Sunday, June 27, 2010

Facts, Facts, Facts, Just Not That One

In an article entitled ‘Aids and Evidence: Interrogating Some Ugandan Myths’, Tim Allen concludes something that others have also concluded about HIV, in relation to Uganda, in particular: ‘Much less is known about the epidemic than is asserted’. We don’t know why prevalence and even incidence in Uganda dropped from very high rates in the 1980s to far lower rates in the 2000s. There is a lot of speculation about why this happened, but it remains speculation. It is possible that much of the apparent improvement in Uganda’s epidemic was a result of the disease taking its natural course. And it is fairly clear that many of the things that are said to have contributed to the epidemic’s decline either didn’t occur or didn’t have much effect.

It was established quite early on that HIV could be transmitted through blood and other bodily fluids, not just through sexual contact. This meant that people could be infected through medical procedures such as injections and blood transfusions, intravenous drug users could be infected, HIV positive mothers could pass on the infection to their babies, either in the womb, during delivery or through breastfeeding and people might even be infected by their hairdresser or manicurist, if they didn't take proper precautions. Early on in the epidemic, these considerations probably influenced the measures that countries such as Uganda took to reduce the spread of HIV. But later, as HIV became more dominated by political and religious leaders, it was treated as if it was almost entirely sexually transmitted. According to the official view, this is only true of developing countries, though.

For me, the thing that doesn’t ring true in the many allusions to Uganda’s great success in fighting HIV is that they all assume the truth of the behavioural paradigm. They all assume that because HIV is mainly sexually transmitted, what a country needs to do is tell people everything about ‘safe sex’, give them some condoms and everything will be ok. When Uganda first started putting in place measures to reduce the spread of HIV, they probably didn’t subscribe to what became the enduring fiction that drives HIV policy, national and international. But later, when donors, politicians, religious prognosticators and commercial interests become involved, Uganda said whatever was required to get the money flowing and to keep it flowing.

Because the most prominent people in the industry so much want everyone to believe that HIV is primarily sexually transmitted, they even want to believe it themselves, they have rewritten everything that happened before the fiction was created. They so much want this fiction to be true that they refuse to countenance the possibility that a certain amount of HIV, perhaps a very large amount, comes from non-sexual processes. Even though there are measures that can be taken to prevent non-sexual HIV transmission, these measures are generally not taken in developing countries. Even though we know that it is not possible to significantly influence people’s sexual behaviour just by telling them what they should and shouldn’t do, that’s what most HIV prevention programmes consist of.

Given that those who control the HIV industry and its considerable wealth base all their decisions on a fiction, it’s not surprising that others, who don’t have access to the same levels of data, expertise and other resources, weave their own fictions. A man calling himself ‘Dr’ Ayiko, seems to accept the fiction based on the behavioural paradigm. He therefore also accepts the story about Uganda reducing HIV prevalence by exhorting people to abstain from sex, be faithful to one partner and use condoms. But he feels that this approach no longer works and that one of the main reasons for the continued spread of HIV is ‘intentional’ transmission.

I assume he means the intentional spread of HIV through sexual means. He refers to the bill currently being discussed in the Ugandan parliament that would make it a capital offence to intentionally spread HIV and I think the bill is aimed at sexual transmission, though I’m not sure and I doubt if many Ugandans, including the ‘Dr’ in question, are sure either. Anyhow, Dr Ayiko says that ‘in virtually all the 112 districts [of Uganda], there are people who boast of having successfully lured 20 plus people into unprotected sex knowing they are HIV positive’.

The deluded man goes on to make the ‘modest’ assumption that there are eight such people in each district and that if each of them infects 20 people who all go on to infect two more people, there will be many tens of thousands of people infected (although his calculations go a bit awry here). Even if Dr Ayiko is right in assuming that there are many people who behave this way and that they have many partners who also have many partners, HIV is not transmitted quite so fast. If it was, HIV prevalence would be a lot higher, in every country in the world, not just in Uganda. The partners of HIV positive people can remain HIV negative for many years, even if they are having regular, unprotected sex. HIV just doesn’t spread that quickly through heterosexual sex.

What the doctor needs to do is calculate how many times each of the 8 people per district would have had to have sex with the 20 others and how many times they would have to have sex in order to infect two others each, given the probability of heterosexual HIV transmission per sex act. That’s not a simple calculation and I won’t even attempt it here. But even if the probability is relatively high, each HIV positive person would have to have sex with each HIV negative person several hundred times for HIV to spread at the speed Dr Ayiko suggests. Deliberately spreading HIV is despicable, especially where there may be force or coercion involved. But deliberate spread of HIV through heterosexual intercourse would be a very slow process indeed. However heinous, it is not a major factor in Uganda’s HIV epidemic.

I would suggest to Dr Ayiko and others who support the Ugandan bill that purposely ignoring what could be the main modes of HIV transmission, non-sexual modes, is despicable. Not only is it despicable but some non-sexual modes of transmission, such as certain unsafe medical practices, are very efficient, far more efficient than sexual transmission. Worse still, the same people who have all the data and the epidemiological expertise that Dr Ayiko lacks are the ones who continue to ignore these modes of HIV transmission. UNAIDS, WHO, CDC and the rest of the HIV industry know that they are wrong about non-sexual HIV transmission in developing countries but they don’t admit it, for some reason.

Tim Allen notes the current dependency on large scale rollout of antiretroviral treatment (ART) as a possible remedy for HIV epidemics, despite the fact that we know so little about how these epidemics increase and decline. He warns that such dependence could give rise to widespread resistance, which could result in Uganda’s epidemic taking a serious turn for the worse. And it does seem sensible to find out how the epidemic progressed in the first place before climbing on the latest bandwagon, ART. In a country where it is not even clear how much medical treatment contributed to the epidemic, it seems rash to advocate purely for more medical treatment. There’s something of the black box about the HIV industry.


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