularity in the argument.

So, how far have we moved on 80 years after the Eugenics Review quote, above? Here’s Catherine Hankins, from the Amsterdam Institute for Global Health and Development (formerly a senior officer in UNAIDS):
As Hankins surmises, in some cultures what you do with your sexual partners over time is different. In the West we tend to be serially monogamous.
In Africa, if you've had sex with someone at some point, the door isn't considered closed on picking up on that relationship again.
"Take a middle-class African businessman. He has had five women - nothing excessive. But the pattern we find is that he has a wife. He also has an on-off affair with an office colleague. He also has what the French call a 'deuxième bureau' - a mistress who might have a child. And once a year he goes back to his home village and has sex with his original village sweetheart. Then he gets HIV from a bar girl on a business trip.
"Within a year he may have infected four other women. Now, if I've had five sexual partners and catch HIV from the fifth, as a western woman I'm unlikely to return to the other four and infect them!"
You might object that it is unfair to criticize what is clearly just an opinion, however ‘expert’. But policy is based on such opinions, HIV programs are guided by them, enormous amounts of money are spent (entirely in vain) on them. Worse still, the scientific data so assiduously collected shows that Hankins is as wrong as the eugenicists. Ostensibly, at least, Hankins was responding to scientific findings, published in a scientific journal, not to someone's opinion.

You can look through any Demographic and Health Survey you like, where you will find numerous tables about sexual behavior, family life, people’s ability to recall selective tidbits about HIV, etc, but you will not find a country where a large number of people have lots of sexual partners, or engage in sexual activities considered to be unsafe.

In addition, the circularity mentioned above comes across very clearly in Hankins’ invective: HIV prevalence is high because rates of ‘unsafe’ sexual behavior are high, and we know about sexual behavior because HIV prevalence is high. Hankins clearly believes all these prejudices that she expresses about sexual behavior among ‘Africans’!

Three countries account for about one third of all HIV positive people, globally; South Africa (6.8m), Nigeria (3.2m) and India (2m). The same three countries also accounted for more than half of all aids-related deaths in the past few years. It is notable that prevalence is low in India, at less than 0.3%. This compares to about 3% prevalence in Nigeria, and about 19% in South Africa, more than 60 times higher than in India (and it can rise to well over 100 times higher in certain demographics).

Whatever is behind the huge rates of HIV transmission in these countries, which tend to be concentrated in certain geographical areas and populations, it is likely to be something that is amenable to scrutiny, whether it involves the copious quantities of sex that UNAIDS would claim, or something else, for example, dangerously low standards of hygiene and infection control in some health facilities.

Hankins seems intent on mimicking the media approach to HIV, concentrating on relatively rare and infrequent phenomena (deliberate transmission, ‘virgin cures’, fake healers, ‘traditional’ practices, etc), but failing to notice the appalling conditions in healthcare in some of the areas worst hit by HIV. What is it that is deflecting attention from everyday phenomena, allowing such extreme views to prevail, but failing to reduce infections in the worst hit areas?

allvoices

Friday, September 15, 2017

Pre-Exposure Prophylaxis: Risks in the Pipeline?

An estimated 1 million Kenyans are receiving antiretroviral drugs, about 64% of all HIV positive people. Partly as a result of this, death rates, along with the rate of new infections, have continued a decline that started in the early 2000s, and the early to mid 90s, respectively. Now pre-exposure prophylaxis (PrEP) is being added to the country’s HIV strategy, a course of antiretroviral drugs taken by HIV negative people, which should significantly reduce the risk of their being infected.

So this should be a good time to look at how HIV treatment in its various forms should be targeted. ARVs are relatively straightforward, people testing positive can be put on treatment. But PrEP, if it is expected to reduce infections, needs to be prescribed for those most at risk. This is not as simple as it sounds, because HIV resources have so far been flung far and wide in Kenya, as if those who most need them will magically benefit.

The ruling assumption for high prevalence countries has been that 80-90% of all HIV transmission is a result of ‘unsafe’ sexual behavior. HIV prevalence is seen as a reliable indicator of ‘unsafe’ sexual behavior, and ‘unsafe’ sexual behavior, or perceived behavior, is seen as a reliable indicator of prevalence.

This is completely circular, of course. But if these prejudices are carried over from addressing the HIV positive population, and applied equally to the HIV negative population, the bulk of the drugs may as effectively be flushed down the toilet. The majority of Kenyans are, were, or will be sexually active. But the majority are not at risk of being infected with HIV.

Kenya’s HIV epidemic, in common with the epidemics in several other East African countries, is quite old. The virus has been circulating since the 50s and 60s, so the epidemic is about half a century old, give or take a few years. In other countries, such as the DRC, the virus has probably been around for about 100 years, although it must have affected only small numbers of people for many decades.

Don’t be fooled by figures suggesting that HIV has only been around since it was first recognized by doctors in the early 1980s (or just a little bit earlier), and later described by scientists. UNAIDS estimate that prevalence was already about 3% in Kenya by 1990, rising to over 10% later in the decade, to peak at almost 11%. From 2000, prevalence declined for a few years, rose again from 2005, then dropped to 6%.

This suggests that the rate of new infections (incidence) peaked and started to decline in the early to mid 90s, prevalence peaked and started to decline by the late 90s, and death rates would have peaked in the early 2000s. By 2007 prevalence was 8% and it is now 6%, so it has hovered between 6 and 8% for more than 10 years. Declines are slow, irrespective of major interventions.

Although the widespread use of ARVs, which began in the late 2000s, has contributed to a decline in new infections, prevalence and death rates, it is not possible to attribute these improvements to drugs alone. Making PrEP available to all those assumed to be ‘at risk’ of being infected, purely on the basis of the circular argument mentioned above means that this is going to be an expensive, but very ineffective intervention.

This sounds like bad news, but it doesn’t have to be seen that way. If the HIV risks people face could be identified, whether they are sexual or non-sexual, this will reduce the number of people who need PrEP. Most non-sexual risks, for example, exposure to blood and other bodily fluids through unsafe healthcare, cosmetic and traditional practices, are easily and cheaply avoided. No need to give PrEP to all the patients at a clinic when you could just clean up the clinic, right?

But also, things have changed, PrEP allows us to target those most at risk much more accurately than before. If people know they can protect themselves, they will. Clinics can now safely return to the practice of ‘contact tracing’, identifying how each person testing positive may have been infected, and then addressing that source of infection, whether it was a sexual partner, a clinic, a tattoo artist, or whatever.

The decision to discontinue tracing contacts, which was made in a very different context (a rich country, where the bulk of HIV transmissions were occurring among a relatively small population, and resulting from an easily identified set of behaviors) is inappropriate for a country with a massive HIV epidemic, where the risks have not been clearly demonstrated, and averted. In Kenya, for example, the majority of people who become infected with HIV do not face the high risks identified in rich countries, receptive anal sex and injecting drug use.

If identifying how people become infected can allow HIV negative people to avoid being infected, and allow HIV positive people to avoid infecting others, then contact tracing is vital in high prevalence countries. It is also vital if interventions such as PrEP are to be effective, or even affordable. Already, researchers have found that not being able to identify where the risks are coming from will significantly increase the quantity of drugs each person needs, in addition to vastly increasing the number of people deemed to be in need of PrEP.

Despite ample evidence that non-sexual risks are as important as sexual risks, evidence that has been available since the virus was first identified as causing Aids, most research concentrates on reporting sexual risk only, collecting data about sexual risks, recommending strategies to reduce sexual risks only, while ignoring, denying or failing to collect data on non sexual risks.

Mass ARV rollout complements pre-existing trends in HIV epidemics, though not as much as it could have, had the contribution of non-sexual transmission been acknowledged. However, PrEP will be a slow and inefficient solution unless targeted at those truly at risk, as opposed to the tens or hundreds of millions who are sexually active. People can only protect themselves if they know what the risks are, whether they do it by avoiding exposure, or by taking prophylactic drugs.

allvoices

Tuesday, September 12, 2017

HIV in 'Africa':12 Steps to Unknowing Knowns

Sometimes it’s hard to believe that both sexual and non-sexual transmission routes for HIV were recognized in the early 1980s, even before the virus had been identified. Some of the earliest responses included recognizing lack of infection control in health facilities, and transmission rates are likely to have been cut substantially as a result of these responses alone.

The bulk of transmissions in rich countries, such as the US, are still accounted for by male to male sex, with a far smaller proportion being a result of injected drug use. But in poor countries, especially sub-Saharan African countries, where the majority of HIV transmissions occurred and continue to occur, most people infected are not men who have sex with men, nor injected drug users.

The ruling assumption behind HIV ‘strategies’ in high prevalence African countries became ‘promiscuity’. UNAIDS and the HIV industry grew up around claims that 80-90% of HIV transmission in African countries is a result of ‘unsafe’ heterosexual sex. Given the low probability of transmission during heterosexual sex, long-held notions about ‘African’ sexuality were dusted off, and spawned the behavior change industry.

Sex (among Africans, of course) came to be presented as an addiction, a pathological condition. Predictably, one of the most popular approaches to addiction, The Twelve Steps, was adapted for the behavior change sector. Billions of dollars were wasted on programs that were shaped by familiar assumptions about what ‘African’ men do to ‘African’ women, and how frequently.

It’s not clear how much George W Bush himself was involved in earlier versions of behavior change and abstinence only programs, claimed to reduce HIV transmission (and, eventually, eradicate it altogether). But he is likely to have been familiar with the Alcoholics Anonymous program, given his own experience with drink (and evangelical religion).

It would be tedious to go through every step individually, but it’s worth broadly comparing the 12 steps with received views about HIV in ‘Africa’. Aside from connections with a ‘higher power’, confessions, testimonials, evangelism and notions of ‘rescue’ or being ‘saved’, there’s also the oppressive emphasis on ‘abstinence only’ that has been the downfall of all 12 step programs, whatever they aimed to remedy.

It’s like the line in the movie ‘Burn Before Reading’: “Fuck you, Peck! You're a Mormon! Next to you, we all have a drinking problem!” All sex (in ‘Africa’) is ‘unsafe’ sex, all sex is wrong, all sexually active people are ‘promiscuous’, all HIV is either a result of ‘unsafe’ sex, or of contact with someone who engaged in ‘unsafe’ sex.

Why is the HIV industry so firmly wedded to abstinence only programs? They have failed for drink, drugs, sex, gambling, eating, smoking, etc; abstinence-only just doesn’t work. Since all the serious HIV epidemics in sub-Saharan African countries peaked and started to decline, mostly before these behavior change programs had been deified, many millions of people have been newly infected.

If sex were the only risk for HIV, almost everyone would be able to protect themselves, and most would do so. There would only be a minority for whom sex is an addiction, an occupational hazard or unavoidable risk that exposes them to HIV, STIs and other hazards. Most sexually active people are not ‘promiscuous’, and recognizing this is key to reducing HIV transmission in sub-Saharan Africa.

allvoices

Thursday, September 7, 2017

Choke on it: Peak Free Lunch at HIV Inc?

There have been several mentions recently of significant cuts in HIV funding, including PEPFAR and the Global Fund for Aids, TB and Malaria. It is said that funding could be cut by several billion dollars per annum, even as much as one third of all funding. Should we be worried?

According to UNAIDS, funding available for low and middle income countries has grown from $4.8 billion in 2000 to $19.5 billion in 2016. During that time, deaths from Aids have dropped from a peak of 1.9 million people in 2005 to 1 million in 2016.

The number of new infections has gone from about 4.7 million in 1995 to 1.8 million in 2016 and the number accessing treatment has gone from 685,000 people in 2000 to 19.5m people in 2016. The fear is that the number of deaths will cease to drop, or even increase, as the number of people on treatment flattens out or drops.

The gains over the last 15 years are certainly impressive, especially the increases in funding. But the correlation between increases in funding and improvements in HIV indicators is not so clear. Drops in rates of new infections had started many years before, and even death rates had peaked and started to decline before funds such as PEPFAR and GPATM would have had much impact.

In fact, figures for new transmissions in some high prevalence countries started to drop in the 80s (Uganda) and 90s (Kenya and Tanzania), long before big funding and large treatment programs were available. By the 2000s, several countries with serious epidemics were already seeing a substantial downward trend (Zimbabwe), with only an occasional upward blip, such as that experienced in Uganda.

Here are some ways that a lot more could be achieved with a lot less money:
  • Trace the possible source of every new infection; every new infection is potentially the source of more than one further infection, so failure to trace sources represents one of the biggest missed opportunities of the last 30 years of providing HIV services
  • Offer non-HIV healthcare services to those who test negative (as an incentive to testing), eg, free treatment for conditions other than HIV, including STIs
  • Re-examine the relative contributions of non-sexual and sexual infection routes for HIV, which must vary considerably from country to country, even within countries
  • Re-integrate HIV clinics and services into other health facilities, getting rid of expensive parallel HIV-specific structures
  • Distribute funding at a level closer to people on the ground, such as HIV positive people and those providing services
  • Re-direct some of the remaining funding to improving safety in certain service areas, eg, maternal health
  • ‘No blame’ investigations into serious outbreaks, especially among those whose risk should be low, eg, maternal health beneficiaries, virgins, infants, etc
  • Drop failing programs, such as abstinence-only and other behavioral programs that are aimed solely at sexual behavior
  • Listen to leaders who are calling for positive change, for things to be done differently, for a re-think of some of the strategies that have been failing for a long time
Big reductions in HIV funding could be used as an opportunity to make positive changes in the way the remaining funding is spent, and allow each dollar to go much further. Country leaders need to think differently, rather than chaining themselves to strategies that have been failing for years. Massive HIV NGOs and other institutions are too far removed from individual epidemics to be able to see differences between countries and within countries.

What we should worry about is stasis: static thinking in HIV institutions, static research focus in universities, static behavior in health facilities, static attitudes that have not moved on from the sensationalist finger-pointing of the 1980s. Static or falling funding is irrelevant so long as HIV spending remains independent of what’s happening on the ground. A radical drop in funding may bring about the very changes that have been wanting for decades.

allvoices

Monday, September 4, 2017

Mandatory HIV Tests: Shouldn’t Zambians Decide?

The Lancet has an article by Andrew Green about the recent decision of the government of Zambia to introduce mandatory HIV testing in all government health facilities; if they visit a clinic, they must agree to be tested. Green urges against mandatory testing, using the often heard claim that people will be reluctant to go to health facilities if they think they will be compelled to take a HIV test.

It is argued that people could feel ‘stigmatized’ if they are found to be HIV positive, or perhaps even if they are just tested for it. Indeed, the orthodox view of HIV is that it is almost always sexually transmitted in African countries, and that there are excessively high levels of ‘promiscuity’ (in case you were wondering where the stigma comes from). Popular supporters of the orthodoxy Avert.org, write: “Unprotected heterosexual sex drives the Zambian HIV epidemic, with 90% of new infections recorded as a result of not using a condom”.

Zambia ranks 7th in the world by HIV prevalence, around 13%, and 9th by number of people infected with the virus, about 1.2 million. The epidemic in Zambia probably started before the 80s because it had already reached 9% prevalence by 1990. Prevalence has stood at over 10% for about 25 years. It peaked in the mid 90s, so it has only dropped by a few percentage points in the past two decades. Population growth would suggest that new infection rates have not dropped at all.

Health Minister Chitalu Chilufya told Green “We can't continue doing things the same way and hope that things will get better”. Chilufya is a doctor, not just a politician, and it’s hard to disagree with his response. What has been done so far has failed. The epidemic has remained ahead of the HIV industry, with 60,000 new infections a year, far outnumbering the 20,000 deaths from AIDS. Maybe it’s time to do something different?

Green cites the World Health Organization as an authority for the view that testing should not be mandatory or coerced. But where does the view that people will stop going to health facilities come from? Is there any country that has made testing mandatory, and found that people stopped seeking healthcare of any kind? Perhaps people are more reluctant when it comes to HIV because they know that it is seen as an indication that they have been ‘promiscuous’. Might they be more willing to be tested if WHO drops their mantra about sexual transmission?

Cuba is an example of a country that has taken a very different path from almost every other country when it comes to HIV, and healthcare as a whole. Most countries are heavily influenced (dominated?) by the WHO, or by US funding and HIV ‘policy’. But things in Cuba couldn’t be more different from Zambia, and sub-Saharan Africa more broadly, with one of the best controlled HIV epidemics in the world.

The UNAIDS current ditty is ‘90-90-90’, at least 90% of HIV positive people tested, at least 90% of those found positive on medication and at least 90% with an undetectable viral load by the year 2020. So, what is their strategy to achieve this, aside from assuming that everyone should continue to copy all the failed strategies of the US, hoping that things will be different for them?

Targeting people thought to be at risk of HIV purely on the basis of their perceived levels of ‘promiscuity’ means those infected non-sexually, or at risk of being infected, will be missed. Unless they start to estimate non-sexual transmission sources, and start to reduce transmissions of this type, untold numbers of Zambians will be infected, and can go on to infect others, directly or indirectly.

If the orthodoxy are confident that 90% of HIV infections are sexually transmitted, they have nothing to lose by tracing people’s contacts, sexual and non-sexual. This doesn’t violate anything. HIV positive people have a right to know how they were infected and HIV negative people have a right to know how to protect themselves from risks. But if Zambia 'returns to the flock', and keeps all testing voluntary, what rights might this threaten?

If contacts are not traced, many people won’t know what the risks are, and therefore how to protect themselves. HIV positive people won’t know for sure how they were infected. According to the Lisbon Declaration on the Rights of the Patient, people are entitled to be informed of things like this by their health facilities, by healthcare personnel. People are also entitled to accurate health information and education. Where is this accurate information to come from if health facilities don’t collect it, or if it is never analyzed or followed up?

People have a right to know about hygiene, safety and infection control in health facilities, and similar information. It would be obtuse to argue for a right to health or healthcare, but against ensuring safe healthcare. In any population, including Zambia’s, there are unexplained transmissions. Examples include HIV positive virgins (who were not infected through mother to child transmission), HIV positive people who have never had sex with a HIV positive person, HIV positive people whose only sexual partner has tested HIV negative, HIV positive infants whose mother is negative, etc.

Green seems to be arguing on behalf of an orthodoxy that is afraid people will realize that there are non-sexual risks, as well as sexual, and that people have been systematically denied their right to this information. He seems to want to help cover up the fact that possible non-sexual infections that may point to unsafe healthcare, for example, have never been investigated in high HIV prevalence countries, or any countries whose HIV strategy is entirely dominated by the WHO, CDC, UNAIDS and the like.

Rather than challenging opposition to mandatory HIV testing, perhaps Zambia could investigate possible healthcare associated transmission of HIV. There is no violation involved if non-sexual contacts are traced, such as unsafe healthcare, traditional practices, or even cosmetic practices, such as tattooing. If Zambia doesn’t do something different, the epidemic could follow the Lindy Effect, lasting another 40 years. But the matter should be decided by Zambians, not by The Lancet.

allvoices

Friday, September 1, 2017

America's Other Epidemic: HIV in Confederate States

Almost 70% of new HIV infections each year in the US are a result of male to male sex. The other 30% results from injecting drug use and non-male to male sex. But prevalence varies considerably from state to state. An estimated 45% of all HIV positive people live in the southern region of the US. Prevalence is also high in some northeastern states, especially in some cities.

The southern region consists of Alabama, Arkansas, Delaware, Dist. Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia. Prevalence is highest in the District of Columbia; at 3.61% that's higher than in 138 countries. Florida has the highest HIV positive African American population, 48,500 people, higher than in 109 countries.

In the southern states, an estimated 55% of the people living with HIV are African Americans. The figure for the Midwest is 47%, 42% for the Northeast and 18% for the West. Although African Americans only make up just over 13% of the population, almost half live in southern states, about 22 million people. And HIV prevalence among African Americans in southern states is 7 times higher than it is among white Americans.

Prevalence in every southern state is several times higher among African Americans than it is among white Americans; it’s 3 times higher in the District of Columbia and 9 times higher in Maryland. In 2014, almost half of all new HIV infections in the US were among African Americans and two thirds of people living with HIV in southern states are African Americans.

The contrast is also stark for heterosexual HIV: there were more than 4,600 female African Americans infected, compared to just over 1,100 female white Americans infected. Infections classified as ‘white heterosexual male’ are low in number, whereas an estimated 2,000 were classified as ‘black heterosexual male’.

Why would sexual behavior among African Americans, homosexual and heterosexual, be more risky than sexual behavior among white Americans? And why would sexual behavior be exceptionally risky in southern states? Or is there more to high HIV prevalence than levels of sexual behavior and types of sexual practice?

To put it another way, do African Americans tend to conform to the many stereotypes about them, such as levels of sexual behavior, types of sexual behavior, attitudes towards sex, etc? Or are there things about the environment, such as living conditions, economic and social conditions and conditions in healthcare facilities, for example, that increase the risk of infection that African Americans face?

It’s hard to know what conditions, exactly, could increase risk to such a degree, or even how. But there certainly are factors that are particularly acute in southern states. The bottom 11 states for life expectancy are in the southern region, as are most of the states with the highest incarceration rates. Almost all the poorest states are in the south. States with the lowest rankings for educational attainment, at all levels, are in the south. Rates of unemployment and homicide rates are high.

Of course, some of the southern states are among the richest by GDP, with the highest household income. But they also have the some of the highest levels of inequality, with several states ranking lowest for economic indicators and several ranking poorest in the US. As a result, most of the states with the lowest Human Development Index are in the southern region. Rates of religiosity are high.

Some sexual practices are low risk for HIV, some are high risk. But why do African Americans, gay and straight, face far higher risk of infection than white people? Prevalence in Somalia, Senegal, Niger, Sudan, Morocco, Tunisia and Egypt is lower than in the US (.6%). Prevalence in Burundi, DRC, Liberia, Burkina Faso, Eritrea and Mauritania is lower than in the US south (1.12%). HIV prevalence does not correlate well with sexual behavior data. So what other factors could be involved?

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