Since mentioning the Vienna Declaration (on drug policy) yesterday, I have heard that Kenya is one of the countries that 'may' be funded to supply intravenous drug users with sterile injection equipment. The Declaration objects to current policy in many countries, which criminalizes intravenous drug use and does not permit 'harm reduction' programmes, such as injection equipment exchange.
For many years it has been known that harm reduction programs can help reduce a social problem such as intravenous drug use. These programs can also play a part in reducing transmission of viruses such as HIV and hepatitis. Despite the evidence, a lot of governments of countries with high levels of intravenous drug use refuse to allow harm reduction programs, some as a result of HIV funders banning this particular use of funds. These funders argue that distributing sterile injection equipment will give rise to increased intravenous drug use, although this has been shown to be untrue.
One of the biggest sources of HIV prevention funding is the US's PEPFAR Program (President's Emergency Plan for Aids Relief). This fund has been criticized since it began for having various clauses banning certain types of program, including supply of sterile equipment to intravenous drug users. Even when PEPFAR didn't specifically ban measures, things perceived to be deprecated were often avoided for fear of losing funding. Now, apparently, PEPFAR has relaxed some of its conditions. Let's hope perceptions also relax.
According to NASCOP (Kenya's National Aids Control Program) head, Dr Nicholas Muraguri, needle sharing is second only to blood transfusion when it comes to HIV transmission efficiency. Intravenous drug use with contaminated equipment is estimated to account for 3.8% of new HIV infections a year. Reducing this risk with an injection equipment exchange program could prevent hundreds of new infections every year. However, intravenous drug users are worried that police will still harass them, especially if they find them with injecting equipment.
But it is highly significant that Dr Muraguri acknowledges that injection equipment sharing is an important mode of HIV transmission. The WHO estimates that around 17% of HIV infections in Africa are due to unsafe injections. That's injections in healthcare settings, not injections relating to intravenous drug use. It's not just injections that can spread HIV, either. All sorts of medical procedures can carry a risk if adequate precautions are not taken to ensure blood safety and sterile conditions. I hope Dr Muraguri will get behind a program that takes measures to reduce medical transmission, given how efficient a transmitter of HIV it is.
Adding together injection safety for intravenous drug users and medical safety, this may account for around 30% of all HIV transmission. Almost all current HIV prevention programs in African countries assume that HIV is mainly transmitted sexually. However, changing sexual behavior will have no impact on non-sexual HIV transmission (sounds obvious, but try telling UNAIDS) and some programs, such as mass male circumcision, could increase non-sexual transmission.
It's time to move away from the rather atavistic attitude that people with HIV must have done something bad and should be punished accordingly. The effect of this attitude has been to punish people who are vulnerable, such as women, children or poor people, or who are already persecuted and discriminated against, such as intravenous drug users, men who have sex with men and sex workers. This sort of atavism has resulted in HIV continuing to spread, even in countries that have the wherewithal to avoid a serious epidemic. And it continues to be a barrier to reducing transmission in countries with serious epidemics.
But if you insist that most HIV in Africa is transmitted sexually, as the HIV industry does, you are thereby branding Africans as sexually promiscuous if they are found to be HIV positive. If you insist that Africans tend to be sexually promiscuous, it is pointless to then call for stigmatization of HIV positive people to be avoided, as the HIV industry does. Equating a HIV positive diagnosis with sexual promiscuity is what gives rise to HIV positive people being stigmatized.
Friday, July 30, 2010
Thursday, July 29, 2010
HIV: A Story of Blame, Stigma and Criminalization
I may have given the impression in earlier blog postings that I think the Vienna Aids Conference was a complete (and rather repulsive) waste of time and money. Well, there was one good thing to rise from the ashes; the Vienna Declaration (on drug policy). The history of HIV/Aids has been a story of blaming men who have sex with men, sex workers, drug users and Africans. Those whose behavior has been blamed for spreading HIV have been stigmatized and often criminalized.
The true costs of the conference are probably far higher than its achievements could justify, it's unlikely they will every be made public. But challenging policy relating to intravenous drug users, who are at particularly high risk of being infected with HIV and other diseases, is an excellent outcome. You can sign the declaration to show your support.
Persecuting intravenous drug users and putting them in prison has not worked. Despite this, it is still the response in many countries in the world. Yet there are countries in Eastern Europe and Asia who have HIV epidemics that are mainly fueled by intravenous drug use. Outside of Africa, it is said that one third of infections come from illicit drug use. These countries don't have prevalence rates anywhere near those found in a lot of African countries (most of which don't have high levels of intravenous drug use), but they are rising fast. The Vienna Declaration states that such responses to intravenous drug use create barriers to effective HIV prevention, treatment and care.
Much of the spite that has been directed at drug users and that has informed drug policies comes from people who also insist that harm reduction programs, such as supplying users with clean equipment, actually increases the problem. There is decades of evidence to show that this is not the case, that this kind of harm reduction doesn't increase drug use and that it does reduce the spread of blood borne diseases. But evidence has never had much impact on spite and prejudice.
The epidemics in Eastern European and Asian countries that are currently relatively low, but may deteriorate if the terms of the Vienna Declaration are ignored, are extremely worrying. The HIV industry has shown that it is perfectly capable of looking on while epidemics go out of control. This time may be different, we'll have to wait and see. There are many countries that have HIV epidemics that are confined to groups such as men who have sex with men, commercial sex workers and intravenous drug users and have never spread beyond these groups. But it's too late for the worst epidemics in the world, those found in many African countries.
Many countries in Africa have what the HIV industry refer to as 'generalized' epidemics. Most of the people infected are not men who have sex with men, commercial sex workers or intravenous drug users. They are Africans. As surely as if the industry had used the labels 'queer', 'slut' and 'junkie', the industry has stigmatized all Africans by its 'typology' of epidemics. For the industry, Africans have too much sex, much of it is unsafe sex, the men have no respect for the women, the women have no respect for themselves and none of them care much about their children, either.
Consider another couple of epidemics. An assessment of sex workers in three Afghan cities found that prevalence of HIV was 0.19%, despite the fact that 'risky sexual practices were common'. An assessment was carried out in Lebanon involving sex workers, intravenous drug users and men who have sex with men. HIV prevalence was 3.7% among men who have sex with men. There were no cases of HIV among the intravenous drug users or among the sex workers.
These HIV figures for Afghanistan and Lebanon are not for the countries as a whole, they are just for 'at risk' groups, what the HIV industry sometimes refers to as most at risk groups. According to their typology of epidemics, these two countries have 'concentrated' epidemics, where most people infected with HIV are members of one or more most at risk group. HIV prevalence may well increase and the epidemics may, according to the industry's lore, somehow become generalized epidemics. This would be unprecedented, but perhaps it could happen.
But the question the industry hates to hear asked is why, in certain countries only, did a difficult to transmit virus become a 'generalized' epidemic? Why was the virus transmitted (and continues to be transmitted) rapidly among populations, regardless of their sexual behavior? In Swaziland, in the population as a whole, HIV prevalence is over 130 times higher than it is among sex workers in those Afghan cities. The industry has had to build up a whole mythology about African sexuality to explain how this could happen. This mythology is unashamedly racist and sexist, but many Western institutions and governments, and especially the Western press, are racist and sexist, through and through.
With a very minor exception, the issue of non-sexual HIV transmission was not discussed at the Vienna Aids Conference or, at least, there was no hyped press release for the hoards of reporters to repeat, unchanged, unchallenged and unanalyzed. The WHO's Injection Safety Newsletter had an article by Savanna Reid asking why the role of health care transmission was barely acknowledged during the course of the junket. There have been significant outbreaks of HIV that have been caused by unsafe medical practices over the years but, aside from a few exceptions, they have remained uninvestigated. Such outbreaks have occurred in African countries but none have been investigated, to date.
The HIV industry is aware that HIV is transmitted non-sexually in developing countries, they just don't know to what extent because they have never been bothered enough to investigate. When 40,000 people in the US were found to have been treated at a clinic that had low standards of safety, all of them were contacted and tested for HIV, hepatitis B and C. (Some cases of hepatitis were found, non of HIV). But in countries where health care standards are low and many people don't even have access to qualified personnel, such outbreaks are ignored. The industry says they don't want people to lose confidence in their health services, which would be laughable, except that it is the very point being disputed.
Perhaps at the next Aids industry junket, those infected with HIV should wear armbands with a symbol to represent how they were infected, whether it's through sex work, same sex relationships or intravenous drug use. Those infected non-sexually can wear armbands without any symbol because, as far as the industry is concerned, they don't exist. And as for industry officials, they definitely should wear armbands to signify their part in the epidemic. I just can't decide what symbol would be most appropriate. Suggestions?
The true costs of the conference are probably far higher than its achievements could justify, it's unlikely they will every be made public. But challenging policy relating to intravenous drug users, who are at particularly high risk of being infected with HIV and other diseases, is an excellent outcome. You can sign the declaration to show your support.
Persecuting intravenous drug users and putting them in prison has not worked. Despite this, it is still the response in many countries in the world. Yet there are countries in Eastern Europe and Asia who have HIV epidemics that are mainly fueled by intravenous drug use. Outside of Africa, it is said that one third of infections come from illicit drug use. These countries don't have prevalence rates anywhere near those found in a lot of African countries (most of which don't have high levels of intravenous drug use), but they are rising fast. The Vienna Declaration states that such responses to intravenous drug use create barriers to effective HIV prevention, treatment and care.
Much of the spite that has been directed at drug users and that has informed drug policies comes from people who also insist that harm reduction programs, such as supplying users with clean equipment, actually increases the problem. There is decades of evidence to show that this is not the case, that this kind of harm reduction doesn't increase drug use and that it does reduce the spread of blood borne diseases. But evidence has never had much impact on spite and prejudice.
The epidemics in Eastern European and Asian countries that are currently relatively low, but may deteriorate if the terms of the Vienna Declaration are ignored, are extremely worrying. The HIV industry has shown that it is perfectly capable of looking on while epidemics go out of control. This time may be different, we'll have to wait and see. There are many countries that have HIV epidemics that are confined to groups such as men who have sex with men, commercial sex workers and intravenous drug users and have never spread beyond these groups. But it's too late for the worst epidemics in the world, those found in many African countries.
Many countries in Africa have what the HIV industry refer to as 'generalized' epidemics. Most of the people infected are not men who have sex with men, commercial sex workers or intravenous drug users. They are Africans. As surely as if the industry had used the labels 'queer', 'slut' and 'junkie', the industry has stigmatized all Africans by its 'typology' of epidemics. For the industry, Africans have too much sex, much of it is unsafe sex, the men have no respect for the women, the women have no respect for themselves and none of them care much about their children, either.
Consider another couple of epidemics. An assessment of sex workers in three Afghan cities found that prevalence of HIV was 0.19%, despite the fact that 'risky sexual practices were common'. An assessment was carried out in Lebanon involving sex workers, intravenous drug users and men who have sex with men. HIV prevalence was 3.7% among men who have sex with men. There were no cases of HIV among the intravenous drug users or among the sex workers.
These HIV figures for Afghanistan and Lebanon are not for the countries as a whole, they are just for 'at risk' groups, what the HIV industry sometimes refers to as most at risk groups. According to their typology of epidemics, these two countries have 'concentrated' epidemics, where most people infected with HIV are members of one or more most at risk group. HIV prevalence may well increase and the epidemics may, according to the industry's lore, somehow become generalized epidemics. This would be unprecedented, but perhaps it could happen.
But the question the industry hates to hear asked is why, in certain countries only, did a difficult to transmit virus become a 'generalized' epidemic? Why was the virus transmitted (and continues to be transmitted) rapidly among populations, regardless of their sexual behavior? In Swaziland, in the population as a whole, HIV prevalence is over 130 times higher than it is among sex workers in those Afghan cities. The industry has had to build up a whole mythology about African sexuality to explain how this could happen. This mythology is unashamedly racist and sexist, but many Western institutions and governments, and especially the Western press, are racist and sexist, through and through.
With a very minor exception, the issue of non-sexual HIV transmission was not discussed at the Vienna Aids Conference or, at least, there was no hyped press release for the hoards of reporters to repeat, unchanged, unchallenged and unanalyzed. The WHO's Injection Safety Newsletter had an article by Savanna Reid asking why the role of health care transmission was barely acknowledged during the course of the junket. There have been significant outbreaks of HIV that have been caused by unsafe medical practices over the years but, aside from a few exceptions, they have remained uninvestigated. Such outbreaks have occurred in African countries but none have been investigated, to date.
The HIV industry is aware that HIV is transmitted non-sexually in developing countries, they just don't know to what extent because they have never been bothered enough to investigate. When 40,000 people in the US were found to have been treated at a clinic that had low standards of safety, all of them were contacted and tested for HIV, hepatitis B and C. (Some cases of hepatitis were found, non of HIV). But in countries where health care standards are low and many people don't even have access to qualified personnel, such outbreaks are ignored. The industry says they don't want people to lose confidence in their health services, which would be laughable, except that it is the very point being disputed.
Perhaps at the next Aids industry junket, those infected with HIV should wear armbands with a symbol to represent how they were infected, whether it's through sex work, same sex relationships or intravenous drug use. Those infected non-sexually can wear armbands without any symbol because, as far as the industry is concerned, they don't exist. And as for industry officials, they definitely should wear armbands to signify their part in the epidemic. I just can't decide what symbol would be most appropriate. Suggestions?
Wednesday, July 28, 2010
HIV Treatment As Prevention; the Hole in the Patch
Various factions in the HIV industry, and indeed some in the global health industry, are like a bunch of inept tinkers trying to patch up a colander in the hope that they can use it as a pot. They all rush to one hole and stick their latest ill-gotten patch on it, and then stand back to see how well it works. Invariably it doesn't work, but they churn out some more patches and stick them on other holes that they belatedly start to notice. Sooner or later there are patches on top of patches and, alas, still too many holes for boiling cabbage.
What the industry has always tended to miss is that when they try to stick on a patch, for example, by telling everyone about how HIV is transmitted and how they can avoid being infected, they find that there is no infrastructure for this to be effected. There are too few schools, too many students, too few teachers who know too little and too many barriers for some people to go to school or for others to gain much by doing so. A large proportion of the population does not have access to the mass media, which may or may not have the freedom to do what the HIV industry would like them to do.
Once testing was possible, this too was 'rolled out'. And over 20 years or so, about 20-25% of people in developing countries found out whether they were infected or not. It was established that HIV was transmitted sexually and that condoms gave good protection against infection. So condoms were distributed and people were encouraged to use them. Estimates of condom usage vary but it has been difficult to get condoms to the right place in time and to encourage consistent use. But health facilities, both primary health care facilities and others, such as pharmacies and sexually transmitted infection clinics were underfunded, understaffed and oversubscribed. To many, they were completely inaccessible.
So it was expected that educating people about HIV and providing them with what meager facilities were available would be a good place to start. But many people didn't go to school and schools were not very good. And many people didn't go to hospitals and they weren't very good either. The majority of HIV 'prevention' strategies were stymied not because they were rubbish (though many were), but because there were certain prerequisites that hadn't been met. Obvious though some of these prerequisites were, health, education, infrastructure, social services and the rest, they are still wanting.
HIV is not the only disease that has attracted this kind of 'vertical' approach, nor the only disease that the global health industry has failed to have much impact on. There is a whole set of water-borne diseases, some of which have been approached individually, some not. Most of these efforts have failed, not because the diseases can't be prevented and/or cured but because people who suffer from them are still drinking contaminated water. Clean water and adequate sanitation would enable people to avoid some of the most debilitating and deadly diseases.
Respiratory infections kill millions of people, especially infants and under fives. But the environmental and other conditions that result in these infections killing so many have not been dealt with. Many infants die because they don't receive even the most basic level of care; young children die of measles and meningitis; mothers die because of inadequate maternal care; and people of all ages die of malaria, TB and other treatable and curable diseases.
Ensuring health is not about curing diseases, it is about providing people with the conditions that will allow them to avoid these diseases. But the tinkers in the industry think they can run around after sick people and thereby keep others healthy. 'Treatment is prevention', the idea that putting all HIV positive people on antiretroviral drugs so that they are less likely to transmit the virus to others, will fail. It will not fail because the drugs don't work, they do. But most people have not been tested; others refuse to take the drugs; others don't have access to the drugs; and others still take the drugs but they don't work. And while this is going on, far too many people are still being infected with HIV.
Developing countries do not have the infrastructure to test every single sexually active person, let alone test them every year. They don't have the capacity to supply every HIV positive person with drugs, to monitor them, treat them and support them adequately. You can introduce 'task shifting' (a proposed alternative to providing enough trained professionals), microbicides that may work a little, circumcision that probably won't work very well and any other patches the tinkers can dream up. But those basic things that people need most correspond to their human rights.
Allowing people their human rights may not result in HIV being eradicated quickly, given that it has been spreading so long and has infected so many. But the only hope for reducing transmission to the extent that the virus can be eradicated completely is for all those infected to receive treatment and care and for all those who are HIV negative to be provided with everything they need to ensure their complete health. And providing treatment and care and preventing the further spread of HIV requires good health services, schools, infrastructure and public services. Overall health doesn't result from targeting a handful of diseases. Rather, overall health and well-being in a population means that most diseases can be targeted, treated and controlled.
What the industry has always tended to miss is that when they try to stick on a patch, for example, by telling everyone about how HIV is transmitted and how they can avoid being infected, they find that there is no infrastructure for this to be effected. There are too few schools, too many students, too few teachers who know too little and too many barriers for some people to go to school or for others to gain much by doing so. A large proportion of the population does not have access to the mass media, which may or may not have the freedom to do what the HIV industry would like them to do.
Once testing was possible, this too was 'rolled out'. And over 20 years or so, about 20-25% of people in developing countries found out whether they were infected or not. It was established that HIV was transmitted sexually and that condoms gave good protection against infection. So condoms were distributed and people were encouraged to use them. Estimates of condom usage vary but it has been difficult to get condoms to the right place in time and to encourage consistent use. But health facilities, both primary health care facilities and others, such as pharmacies and sexually transmitted infection clinics were underfunded, understaffed and oversubscribed. To many, they were completely inaccessible.
So it was expected that educating people about HIV and providing them with what meager facilities were available would be a good place to start. But many people didn't go to school and schools were not very good. And many people didn't go to hospitals and they weren't very good either. The majority of HIV 'prevention' strategies were stymied not because they were rubbish (though many were), but because there were certain prerequisites that hadn't been met. Obvious though some of these prerequisites were, health, education, infrastructure, social services and the rest, they are still wanting.
HIV is not the only disease that has attracted this kind of 'vertical' approach, nor the only disease that the global health industry has failed to have much impact on. There is a whole set of water-borne diseases, some of which have been approached individually, some not. Most of these efforts have failed, not because the diseases can't be prevented and/or cured but because people who suffer from them are still drinking contaminated water. Clean water and adequate sanitation would enable people to avoid some of the most debilitating and deadly diseases.
Respiratory infections kill millions of people, especially infants and under fives. But the environmental and other conditions that result in these infections killing so many have not been dealt with. Many infants die because they don't receive even the most basic level of care; young children die of measles and meningitis; mothers die because of inadequate maternal care; and people of all ages die of malaria, TB and other treatable and curable diseases.
Ensuring health is not about curing diseases, it is about providing people with the conditions that will allow them to avoid these diseases. But the tinkers in the industry think they can run around after sick people and thereby keep others healthy. 'Treatment is prevention', the idea that putting all HIV positive people on antiretroviral drugs so that they are less likely to transmit the virus to others, will fail. It will not fail because the drugs don't work, they do. But most people have not been tested; others refuse to take the drugs; others don't have access to the drugs; and others still take the drugs but they don't work. And while this is going on, far too many people are still being infected with HIV.
Developing countries do not have the infrastructure to test every single sexually active person, let alone test them every year. They don't have the capacity to supply every HIV positive person with drugs, to monitor them, treat them and support them adequately. You can introduce 'task shifting' (a proposed alternative to providing enough trained professionals), microbicides that may work a little, circumcision that probably won't work very well and any other patches the tinkers can dream up. But those basic things that people need most correspond to their human rights.
Allowing people their human rights may not result in HIV being eradicated quickly, given that it has been spreading so long and has infected so many. But the only hope for reducing transmission to the extent that the virus can be eradicated completely is for all those infected to receive treatment and care and for all those who are HIV negative to be provided with everything they need to ensure their complete health. And providing treatment and care and preventing the further spread of HIV requires good health services, schools, infrastructure and public services. Overall health doesn't result from targeting a handful of diseases. Rather, overall health and well-being in a population means that most diseases can be targeted, treated and controlled.
Sunday, July 25, 2010
Was the Tenofovir Gel Microbicide Trial Ethical?
Was the trial ethical and were the results valid? The two questions go hand in hand.
It's quite hard to decide if there was something unethical or invalidating about the Tenofovir Gel Microbicide trial because there could be important details about the trial that have not yet been published. For a start, the trial assumes that most HIV transmission among the participants is sexual. But did the researchers involved actually establish that HIV transmission was all or even mostly sexual? If they did, they haven’t said so in the paper.
The question is important because, during the course of the trial, researchers would have had the opportunity to find out, for each participant who became infected with HIV, how they became infected. One might say they had a duty to find out how they became infected. Were the partners of all the women who seroconverted HIV positive? I don't believe this data was collected. If it was, it should have been published because those who were infected non-sexually should have been excluded from the results. The gel is supposed to protect against heterosexually transmitted HIV, not, for example, HIV transmitted by unsafe medical procedures.
Participants were given the gel as a prophylactic against HIV. They were given to understand that they would be protected against HIV infection. They wouldn't have been told that they were protected against non-sexual HIV transmission. But they don't appear to have been warned about the possibility of non-sexual transmission. If the researchers didn’t exclude the possibility of non-sexual HIV transmission, and they don’t appear to have done so, the results are of questionable validity.
Nearly 900 people were recruited to take part in a trial and it was known that some, perhaps a lot of participants, would become infected with HIV before the end of the trial. It was not known how many would become infected or which participants. Perhaps non-participants in the area may face an even higher risk of becoming infected. But I don't think that excuses those running the trial for failing to ensure the safety of those taking part, or for failing to establish the cause of each HIV infection.
Participants were "provided with comprehensive HIV prevention services (HIV pre- and post-test counseling, HIV risk reduction counseling, condoms, and STI treatment), reproductive health services...". They were made aware of the risk of being infected with HIV sexually, but not non-sexually; this is not comprehensive. But despite this preparation, which surpasses the level of prevention available to most people in most African countries, HIV transmission rates were extremely high.
Why, given all these precautions, including very high condom use, were transmission rates so high? And why did the researchers not make any attempt to find out how people were becoming infected? Did they not have a duty to find out if their gel could even have had any influence on rates of HIV infection, or what level of influence it could have had?
In fact, it is not accurate to say that "All women were counselled on the risk of HIV and encouraged to use condoms at all times..." as one report said. All women were counselled on risks of *sexual* HIV transmission. Condoms wouldn't have been much use if any of the women were infected non-sexually.
A BBC article inadvertently puts its finger on the problem: "A vaginal gel has significantly cut the rate of women contracting HIV from infected partners...". But the trial has not established if partners were infected or uninfected. So we don't know if the vaginal gel has achieved this, or exactly what it has achieved.
The same article goes on: "Such a gel could be a defence for women whose partners refuse to wear condoms." But reported levels of condom use were very high and they increased during the course of the trial. Condoms should be far more effective than they appear to have been during this trial. Condom manufacturers must be asking if it is safe to use the gel when using condoms or if the gel actually weakens them or causes them to burst. I certainly hope they are asking these questions.
The article cites one of the researchers as claiming: "Women who used the gel more consistently were much less likely to be infected…". But women using the gel more consistently also had less sex. And those having more sex tended to use the gel less consistently. It's hard to know exactly how to interpret the results of this trial. If the results were truly valid and significant, how would we know? The research seems to be incomplete in many ways.
Executive director of UNAIDS, Michel Sidibe, is quoted as saying: "For the first time we have seen results for a woman-initiated and controlled HIV prevention option." Well here's another one: Patient Observed Sterile Treatment (POST). In order to protect themselves from non-sexual HIV transmission, people need to be made aware that HIV is not always transmitted sexually and of the precautions they can take. Concentrating on sexual risk alone leads to the sort of travesty that this gel trial appears to have been. If the Executive director of UNAIDS is not aware of this, he should resign.
Can we say clearly that the results of the trial could not have been due to chance? Technically, the result is statistically significant, other things being equal. But we just don't know enough (or are not being told enough). The paper notes that, "Overall, condoms were reportedly used in 80.3% of sex acts; increasing from 78.5% in the first 6 months to 84.3% in months 18-24". This means that as condom use went up, the efficacy of the gel seemed to go down.
The paper goes on "we observed declining HIV incidence rates in the placebo gel arm. This may have been due to their declining coital frequency and increasing condom use." So, are they saying that over time, the efficacy of the placebo gel increased as the efficacy of the Tenofovir gel decreased? That seems like a strange result. If the trial had gone on for five years, would these two trends have continued? Not only is the trial questionable ethically, it is also of questionable validity.
The trial could be unethical because the researchers would have known in advance, or should have known in advance, that at least some HIV is transmitted non-sexually. Yet they made no effort to protect people from this. Nor did they make any effort to inform people that such a risk exists. And the results are of questionable validity because we don't know how people became infected and, therefore, why some people didn't become infected. There could have been many factors that increased the risk of infection and others that decreased the risk. Tenofovir gel may have had some effect, but we don't know what effect it had or why it had an effect.
It's quite hard to decide if there was something unethical or invalidating about the Tenofovir Gel Microbicide trial because there could be important details about the trial that have not yet been published. For a start, the trial assumes that most HIV transmission among the participants is sexual. But did the researchers involved actually establish that HIV transmission was all or even mostly sexual? If they did, they haven’t said so in the paper.
The question is important because, during the course of the trial, researchers would have had the opportunity to find out, for each participant who became infected with HIV, how they became infected. One might say they had a duty to find out how they became infected. Were the partners of all the women who seroconverted HIV positive? I don't believe this data was collected. If it was, it should have been published because those who were infected non-sexually should have been excluded from the results. The gel is supposed to protect against heterosexually transmitted HIV, not, for example, HIV transmitted by unsafe medical procedures.
Participants were given the gel as a prophylactic against HIV. They were given to understand that they would be protected against HIV infection. They wouldn't have been told that they were protected against non-sexual HIV transmission. But they don't appear to have been warned about the possibility of non-sexual transmission. If the researchers didn’t exclude the possibility of non-sexual HIV transmission, and they don’t appear to have done so, the results are of questionable validity.
Nearly 900 people were recruited to take part in a trial and it was known that some, perhaps a lot of participants, would become infected with HIV before the end of the trial. It was not known how many would become infected or which participants. Perhaps non-participants in the area may face an even higher risk of becoming infected. But I don't think that excuses those running the trial for failing to ensure the safety of those taking part, or for failing to establish the cause of each HIV infection.
Participants were "provided with comprehensive HIV prevention services (HIV pre- and post-test counseling, HIV risk reduction counseling, condoms, and STI treatment), reproductive health services...". They were made aware of the risk of being infected with HIV sexually, but not non-sexually; this is not comprehensive. But despite this preparation, which surpasses the level of prevention available to most people in most African countries, HIV transmission rates were extremely high.
Why, given all these precautions, including very high condom use, were transmission rates so high? And why did the researchers not make any attempt to find out how people were becoming infected? Did they not have a duty to find out if their gel could even have had any influence on rates of HIV infection, or what level of influence it could have had?
In fact, it is not accurate to say that "All women were counselled on the risk of HIV and encouraged to use condoms at all times..." as one report said. All women were counselled on risks of *sexual* HIV transmission. Condoms wouldn't have been much use if any of the women were infected non-sexually.
A BBC article inadvertently puts its finger on the problem: "A vaginal gel has significantly cut the rate of women contracting HIV from infected partners...". But the trial has not established if partners were infected or uninfected. So we don't know if the vaginal gel has achieved this, or exactly what it has achieved.
The same article goes on: "Such a gel could be a defence for women whose partners refuse to wear condoms." But reported levels of condom use were very high and they increased during the course of the trial. Condoms should be far more effective than they appear to have been during this trial. Condom manufacturers must be asking if it is safe to use the gel when using condoms or if the gel actually weakens them or causes them to burst. I certainly hope they are asking these questions.
The article cites one of the researchers as claiming: "Women who used the gel more consistently were much less likely to be infected…". But women using the gel more consistently also had less sex. And those having more sex tended to use the gel less consistently. It's hard to know exactly how to interpret the results of this trial. If the results were truly valid and significant, how would we know? The research seems to be incomplete in many ways.
Executive director of UNAIDS, Michel Sidibe, is quoted as saying: "For the first time we have seen results for a woman-initiated and controlled HIV prevention option." Well here's another one: Patient Observed Sterile Treatment (POST). In order to protect themselves from non-sexual HIV transmission, people need to be made aware that HIV is not always transmitted sexually and of the precautions they can take. Concentrating on sexual risk alone leads to the sort of travesty that this gel trial appears to have been. If the Executive director of UNAIDS is not aware of this, he should resign.
Can we say clearly that the results of the trial could not have been due to chance? Technically, the result is statistically significant, other things being equal. But we just don't know enough (or are not being told enough). The paper notes that, "Overall, condoms were reportedly used in 80.3% of sex acts; increasing from 78.5% in the first 6 months to 84.3% in months 18-24". This means that as condom use went up, the efficacy of the gel seemed to go down.
The paper goes on "we observed declining HIV incidence rates in the placebo gel arm. This may have been due to their declining coital frequency and increasing condom use." So, are they saying that over time, the efficacy of the placebo gel increased as the efficacy of the Tenofovir gel decreased? That seems like a strange result. If the trial had gone on for five years, would these two trends have continued? Not only is the trial questionable ethically, it is also of questionable validity.
The trial could be unethical because the researchers would have known in advance, or should have known in advance, that at least some HIV is transmitted non-sexually. Yet they made no effort to protect people from this. Nor did they make any effort to inform people that such a risk exists. And the results are of questionable validity because we don't know how people became infected and, therefore, why some people didn't become infected. There could have been many factors that increased the risk of infection and others that decreased the risk. Tenofovir gel may have had some effect, but we don't know what effect it had or why it had an effect.
Friday, July 23, 2010
How Convinced Were You by the Microbicide Story?
The six day Vienna Aids Conference has come to an end and the freeloaders will have to finish up their last free drinks until the next junket. The press has excelled itself by repeating, almost word for word, everything they were told to publish. Searches for any of the conference catch phrases, such as 'Treatment 2.0', 'treatment as (or 'is') prevention', 'rights here, right now' or 'Tenofovir gel', etc, will yield thousands of results, all equally uninformative.
Outside the mainstream press, the Huffington Post has an article that questions the big story of the week, the announcement that a vaginal gel, using the antiretroviral drug Tenofovir, has shown some promise in trials. The author, John R Talbott, points out that the results are not really as exciting as they seem and that using this gel will only give a relatively small amount of protection. Over a lifetime, the majority of people in a population like the one in the trial will still eventually become infected, even if they use the gel all the time.
The paper entitled 'Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women' is indeed very unconvincing. Even the authors must feel pretty uncomfortable about the results of their trial and the many unanswered questions thrown up. In the introduction, they mention that in the past three decades "Only five of 37 randomized controlled trials, which tested 39 HIV prevention strategies, have demonstrated protection against sexual transmission of HIV infection". Three of the five are circumcision trials, which were well publicized but not very encouraging. The fourth was a vaccine in Thailand, which was also disappointing.
The fifth was a sexually transmitted infection (STI) treatment trial in Tanzania. Similar trials were carried out in other locations at the same time but they didn't result in any reduction in HIV transmission. The trial in Tanzania seemed to, except that there was an injection safety trial going on at the same time in the same place. It is highly likely that this affected the results of the STI trial. Yet, even though those working on it knew about the injection safety trial, they failed to mention it until many years after publishing their initial results.
The history of HIV prevention is notable not so much for its failures as for the way those failures have been dressed up as successes. The Vienna Conference has pushed the Tenofovir gel trial as a great breakthrough and the press have bounced the story around the world (and the www). The authors of the paper may well be regretting that their work has been chosen to be hyped above all others this time around. They, of all people, are probably painfully aware that we are still a long way from a pharmaceutical product that will have a significant impact on HIV transmission.
The trial itself is quite tentative, involving a small number of people. And the scope of the research was very narrow. One of the most shocking things is how high incidence is, in both the intervention (5.6%) and the control (9.1%) groups. If you had hundreds of people whose sexual behavior you were studying, you might want to investigate their sexual behavior. This trial didn't really do that. They didn't test the participants' partners. They don't even know if those who contracted HIV did so through sexual behavior! Or, if they did check the partners, they don't mention this in the paper.
Another extraordinary thing about the trial is that condom use was high and steady throughout the trial, in both intervention and control groups. Condom manufacturers must be wondering exactly what the participants did with the condoms to have such poor results with them.
Over the trial period, the number of sex acts involved was not particularly high. Even if none of the participants had used condoms, incidence of between 5.6 and 9.1% would be hard to explain. The authors speculate about the women having sex with 'migrant workers' but they don't say if the women did so. The trial selected women that were at low risk of being infected with HIV, so why did so many turn out to be at high risk?
Not only did the women in the trial not have sex particularly often but they had sex less and less often as the trial went on. The number of sex acts per month went from 7.2 to 3.1 per month. The more people were having sex, the less likely they were to use the gel and those who were having sex least frequently were the most likely to use the gel. But frequency of sex doesn't seem to change the risk of becoming infected. It's as if sexual behavior is not especially relevant to the results of the trial.
Talbott touts his own theory of why HIV rates are so high in Africa. He concludes that it is because of the "numerous and informal sexual affairs common in Southern African nations, found both among married and unmarried men, especially with a much smaller highly infected group of very sexually active women who trade sexual favors for material goods and money". There is, in fact, no evidence that 'Southern Africans' have more 'informal sexual affairs' than many people in other continents (or countries). But the Tenofovir trial itself even finds that sexual behavior is not very frequent. Nor does it appear to involve a lot of 'unsafe' sex.
And, like many people who rush to such conclusions, Talbott also doesn't explain how large groups of sexually promiscuous men and small groups of sexually promiscuous women can give rise to far more women being infected than men. Perhaps he would, along with others, say that all these men go home and infect their wives. But about half of the HIV positive married women have HIV negative husbands. His argument suggests, as all arguments do that try to explain high HIV prevalence by reference to sexual behavior alone, that Africans have a lot more unsafe sex than non-Africans and that many of the women are exceptionally promiscuous.
Firstly, we know that Africans don't have a lot more unsafe sex than non-Africans, secondly, we know that African women are not exceptionally promiscuous and thirdly, it has also been shown that even very high rates of unsafe sexual behavior do not explain the levels of HIV prevalence found in some African countries. I applaud Talbott for criticizing the dubious claims being made about the Tenofovir gel trials. But he doesn't do much for his credibility, or that of the Huffington Post, by falling back on the racist and sexist views of the HIV industry.
Talbott calls for testing. What is needed is investigation. Why are so many women whose lifestyle is not risky becoming infected with a virus that is difficult to transmit? Why were their partners not tested, or if they were, why were the results not published? Who cares whether the gel works or not when we don't even know how the women were becoming infected? Like all the other 'major breakthroughs' discussed at the conference, this gel will only be useful if HIV is mostly sexually transmitted. This is far from evident.
Outside the mainstream press, the Huffington Post has an article that questions the big story of the week, the announcement that a vaginal gel, using the antiretroviral drug Tenofovir, has shown some promise in trials. The author, John R Talbott, points out that the results are not really as exciting as they seem and that using this gel will only give a relatively small amount of protection. Over a lifetime, the majority of people in a population like the one in the trial will still eventually become infected, even if they use the gel all the time.
The paper entitled 'Effectiveness and Safety of Tenofovir Gel, an Antiretroviral Microbicide, for the Prevention of HIV Infection in Women' is indeed very unconvincing. Even the authors must feel pretty uncomfortable about the results of their trial and the many unanswered questions thrown up. In the introduction, they mention that in the past three decades "Only five of 37 randomized controlled trials, which tested 39 HIV prevention strategies, have demonstrated protection against sexual transmission of HIV infection". Three of the five are circumcision trials, which were well publicized but not very encouraging. The fourth was a vaccine in Thailand, which was also disappointing.
The fifth was a sexually transmitted infection (STI) treatment trial in Tanzania. Similar trials were carried out in other locations at the same time but they didn't result in any reduction in HIV transmission. The trial in Tanzania seemed to, except that there was an injection safety trial going on at the same time in the same place. It is highly likely that this affected the results of the STI trial. Yet, even though those working on it knew about the injection safety trial, they failed to mention it until many years after publishing their initial results.
The history of HIV prevention is notable not so much for its failures as for the way those failures have been dressed up as successes. The Vienna Conference has pushed the Tenofovir gel trial as a great breakthrough and the press have bounced the story around the world (and the www). The authors of the paper may well be regretting that their work has been chosen to be hyped above all others this time around. They, of all people, are probably painfully aware that we are still a long way from a pharmaceutical product that will have a significant impact on HIV transmission.
The trial itself is quite tentative, involving a small number of people. And the scope of the research was very narrow. One of the most shocking things is how high incidence is, in both the intervention (5.6%) and the control (9.1%) groups. If you had hundreds of people whose sexual behavior you were studying, you might want to investigate their sexual behavior. This trial didn't really do that. They didn't test the participants' partners. They don't even know if those who contracted HIV did so through sexual behavior! Or, if they did check the partners, they don't mention this in the paper.
Another extraordinary thing about the trial is that condom use was high and steady throughout the trial, in both intervention and control groups. Condom manufacturers must be wondering exactly what the participants did with the condoms to have such poor results with them.
Over the trial period, the number of sex acts involved was not particularly high. Even if none of the participants had used condoms, incidence of between 5.6 and 9.1% would be hard to explain. The authors speculate about the women having sex with 'migrant workers' but they don't say if the women did so. The trial selected women that were at low risk of being infected with HIV, so why did so many turn out to be at high risk?
Not only did the women in the trial not have sex particularly often but they had sex less and less often as the trial went on. The number of sex acts per month went from 7.2 to 3.1 per month. The more people were having sex, the less likely they were to use the gel and those who were having sex least frequently were the most likely to use the gel. But frequency of sex doesn't seem to change the risk of becoming infected. It's as if sexual behavior is not especially relevant to the results of the trial.
Talbott touts his own theory of why HIV rates are so high in Africa. He concludes that it is because of the "numerous and informal sexual affairs common in Southern African nations, found both among married and unmarried men, especially with a much smaller highly infected group of very sexually active women who trade sexual favors for material goods and money". There is, in fact, no evidence that 'Southern Africans' have more 'informal sexual affairs' than many people in other continents (or countries). But the Tenofovir trial itself even finds that sexual behavior is not very frequent. Nor does it appear to involve a lot of 'unsafe' sex.
And, like many people who rush to such conclusions, Talbott also doesn't explain how large groups of sexually promiscuous men and small groups of sexually promiscuous women can give rise to far more women being infected than men. Perhaps he would, along with others, say that all these men go home and infect their wives. But about half of the HIV positive married women have HIV negative husbands. His argument suggests, as all arguments do that try to explain high HIV prevalence by reference to sexual behavior alone, that Africans have a lot more unsafe sex than non-Africans and that many of the women are exceptionally promiscuous.
Firstly, we know that Africans don't have a lot more unsafe sex than non-Africans, secondly, we know that African women are not exceptionally promiscuous and thirdly, it has also been shown that even very high rates of unsafe sexual behavior do not explain the levels of HIV prevalence found in some African countries. I applaud Talbott for criticizing the dubious claims being made about the Tenofovir gel trials. But he doesn't do much for his credibility, or that of the Huffington Post, by falling back on the racist and sexist views of the HIV industry.
Talbott calls for testing. What is needed is investigation. Why are so many women whose lifestyle is not risky becoming infected with a virus that is difficult to transmit? Why were their partners not tested, or if they were, why were the results not published? Who cares whether the gel works or not when we don't even know how the women were becoming infected? Like all the other 'major breakthroughs' discussed at the conference, this gel will only be useful if HIV is mostly sexually transmitted. This is far from evident.
Thursday, July 22, 2010
Sniff it, Lick it, Publish it
If someone at the Vienna Aids Conference put out a press release saying tests have shown that regular use of bouncy castles cures HIV, would the world's media repeat it, just as they have done with every other improbable press release that has come out over the past few days? Have these journalists ever heard of criticism, originality, judgment, analysis or even writing? They did the same during the World Cup, regurgitating every scrap of rubbish they could find. Was everything washed down with free beer (Fifa approved, of course)? If so, no doubt they are washing things down with good wine in Vienna.
Even Reuters' AlertNet follows the flock with their triumphalist 'MTV drama brings cool to HIV prevention'. Apparently this drama, 'Shuga', was aired some time last year, but where? Perhaps it was aired in Nairobi or in private schools but I don't know anyone who has seen it or even heard of it. "In Kenya, the drama was watched by an astonishing 60 percent of young people – those are amazing figures for any programme," Bill Roedy, CEO of MTV, told IRIN/PlusNews. They're not just amazing, they are not credible. Where's the evidence, Roedy?
Over 80% of Kenyans live in rural areas and about 70% of those who live in urban areas live in slums. Official figures claim that only about 30% of Kenyans do not have access to electricity and that only about 25% don't have regular access to the media (print, radio and TV). But how many people have TVs or regular access to TVs? Most people in the areas I've been working in don't. But in the euphoria at Vienna, with the desperation to churn out feel-good stories, the press will repeat anything they are fed. Haven't they ever heard of evidence?
As for the 'evaluation' of what people learned and think and what that might show, what does that mean? Most people visit the bathroom after watching a few TV shows, does that mean they are good laxatives? Of course young people will be able to repeat what they have heard, especially when treated to a TV show about sex (though I'm still wondering how many have really seen it). Children here, and adults, have been blasted with rubbish about HIV and sex for so long now they know exactly what to say when asked. The problem is, even people who work with HIV have no idea that HIV can be and is transmitted non-sexually, nor any idea how to protect themselves from non-sexual HIV transmission.
This is an extremely dangerous situation. I've sat with people and discussed conditions in hospitals, their experiences with doctors, nurses, dentists and others who might pose a risk of blood-borne infection of some kind. But when the conversation turns to HIV risk reduction, they always talk about sexually transmitted HIV. Of course, Shuga is about sexually transmitted HIV, from what I can glean. What else is there, if you're part of the mainstream media, which MTV most certainly is.
Contradictions are not considered important in the HIV industry but one of the feel-good stories that's been churned around before and during the conference has been about young people 'leading' the drop in the spread of HIV. Yet now, the AlertNet article says "Worldwide, 40 percent of new HIV infections occur among young people between the ages of 15 and 24. Behaviour change campaigns have shown some success...". Behaviour change campaigns have resulted in people being able to answer questions about things they have been taught but they have not resulted in significant levels of behaviour change. And they have had no impact whatsoever on HIV transmission rates.
The 'evaluation' was carried out by the Johns Hopkins Centre for Communication Programs. Johns Hopkins, like the HIV industry, is vehemently opposed to the idea that HIV is commonly transmitted non-sexually in African countries. But just because the HIV industry is completely biased against anything that could threaten their massive levels of funding, that doesn't mean the media should behave as the lapdog of industry, academia and anyone else handing out free booze (or whatever they get out of it).
There's no polite way to say this and politeness would be misplaced anyway: the Vienna Aids Conference is an (expensive) exercise in arse sniffing, a specialty of the press. One can only wonder what they all do to while away the time during those long presentations and seminars. When I tell people in rural areas about things like the HIV industry and conferences, they ask reasonable questions, such as 'what is HIV prevalence like in Vienna?', 'why are they there?', 'how expensive are these conferences?' and 'if the industry gets so much money, why does none of it end up here?' Any chance of a woof, a yelp or even a whimper from the pampered, or they too well bred?
Even Reuters' AlertNet follows the flock with their triumphalist 'MTV drama brings cool to HIV prevention'. Apparently this drama, 'Shuga', was aired some time last year, but where? Perhaps it was aired in Nairobi or in private schools but I don't know anyone who has seen it or even heard of it. "In Kenya, the drama was watched by an astonishing 60 percent of young people – those are amazing figures for any programme," Bill Roedy, CEO of MTV, told IRIN/PlusNews. They're not just amazing, they are not credible. Where's the evidence, Roedy?
Over 80% of Kenyans live in rural areas and about 70% of those who live in urban areas live in slums. Official figures claim that only about 30% of Kenyans do not have access to electricity and that only about 25% don't have regular access to the media (print, radio and TV). But how many people have TVs or regular access to TVs? Most people in the areas I've been working in don't. But in the euphoria at Vienna, with the desperation to churn out feel-good stories, the press will repeat anything they are fed. Haven't they ever heard of evidence?
As for the 'evaluation' of what people learned and think and what that might show, what does that mean? Most people visit the bathroom after watching a few TV shows, does that mean they are good laxatives? Of course young people will be able to repeat what they have heard, especially when treated to a TV show about sex (though I'm still wondering how many have really seen it). Children here, and adults, have been blasted with rubbish about HIV and sex for so long now they know exactly what to say when asked. The problem is, even people who work with HIV have no idea that HIV can be and is transmitted non-sexually, nor any idea how to protect themselves from non-sexual HIV transmission.
This is an extremely dangerous situation. I've sat with people and discussed conditions in hospitals, their experiences with doctors, nurses, dentists and others who might pose a risk of blood-borne infection of some kind. But when the conversation turns to HIV risk reduction, they always talk about sexually transmitted HIV. Of course, Shuga is about sexually transmitted HIV, from what I can glean. What else is there, if you're part of the mainstream media, which MTV most certainly is.
Contradictions are not considered important in the HIV industry but one of the feel-good stories that's been churned around before and during the conference has been about young people 'leading' the drop in the spread of HIV. Yet now, the AlertNet article says "Worldwide, 40 percent of new HIV infections occur among young people between the ages of 15 and 24. Behaviour change campaigns have shown some success...". Behaviour change campaigns have resulted in people being able to answer questions about things they have been taught but they have not resulted in significant levels of behaviour change. And they have had no impact whatsoever on HIV transmission rates.
The 'evaluation' was carried out by the Johns Hopkins Centre for Communication Programs. Johns Hopkins, like the HIV industry, is vehemently opposed to the idea that HIV is commonly transmitted non-sexually in African countries. But just because the HIV industry is completely biased against anything that could threaten their massive levels of funding, that doesn't mean the media should behave as the lapdog of industry, academia and anyone else handing out free booze (or whatever they get out of it).
There's no polite way to say this and politeness would be misplaced anyway: the Vienna Aids Conference is an (expensive) exercise in arse sniffing, a specialty of the press. One can only wonder what they all do to while away the time during those long presentations and seminars. When I tell people in rural areas about things like the HIV industry and conferences, they ask reasonable questions, such as 'what is HIV prevalence like in Vienna?', 'why are they there?', 'how expensive are these conferences?' and 'if the industry gets so much money, why does none of it end up here?' Any chance of a woof, a yelp or even a whimper from the pampered, or they too well bred?
Tuesday, July 20, 2010
Whose Rights, Which Rights and Where?
The punchline for the Vienna Aids Conference that's taking place at the moment is 'Rights Here, Right Now'. But it is only recently that the HIV industry has been making it clear whose rights they are demanding. They are demanding that HIV positive people, all of them, receive treatment. HIV positive people have a right to treatment but the conference rally cry seems to ignore the right that HIV negative people have to stay negative, indeed, the same right that HIV positive people have already been denied. Of course sick people have a right to treatment. But what the industry is claiming is that treatment for HIV positive people will ensure that HIV negative people stay that way; not healthy (not by a long shot), just HIV negative.
Well, in an ideal world, HIV positive people on successful antiretroviral treatment (ART) are less likely to transmit the virus to other people. We actually live in a world where most HIV positive people are not on ART, for a variety of reasons, and that will probably remain the case for the foreseeable future. But UNAIDS and the rest of the HIV industry don't live in this world. They live in a better carpeted world, better paid, where a disaster is having to drink a coffee with full fat milk when they ordered skinny. They themselves have a right to health. Others have a right to (HIV) treatment, and let's be clear, we are talking about people in developing countries here.
The Alma-Ata Declaration defines health as follows:
There are several manifestations of the industry's desire to see treatment as prevention. In some places, where circumcision rates are low, there are plans to circumcise millions of men. This may or may not protect those circumcised, the evidence is slim. But it is unlikely to protect those with whom they have sex. The difference here is that millions of people, most of whom are not sick, are being told to have an operation that will keep them healthy. It is further implied that their being healthy will ensure the health of others. And this is in countries that have few health facilities, doctors or nurses and chronic shortages of equipment and medication.
Another manifestation is called pre-exposure prophylaxis or PrEP. This involves people who are HIV negative taking ART drugs on the grounds that they will be less likely to become infected. So treatment is not only being offered to those who are HIV positive, it is also being offered to those who 'may' become infected, in the opinion of a bunch of 'experts' who think that HIV treatment is a substitute for health. HIV industry spokespeople like to talk about 'science' and 'evidence', but what about rights, logic and common sense? Is a healthy person just a potential customer to them?
The industry has long insisted (it's a bit tenuous to call it a belief) that HIV is almost always transmitted through heterosexual sex in developing countries. There are two problems with this 'behavioral paradigm': firstly, given that those in developing countries don't engage in more sex, safe or unsafe, than those in rich countries, why do some developing countries have unbelievably high rates of HIV transmission, far beyond what could be reasonably explained by sexual behavior? Secondly, it is clear that a lot of HIV transmission must occur through non-sexual routes, but what exactly are these routes and how much transmission do they account for?
The first problem is vexing because there has never been any evidence for the rampant levels of unsafe sex that would be required for 20 or 30% of any population to become infected with a virus that is difficult to transmit through sexual intercourse. The industry has reacted by insisting that some people really do have the time, the opportunity and the inclination to lead a life that, previously, only existed in porn films. The second problem, the industry simply ignores. Almost everything about the industry assumes the truth of the behavioral paradigm. You could say that they view everybody (in developing countries, of course) as already sick and that they see the treatment as being preemptive (without being preventive).
Until we know why people in developing countries are becoming infected with HIV in such large numbers, it is senseless to keep droning on about sexual behavior. If there is something about sexual behavior in developing countries that results in a difficult to transmit virus being transmitted with ease, we don't know what it is yet. But we do know that there is a lot more non-sexual HIV transmission than the HIV industry are prepared to admit. HIV treatment is for HIV positive people, and I hope everybody who needs it receives it, regardless of their race, religion, sexual status or anything else. But everyone has a right to health; everyone has a right to live free of HIV. Avoidable HIV transmission needs to be prevented.
There is still a need for genuine HIV prevention and if UNAIDS can't come up with anything better than slogans, the agency should be abolished. They have shown a complete unwillingness to drop the behavioral paradigm despite there being no evidence for it and a lot against it. Their calls for rights are just humbug and they seem to be more interested in self-preservation than anything else. As more and more people become infected unnecessarily and many die every day, UNAIDS and the rest of the industry do little but spread stigma and lies about HIV. Those who are HIV positive, many as a result of the industry's failures, have a right to treatment. Others have a right to health, the same right that so many HIV positive people have been denied by this industry.
The Vienna Aids Conference is being used as a platform to make desperate pleas for yet more donor money to be ploughed into an industry that has failed to reduce HIV transmission and will continue to fail, given their present trajectory. They do not have any new ideas; they have just dressed up their old prejudices in new terminology. People have a right to health. Those who are sick have a right to treatment, a right to live lives that are as close to healthy as possible. But enough money has been wasted on political and commercial interests. We know enough about HIV to do things much better.
(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)
Well, in an ideal world, HIV positive people on successful antiretroviral treatment (ART) are less likely to transmit the virus to other people. We actually live in a world where most HIV positive people are not on ART, for a variety of reasons, and that will probably remain the case for the foreseeable future. But UNAIDS and the rest of the HIV industry don't live in this world. They live in a better carpeted world, better paid, where a disaster is having to drink a coffee with full fat milk when they ordered skinny. They themselves have a right to health. Others have a right to (HIV) treatment, and let's be clear, we are talking about people in developing countries here.
The Alma-Ata Declaration defines health as follows:
health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and [...] the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.Notice, it is not about treatment, which is for sick people. Telling healthy people who are hoping to stay healthy that treating the sick will also be good for them is not promoting their health. Treatment is not prevention, it is just treatment. But putting as many people as possible on treatment will not have the effect of eradicating HIV. Mass treatment may slow transmission down a bit, but refusing to do anything to reduce transmission aside from treating those known to be HIV positive and willing to be treated with ART, is denying the majority of people their right to health.
There are several manifestations of the industry's desire to see treatment as prevention. In some places, where circumcision rates are low, there are plans to circumcise millions of men. This may or may not protect those circumcised, the evidence is slim. But it is unlikely to protect those with whom they have sex. The difference here is that millions of people, most of whom are not sick, are being told to have an operation that will keep them healthy. It is further implied that their being healthy will ensure the health of others. And this is in countries that have few health facilities, doctors or nurses and chronic shortages of equipment and medication.
Another manifestation is called pre-exposure prophylaxis or PrEP. This involves people who are HIV negative taking ART drugs on the grounds that they will be less likely to become infected. So treatment is not only being offered to those who are HIV positive, it is also being offered to those who 'may' become infected, in the opinion of a bunch of 'experts' who think that HIV treatment is a substitute for health. HIV industry spokespeople like to talk about 'science' and 'evidence', but what about rights, logic and common sense? Is a healthy person just a potential customer to them?
The industry has long insisted (it's a bit tenuous to call it a belief) that HIV is almost always transmitted through heterosexual sex in developing countries. There are two problems with this 'behavioral paradigm': firstly, given that those in developing countries don't engage in more sex, safe or unsafe, than those in rich countries, why do some developing countries have unbelievably high rates of HIV transmission, far beyond what could be reasonably explained by sexual behavior? Secondly, it is clear that a lot of HIV transmission must occur through non-sexual routes, but what exactly are these routes and how much transmission do they account for?
The first problem is vexing because there has never been any evidence for the rampant levels of unsafe sex that would be required for 20 or 30% of any population to become infected with a virus that is difficult to transmit through sexual intercourse. The industry has reacted by insisting that some people really do have the time, the opportunity and the inclination to lead a life that, previously, only existed in porn films. The second problem, the industry simply ignores. Almost everything about the industry assumes the truth of the behavioral paradigm. You could say that they view everybody (in developing countries, of course) as already sick and that they see the treatment as being preemptive (without being preventive).
Until we know why people in developing countries are becoming infected with HIV in such large numbers, it is senseless to keep droning on about sexual behavior. If there is something about sexual behavior in developing countries that results in a difficult to transmit virus being transmitted with ease, we don't know what it is yet. But we do know that there is a lot more non-sexual HIV transmission than the HIV industry are prepared to admit. HIV treatment is for HIV positive people, and I hope everybody who needs it receives it, regardless of their race, religion, sexual status or anything else. But everyone has a right to health; everyone has a right to live free of HIV. Avoidable HIV transmission needs to be prevented.
There is still a need for genuine HIV prevention and if UNAIDS can't come up with anything better than slogans, the agency should be abolished. They have shown a complete unwillingness to drop the behavioral paradigm despite there being no evidence for it and a lot against it. Their calls for rights are just humbug and they seem to be more interested in self-preservation than anything else. As more and more people become infected unnecessarily and many die every day, UNAIDS and the rest of the industry do little but spread stigma and lies about HIV. Those who are HIV positive, many as a result of the industry's failures, have a right to treatment. Others have a right to health, the same right that so many HIV positive people have been denied by this industry.
The Vienna Aids Conference is being used as a platform to make desperate pleas for yet more donor money to be ploughed into an industry that has failed to reduce HIV transmission and will continue to fail, given their present trajectory. They do not have any new ideas; they have just dressed up their old prejudices in new terminology. People have a right to health. Those who are sick have a right to treatment, a right to live lives that are as close to healthy as possible. But enough money has been wasted on political and commercial interests. We know enough about HIV to do things much better.
(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)
Monday, July 19, 2010
Difficult Questions That Won't Be Asked in Vienna
Press releases say that about 20,000 people are expected to attend the Vienna Aids Conference this year. I don't know if they will all attend for the whole six days but if they do, it is likely that someone or some institution will be paying an average of $200 per day per person. They conference may not cost $24,000,000, perhaps it will only cost $10,000,000. But even so, that could supply 50,000 people in developing countries with antiretroviral treatment (ART), the drugs and other aspects of treatment, for a year. That's assuming that an average of $200 is being spent per person.
I wouldn't want to suggest that the Vienna Aids Conference is a useless waste of money, it may well have its value. But that much money and that many people in that city? Much of the discussions will be matters that have been both published and well publicized over the last year or two. In fact, a lot of money has already been spent on disseminating the data, reports, presentations, findings, opinions, maunderings, crackpot ideas and things swept up after previous conferences and stuck together with cello tape.
We know already from pre-conference releases that many of those attending buy into the 'behavioral paradigm', the view that HIV is primarily transmitted by heterosexual sex (in African countries) and that in order to reduce transmission, people need to change their sexual behavior. The behavioral paradigm is divisive, racist and sexist and even its closest adherents know that it is entirely without foundation. Yet, there are unlikely to be many people presenting at this conference, or any other Aids conference, willing to admit that their whole theory of HIV transmission is based on a falsehood.
We can only speculate about why the HIV industry seems hell bent on allowing HIV to be transmitted through non-sexual means, such as unsafe health care or cosmetic practices. And it is also hard to understand why they will probably continue to allow HIV to be transmitted sexually by failing to implement any effective prevention strategies. Perhaps the industry is concentrating on 'solutions' that make enough money to be attractive to those who hawk those solutions. They do seem to favor technical solutions, ones that involve expensive commodities. But alas, this is only speculation.
It is unusual to see articles in the mainstream media that even mention non-sexual HIV transmission, especially transmission through unsafe health care. But there was one in Media Global yesterday. This article mentions the WHO's estimate that between 5 and 10% of all HIV infections in Africa occur as a result of unsafe blood transfusions. It also mentions that a WHO researcher estimates that 17% of HIV infection in African countries is due to unsafe injections. Worse still, a substantial proportion of transfusions and the majority of infections are entirely unnecessary!
Putting these together, over 20% of infections could be coming from unsafe health care, perhaps almost 30%. To put that in perspective, only around 10% of new HIV infections in Uganda are estimated to come from commercial sex workers, their clients and their clients' partners added together. If 20-30% of infections are coming from unsafe health care, the percentage attributable to sexual transmission must be considerably lower than previously thought. Unsafe health care could even be the main route to transmission.
The HIV industry knows how to make a lot of noise. After all, it's a very well funded industry. It receives billions of dollars of public money every year and the world's media, public and private, hang on to every word that emanates from official HIV industry mouthpieces. They are not shy about trumpeting their successes, their needs, their problems and their highly suspect philosophy. But they are amazingly reticent when it comes to non-sexual HIV transmission. It's as if the very non-sexuality of it is as taboo as the sexuality is in other contexts.
Another thing the HIV industry is reticent about is prevention, but that's understandable. They have frittered away billions in useless programs and spent years researching others which will never fly. They have come up with tonnes of worthless strategies and now they haven't a clue what to say about HIV prevention any more. So they have come up with the idea of saying that treatment is prevention. And so it is, in a sense. If all HIV positive people were to be aware of their status and everybody at risk of becoming infected were to be tested regularly, perhaps every year, then treatment could play a big part in prevention.
But we are very far from that position. It's possible that 20% of HIV positive people know their status. But very few people test regularly. And many of the people who are at risk of being infected don't know they are at risk. The reason they don't know they are at risk is because the HIV industry will not speak about non-sexual risk, nor will they allow anyone associated with them to speak about it. So even their 'treatment as prevention' sleight of hand will fail for the very reason that they will not admit that non-sexual HIV transmission could be as common as sexual transmission and may be even more common.
The HIV industry machinery is concentrating on the usual, money. Some of the biggest sources of funding are being cut or flatlined. I think this is a mistake because the countries with the worst epidemics are most in need of more money, not less. But given how badly the billions of the last 20 years have been spent, is it wise to continue allowing the same people and the same institutions to receive whatever money is being made available? Is it wise to continue spending money on the same failed policies of the past? It's a bad time to knock everything down to the foundations, but which part of the HIV industry is worthy of being allowed to continue? These questions will probably remain unanswered, even unasked, at the Vienna Aids Conference. But if HIV is ever to be eradicated, there will have to be an answer.
Sunday, July 18, 2010
But the Media Doesn't Want to be Free
It's odd how countries that have a 'free' press seem content to publish whatever is put in front of them. Coming up to the Vienna Aids Conference, UNAIDS puts out a press release about their new 'platform', called 'Treatment 2.0', with which they are going to conquer the virus that they have, so far, failed to influence in any way since the UN spawned this curious agency. And the world's press simply echoes what UNAIDS says. You can search for any of their expensively honed terminology and you'll find the same thing, repeated like a fart in a whispering gallery, until it's overtaken by their next performance. And the world's busy dung beetles do what their species does best, rolling out articles as indistinguishable as balls of shit. It's not (yet) as if the global media is entirely owned by the likes of that arch dung-heap master, Rupert Murdoch. But out they come, without thought, comment or criticism. Of course they roll, they're spherical!
Before the World Cup, which apparently involved football and sex, the busy creatures were set to work on UNAIDS' predictable offering. This involved making the connection between football supporters away from home drinking a lot and the possibility of their availing of some of the personal services said to be on offer in South Africa. Every news agency did the usual and warned people to avoid having sex with anyone and if they had to have sex, to make sure they used a condom.
Now that the World Cup is over, news agencies can still churn out articles with the popular mixture of football and sex in the form of warnings to those who may have indulged in any kind of unprotected sex while in South Africa, to go for a HIV test. If their pre-World Cup messages had any effect, many football fans probably used condoms and should be ok. For those who were not reading or heeding the articles, it is a good idea to get tested for HIV and all other sexually transmitted infections.
But one thing these guardians of our health and wellbeing never mentioned is that HIV is not only sexually transmitted. In fact, they have been trotting out the sex message for so long, people have probably heard it by now. UNAIDS and therefore the world's press, meanwhile, have kept what they know about non-sexually transmitted HIV to themselves. UNAIDS are quite explicit in the advice they give to their own employees who may be working in African countries: avoid using health facilities that are not approved or provided by the UN. If the risks are high for UN employees, they may be higher for football supporters and even higher still for Africans.
Football fans visiting South Africa probably had a far greater likelihood of contracting HIV, hepatitis B or C, when visiting a clinic, dentist or tattoo parlor. UNAIDS are well aware of this. But they do not tell Africans, who have no option but to use any facilities they can afford. And they didn't bother to tell football fans. And now, when the press are doing their duty by wallowing through the latest releases, they too are neglecting to mention this risk. People who had unsafe sex may go and get tested, but people who had medical or cosmetic treatment are far more likely to transmit HIV or anything else to their partner before discovering, probably some years from now, that they picked up something during the World Cup.
The BBC runs a typical article, mainly targeting men, despite the fact that women who had medical or cosmetic treatment in South Africa could be just as much at risk. The article is about a campaign being run in the UK, which trots out the half-truth about HIV being sexually transmitted, even though it has always been known that HIV can be transmitted in other ways. Although the article mentions holiday makers in general, many of whom may be visiting developing countries, there is still no acknowledgement of the risks people face in health and cosmetic facilities.
One commentator referred to the campaign as "amusing and engaging". It may well be, but what's the point in amusing people and engaging their attention when the message has been mangled, for whatever perverse reason? South Africa is not just the country with the highest number of HIV positive people in the world. In common with most other African countries, South Africa also has appalling health conditions and run down facilities which are barely accessible to most people. Holiday makers may not have to use the facilities that ordinary Africans have to use. But there is as much of a risk to holiday makers from unsafe medical and cosmetic practices as there is from unsafe sex, perhaps more. So why the failure to mention this?
Before the World Cup, which apparently involved football and sex, the busy creatures were set to work on UNAIDS' predictable offering. This involved making the connection between football supporters away from home drinking a lot and the possibility of their availing of some of the personal services said to be on offer in South Africa. Every news agency did the usual and warned people to avoid having sex with anyone and if they had to have sex, to make sure they used a condom.
Now that the World Cup is over, news agencies can still churn out articles with the popular mixture of football and sex in the form of warnings to those who may have indulged in any kind of unprotected sex while in South Africa, to go for a HIV test. If their pre-World Cup messages had any effect, many football fans probably used condoms and should be ok. For those who were not reading or heeding the articles, it is a good idea to get tested for HIV and all other sexually transmitted infections.
But one thing these guardians of our health and wellbeing never mentioned is that HIV is not only sexually transmitted. In fact, they have been trotting out the sex message for so long, people have probably heard it by now. UNAIDS and therefore the world's press, meanwhile, have kept what they know about non-sexually transmitted HIV to themselves. UNAIDS are quite explicit in the advice they give to their own employees who may be working in African countries: avoid using health facilities that are not approved or provided by the UN. If the risks are high for UN employees, they may be higher for football supporters and even higher still for Africans.
Football fans visiting South Africa probably had a far greater likelihood of contracting HIV, hepatitis B or C, when visiting a clinic, dentist or tattoo parlor. UNAIDS are well aware of this. But they do not tell Africans, who have no option but to use any facilities they can afford. And they didn't bother to tell football fans. And now, when the press are doing their duty by wallowing through the latest releases, they too are neglecting to mention this risk. People who had unsafe sex may go and get tested, but people who had medical or cosmetic treatment are far more likely to transmit HIV or anything else to their partner before discovering, probably some years from now, that they picked up something during the World Cup.
The BBC runs a typical article, mainly targeting men, despite the fact that women who had medical or cosmetic treatment in South Africa could be just as much at risk. The article is about a campaign being run in the UK, which trots out the half-truth about HIV being sexually transmitted, even though it has always been known that HIV can be transmitted in other ways. Although the article mentions holiday makers in general, many of whom may be visiting developing countries, there is still no acknowledgement of the risks people face in health and cosmetic facilities.
One commentator referred to the campaign as "amusing and engaging". It may well be, but what's the point in amusing people and engaging their attention when the message has been mangled, for whatever perverse reason? South Africa is not just the country with the highest number of HIV positive people in the world. In common with most other African countries, South Africa also has appalling health conditions and run down facilities which are barely accessible to most people. Holiday makers may not have to use the facilities that ordinary Africans have to use. But there is as much of a risk to holiday makers from unsafe medical and cosmetic practices as there is from unsafe sex, perhaps more. So why the failure to mention this?
The media seems to need a reminder that they are allowed, they are even encouraged, to analyse, criticize and comment on what they write about. They are even permitted to disagree. If UN agencies like UNAIDS spew out dung, there is no reason why the media should passively roll it up and pass it on to their readers. If every news agency carries the same story, word for word, as they do in the case of HIV and sexual transmission, without ever mentioning non-sexual transmission, there is only need for one news agency. Right now, it almost seems as if there is only one news agency, run entirely by dung beetles.
Friday, July 16, 2010
HIV Industry Parties As Virus Spreads
The HIV industry has a very important junket coming up in Vienna and some of the industry's biggest donors are threatening to reduce funds. The World Bank's Global Fund and the US PEPFAR fund (President's Emergency Fund for Aids Relief), which represent a large proportion of global HIV funding, will be reduced over the next few years. Industry representatives are busy writing press releases, lobbying governments and doing everything in their power to fight for their right to party.
That sounds very cynical, but many people will die of Aids during the coming Vienna Aids Conference and during the many expensive junkets the industry treats itself to. The amount of money spent on such events must be astronomical and they are not usually even held in countries with high HIV prevalence. The same amount of money spent on HIV prevention or treatment could save a lot of lives. But HIV policy is mainly written by Westerners in expensive Western offices and when the policy is written, the writers celebrate in Western bars.
With all the hype around the much touted 'Treatment 2.0', it's hard to believe there will be much left to talk about at the conference. Ironically, there is a lot of talk about the use of mobile phones, laptops, wireless and various other technologies in the fields of HIV and global health in general. But you wouldn't think it to see all these people rushing to some expensive city, first class, expenses paid. Treatment 2.0 does involve a lot of technology, but not the sort that reduces costs or carbon emissions or anything like that.
According to PlusNews, one of the five priorities at the conference is 'universal' access to HIV drugs. This, despite what you might expect, involves putting 80% of people who need drugs on ART (antiretroviral therapy). The target was to achieve this by the end of 2010 but this will not be met by most countries. Even the target of putting everyone with a CD4 count (a measure of immune strength) of 200, rather than the WHO recommended 350, will not be reached.
Another technological approach is called 'treatment as prevention', the idea that people who are responding to HIV treatment will be less infectious and so will not be likely to transmit HIV. In ideal conditions, this works well. However, with so many countries still a long way from their targets, it is unlikely to have much impact in high HIV prevalence countries. In most of these countries, a substantial percentage of HIV positive people don't even know their status, so they will not be on ART. Treatment as prevention has been talked up for nearly two years now but no one has dared to admit that it is an ideal and will always remain an ideal. Even the jokers who came up with the 'no sex month' idea don't believe it.
Even nuttier than that is an approach called pre-exposure prophylaxis (PrEP). This involves putting those 'most at risk' of being infected with HIV on ART. If we had any idea who was most at risk we could have prevented a lot of infections by now. But we have been pretty unsuccessful in predicting who was most at risk in the past. And recent Modes of Transmission Surveys have shown that many of the people who are becoming infected are not in at risk groups. In fact, one of the characteristics of high HIV prevalence countries is that many of the people most likely to become infected are at low risk, according to official definitions! Figure that one out.
So there are a lot of technologies available but they are either not being used or they are not proving too effective in the field. It is difficult enough to persuade people to get tested for HIV once, let alone once a year for the rest of the time they are sexually active. Many who are HIV positive are either not taking the drugs, not taking the drugs properly or do not have access to the drugs or some other aspect of treatment (shocking, but no, you can't just hand out pills). Perhaps a lot of people are on treatment, but many of them will, eventually, develop resistance and need to go on to a far more expensive 'second line' drug. Technology is not simple, but conditions in developing countries are basic.
So what are the problems, if all this money has been spent for so long? Well countries need infrastructure, especially health infrastructures. They need education, especially health education. They need adequate levels of nutrition and food security. They need clean water and sanitation and many other goods that are considered to be human rights. You cannot roll out a high tech treatment or prevention program without countries having some level of development. It may seem possible to the HIV industry, donors or the public. But not only is it not possible, we've spent years demonstrating the impossibility.
In addition to these technical problems and the problems relating to our relative lack of understanding about exactly how HIV spreads, there is another problem, which is harder to characterize. This is the problem of the HIV industry's refusal to accept that we cannot explain high prevalence, generalized epidemics (where the majority of those infected are not members of high risk groups, such as intravenous drug users, men who have sex with men or sex workers) by almost exclusive reference to heterosexual sex. If you refuse to accept the racist, sexist explanations of HIV transmission in African countries being due to the fact that Africans have lots of unsafe sex, you will also refuse to accept that HIV prevention programs that target sexual behaviour, and nothing else, will reduce transmission to the extent that HIV will eventually be eradicated. I don't see what there is to celebrate.
(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)
That sounds very cynical, but many people will die of Aids during the coming Vienna Aids Conference and during the many expensive junkets the industry treats itself to. The amount of money spent on such events must be astronomical and they are not usually even held in countries with high HIV prevalence. The same amount of money spent on HIV prevention or treatment could save a lot of lives. But HIV policy is mainly written by Westerners in expensive Western offices and when the policy is written, the writers celebrate in Western bars.
With all the hype around the much touted 'Treatment 2.0', it's hard to believe there will be much left to talk about at the conference. Ironically, there is a lot of talk about the use of mobile phones, laptops, wireless and various other technologies in the fields of HIV and global health in general. But you wouldn't think it to see all these people rushing to some expensive city, first class, expenses paid. Treatment 2.0 does involve a lot of technology, but not the sort that reduces costs or carbon emissions or anything like that.
According to PlusNews, one of the five priorities at the conference is 'universal' access to HIV drugs. This, despite what you might expect, involves putting 80% of people who need drugs on ART (antiretroviral therapy). The target was to achieve this by the end of 2010 but this will not be met by most countries. Even the target of putting everyone with a CD4 count (a measure of immune strength) of 200, rather than the WHO recommended 350, will not be reached.
Another technological approach is called 'treatment as prevention', the idea that people who are responding to HIV treatment will be less infectious and so will not be likely to transmit HIV. In ideal conditions, this works well. However, with so many countries still a long way from their targets, it is unlikely to have much impact in high HIV prevalence countries. In most of these countries, a substantial percentage of HIV positive people don't even know their status, so they will not be on ART. Treatment as prevention has been talked up for nearly two years now but no one has dared to admit that it is an ideal and will always remain an ideal. Even the jokers who came up with the 'no sex month' idea don't believe it.
Even nuttier than that is an approach called pre-exposure prophylaxis (PrEP). This involves putting those 'most at risk' of being infected with HIV on ART. If we had any idea who was most at risk we could have prevented a lot of infections by now. But we have been pretty unsuccessful in predicting who was most at risk in the past. And recent Modes of Transmission Surveys have shown that many of the people who are becoming infected are not in at risk groups. In fact, one of the characteristics of high HIV prevalence countries is that many of the people most likely to become infected are at low risk, according to official definitions! Figure that one out.
So there are a lot of technologies available but they are either not being used or they are not proving too effective in the field. It is difficult enough to persuade people to get tested for HIV once, let alone once a year for the rest of the time they are sexually active. Many who are HIV positive are either not taking the drugs, not taking the drugs properly or do not have access to the drugs or some other aspect of treatment (shocking, but no, you can't just hand out pills). Perhaps a lot of people are on treatment, but many of them will, eventually, develop resistance and need to go on to a far more expensive 'second line' drug. Technology is not simple, but conditions in developing countries are basic.
So what are the problems, if all this money has been spent for so long? Well countries need infrastructure, especially health infrastructures. They need education, especially health education. They need adequate levels of nutrition and food security. They need clean water and sanitation and many other goods that are considered to be human rights. You cannot roll out a high tech treatment or prevention program without countries having some level of development. It may seem possible to the HIV industry, donors or the public. But not only is it not possible, we've spent years demonstrating the impossibility.
In addition to these technical problems and the problems relating to our relative lack of understanding about exactly how HIV spreads, there is another problem, which is harder to characterize. This is the problem of the HIV industry's refusal to accept that we cannot explain high prevalence, generalized epidemics (where the majority of those infected are not members of high risk groups, such as intravenous drug users, men who have sex with men or sex workers) by almost exclusive reference to heterosexual sex. If you refuse to accept the racist, sexist explanations of HIV transmission in African countries being due to the fact that Africans have lots of unsafe sex, you will also refuse to accept that HIV prevention programs that target sexual behaviour, and nothing else, will reduce transmission to the extent that HIV will eventually be eradicated. I don't see what there is to celebrate.
(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)
Thursday, July 15, 2010
HIV Programs That Never Happened
A steaming pile with hundreds of flies buzzing around it surely means a fresh press release has been issued. And putting '2.0' after the word 'treatment' has ensured that every big news agency repeats the press release so that if repetition makes something true, there really is a new approach to HIV treatment. And treatment is prevention, that's been repeated a lot too. And young people are leading the prevention revolution, because a press release saying so has been passed in advance of the Vienna Aids Conference, which involves those in the HIV industry meeting up and patting each other on the back. Predictably, the 'free' press has picked up that one as well.
Meanwhile in South Africa, a piece of research gives an idea of what people really think about condoms, which are an important aspect of preventing HIV transmission through sexual contact. In many African countries condoms are used by young people, but only by some young people and only some of the time. A point that has been entirely missed by UNAIDS is that male condoms need to be worn on penises, preferably erect ones, before and during sexual intercourse. They can be removed afterwards. But waving them around conference halls, writing policy papers about them, filling up storage space with them, putting lots of pretty pictures of them on your website and issuing press releases about them has little impact on sexually transmitted HIV.
This paper finds that most women and girls are not in a position of power in a relationship and do not usually get to decide or even discuss whether to use a condom. Also, some people have negative beliefs about condoms, such as that they decrease sexual pleasure. Others feel that if condoms are discussed, there must be a lack of trust in the relationship, although that lack of trust may be quite justified. A lot of people just don't talk about condoms, HIV or risks like pregnancy or infection with a sexually transmitted infection (STI).
But what is probably one of the biggest obstacles to reducing HIV transmission is the association of HIV with sexual promiscuity and casual sex. Many people, under such circumstances, would think twice before buying condoms in a pharmacy where there are lots of other people or even being seen with condoms, even by their most intimate friends. Young people are unlikely to be sold condoms by pharmacists or given them by health workers because of the stigma that HIV has been surrounded with. Given that HIV transmission is not just a matter of sexual behaviour, why all the stigma?
Well, the HIV industry itself plays a big part in fuelling the stigma that surrounds HIV transmission. The big players in the industry (and they are big) maintain that HIV in developing countries is almost always transmitted through heterosexual sex. They deny that there is any significant risk from unsafe healthcare or cosmetic practices, despite many questions about this claim. The fact that there are young children and infants with HIV whose mothers' are HIV negative should set off alarms and give rise to investigations. But in African countries, no such investigations have been carried out. Many women are infected, often after they become pregnant, even though they have only had sex with their HIV negative husband. Again, no investigations.
Colluding with the HIV industry are the many political interests, African and non-African, commercial interests, generally non-African, and the hoards of religious groups, who can't open their mouths without spreading stigma. And the above research uncovers some of the lies that church leaders spread about HIV, about condoms and about sex education. It's not as if church leaders are above reproach themselves and I'm not just talking about the Catholic Church.
You can accept the plethora of 'good news' HIV press releases or not but it would be very surprising if young people were 'leading the way' in HIV reduction when they are surrounded by a complete absence of accurate information about HIV and a whole lot of lies, often contradictory lies. While UNAIDS tells them that 'safe sex' will protect them from HIV, the churches tell them that condoms are not safe. Many young people are told little or nothing by their parents or teachers, who probably know little more than their children do. If HIV transmission among young people is falling, this is unlikely to have much to do with HIV prevention programs.
Meanwhile in South Africa, a piece of research gives an idea of what people really think about condoms, which are an important aspect of preventing HIV transmission through sexual contact. In many African countries condoms are used by young people, but only by some young people and only some of the time. A point that has been entirely missed by UNAIDS is that male condoms need to be worn on penises, preferably erect ones, before and during sexual intercourse. They can be removed afterwards. But waving them around conference halls, writing policy papers about them, filling up storage space with them, putting lots of pretty pictures of them on your website and issuing press releases about them has little impact on sexually transmitted HIV.
This paper finds that most women and girls are not in a position of power in a relationship and do not usually get to decide or even discuss whether to use a condom. Also, some people have negative beliefs about condoms, such as that they decrease sexual pleasure. Others feel that if condoms are discussed, there must be a lack of trust in the relationship, although that lack of trust may be quite justified. A lot of people just don't talk about condoms, HIV or risks like pregnancy or infection with a sexually transmitted infection (STI).
But what is probably one of the biggest obstacles to reducing HIV transmission is the association of HIV with sexual promiscuity and casual sex. Many people, under such circumstances, would think twice before buying condoms in a pharmacy where there are lots of other people or even being seen with condoms, even by their most intimate friends. Young people are unlikely to be sold condoms by pharmacists or given them by health workers because of the stigma that HIV has been surrounded with. Given that HIV transmission is not just a matter of sexual behaviour, why all the stigma?
Well, the HIV industry itself plays a big part in fuelling the stigma that surrounds HIV transmission. The big players in the industry (and they are big) maintain that HIV in developing countries is almost always transmitted through heterosexual sex. They deny that there is any significant risk from unsafe healthcare or cosmetic practices, despite many questions about this claim. The fact that there are young children and infants with HIV whose mothers' are HIV negative should set off alarms and give rise to investigations. But in African countries, no such investigations have been carried out. Many women are infected, often after they become pregnant, even though they have only had sex with their HIV negative husband. Again, no investigations.
Colluding with the HIV industry are the many political interests, African and non-African, commercial interests, generally non-African, and the hoards of religious groups, who can't open their mouths without spreading stigma. And the above research uncovers some of the lies that church leaders spread about HIV, about condoms and about sex education. It's not as if church leaders are above reproach themselves and I'm not just talking about the Catholic Church.
You can accept the plethora of 'good news' HIV press releases or not but it would be very surprising if young people were 'leading the way' in HIV reduction when they are surrounded by a complete absence of accurate information about HIV and a whole lot of lies, often contradictory lies. While UNAIDS tells them that 'safe sex' will protect them from HIV, the churches tell them that condoms are not safe. Many young people are told little or nothing by their parents or teachers, who probably know little more than their children do. If HIV transmission among young people is falling, this is unlikely to have much to do with HIV prevention programs.
Wednesday, July 14, 2010
Two Point Zero Means We Haven't A Clue
A prominent UNAIDS spokesperson said "We haven't a clue what to do, really, we have never known. But we have noticed that putting '2.0' after anything will get you mentioned in all the press. And it's true, it works! We haven't had any ideas since we were established but we keep on repackaging tired old ideas that didn't work and the press tell the world what a great job we're all doing".
Sadly, a UNAIDS spokesperson didn't say that or anything else that could be verified. Such top-heavy, high spending bureaucrats with well padded buttocks are not known for making verifiable statements. But they do churn out a lot of photographs and colored diagrams. Their website, which was reasonably easy to find things on before, has succumbed to a late 1990s style splash page and underneath that, another splash page. Where they have put all their content has yet to become clear. Perhaps it's part of their 'treatment 2.0' effort. But some would say, quite cynically in my opinion, that this is no loss.
I was supposed to work for an organization that turned out to be siphoning off money from donors and using it for other purposes, nothing to do with development. But they had a real knack for finding people who would turn the right knobs when potential donors visited. If they were return donors, the same people could push all the right buttons to convince the donors that their money had been well spent and they would be wise to spend more. I think UNAIDS are similar. They have realised that one thing was missing from their attempts to break down in tears at every opportunity and beg for the massive amounts of money going to HIV treatment not to be cut.
They have realised that telling everyone that there are more people becoming newly infected with HIV than being put on treatment was not a good tactic, perhaps because it was too embarrassingly true. Even some of the more foolish people involved were able to think their way through the wet paper bag and see that this would mean the epidemic would just continue to expand. So now they are manufacturing figures to convince us that the childish 'prevention' programs they have wasted so much time on have worked, that you can just wave a magic wand and get people to do what you want and stop doing what you don't want.
On the surface, it looks like things have improved in Kenya a bit since 2000 and somewhat less so between 2003 and 2008. But the year 2000 was just after HIV prevalence peaked and started to drop. It dropped more quickly as death rates increased. Death rates probably peaked around 2003 or 2004 and HIV prevalence has changed little since then. It is claimed that hundreds of thousands of people are now on treatment so prevalence could be expected to have gone up as a result. But it doesn't seem to have done so yet. In fact, death rates are still quite high in Kenya. A few figures have improved between 2003 and 2008, people know the right answers to questions by now, but it is likely that HIV transmission is high enough to keep the epidemic going for some time to come.
If you buy the HIV industry's standard excuse (perhaps there's even an ISO number for it), that HIV is mostly caused by heterosexual sex, then you could easily find the figures seductive. More people now say they are having their first sexual experience later, they are having few partners, they use condoms more often, etc, etc. The behavioral paradigm holds that people (in African countries) have too much unsafe sex and all you have to do is persuade them to have less and HIV transmission will go down. The trend for 'safe' sex indicators has been going up since before HIV was ever heard of so, jumping on that bandwaggon, you could conclude that slight drops in HIV transmission have been a result of 'behavior change'.
If sexual behavior has changed significantly it is possible that some people are less likely to become infected with HIV. It all depends on things like whether they are male or female, urban dwelling or rural dwelling, of childbearing age, married or widowed and various other things. Females and urban dwellers are more likely to be infected. But far more people live in rural areas and out of the 1.5 million HIV positive Kenyans, about one million of them are rural dwellers. Also, the ratio of urban to rural infections is changing, with the percentage of rural infections rising. And while there are more women than men infected, that ratio is also changing. The percentage of men infected is catching up.
I have never seen any clear evidence that you can expect whole populations to say 'Oh, very well, then' when some foreign bureaucrats say 'Ok, you're having too much unsafe sex. Abstain, be faithful and use condoms.' People are more likely to say 'Butt out' or even 'What?'. But even if these 'prevention' efforts have had any effect, HIV is not just transmitted sexually. This is not news, it has been realized since HIV was first identified as the virus that causes Aids. It's just that, somehow, the HIV industry that subsequently developed didn't see non-sexual HIV transmission as worthy of their attention. Perhaps it's not 'treatment 2.0' enough.
So the articles about UNAIDS' non-new new approach are all over the place, bureaucrat-speak for 'We've really screwed up, but hey, that's our job, right?'. UNAIDS need to get clear about where HIV is coming from, who is transmitting it, in which areas and exactly how it is being transmitted. They have got by on 'modeled' figures for too long, figures that depend on too many unwarranted assumptions. Many people have been warning for years now that the behavioral paradigm is a piece of racist, sexist clap trap. They have written articles and books demonstrating how deceitful and misleading it is but UNAIDS and the entire HIV industry still takes this flat-earthist line.
The trouble is that when you set up a cabalistic peer-review system it eventually starts to poke up its own ass. All the 'experts' get together to scratch each other's backs, a sort of mutual delousing, and they agree that their articles are very worthy and must be published at once. Anyone from outside the cabal is ignored. There are millions of people being infected with HIV every year and after 25 years of research, all we can come up with is the same regurgitated nonsense in a new package? Why does UNAIDS still exist, after falling stillborn from the prolific UN? Is this is all they can come up with? People in developing countries, both HIV positive and HIV negative, deserve a lot better.
Sadly, a UNAIDS spokesperson didn't say that or anything else that could be verified. Such top-heavy, high spending bureaucrats with well padded buttocks are not known for making verifiable statements. But they do churn out a lot of photographs and colored diagrams. Their website, which was reasonably easy to find things on before, has succumbed to a late 1990s style splash page and underneath that, another splash page. Where they have put all their content has yet to become clear. Perhaps it's part of their 'treatment 2.0' effort. But some would say, quite cynically in my opinion, that this is no loss.
I was supposed to work for an organization that turned out to be siphoning off money from donors and using it for other purposes, nothing to do with development. But they had a real knack for finding people who would turn the right knobs when potential donors visited. If they were return donors, the same people could push all the right buttons to convince the donors that their money had been well spent and they would be wise to spend more. I think UNAIDS are similar. They have realised that one thing was missing from their attempts to break down in tears at every opportunity and beg for the massive amounts of money going to HIV treatment not to be cut.
They have realised that telling everyone that there are more people becoming newly infected with HIV than being put on treatment was not a good tactic, perhaps because it was too embarrassingly true. Even some of the more foolish people involved were able to think their way through the wet paper bag and see that this would mean the epidemic would just continue to expand. So now they are manufacturing figures to convince us that the childish 'prevention' programs they have wasted so much time on have worked, that you can just wave a magic wand and get people to do what you want and stop doing what you don't want.
On the surface, it looks like things have improved in Kenya a bit since 2000 and somewhat less so between 2003 and 2008. But the year 2000 was just after HIV prevalence peaked and started to drop. It dropped more quickly as death rates increased. Death rates probably peaked around 2003 or 2004 and HIV prevalence has changed little since then. It is claimed that hundreds of thousands of people are now on treatment so prevalence could be expected to have gone up as a result. But it doesn't seem to have done so yet. In fact, death rates are still quite high in Kenya. A few figures have improved between 2003 and 2008, people know the right answers to questions by now, but it is likely that HIV transmission is high enough to keep the epidemic going for some time to come.
If you buy the HIV industry's standard excuse (perhaps there's even an ISO number for it), that HIV is mostly caused by heterosexual sex, then you could easily find the figures seductive. More people now say they are having their first sexual experience later, they are having few partners, they use condoms more often, etc, etc. The behavioral paradigm holds that people (in African countries) have too much unsafe sex and all you have to do is persuade them to have less and HIV transmission will go down. The trend for 'safe' sex indicators has been going up since before HIV was ever heard of so, jumping on that bandwaggon, you could conclude that slight drops in HIV transmission have been a result of 'behavior change'.
If sexual behavior has changed significantly it is possible that some people are less likely to become infected with HIV. It all depends on things like whether they are male or female, urban dwelling or rural dwelling, of childbearing age, married or widowed and various other things. Females and urban dwellers are more likely to be infected. But far more people live in rural areas and out of the 1.5 million HIV positive Kenyans, about one million of them are rural dwellers. Also, the ratio of urban to rural infections is changing, with the percentage of rural infections rising. And while there are more women than men infected, that ratio is also changing. The percentage of men infected is catching up.
I have never seen any clear evidence that you can expect whole populations to say 'Oh, very well, then' when some foreign bureaucrats say 'Ok, you're having too much unsafe sex. Abstain, be faithful and use condoms.' People are more likely to say 'Butt out' or even 'What?'. But even if these 'prevention' efforts have had any effect, HIV is not just transmitted sexually. This is not news, it has been realized since HIV was first identified as the virus that causes Aids. It's just that, somehow, the HIV industry that subsequently developed didn't see non-sexual HIV transmission as worthy of their attention. Perhaps it's not 'treatment 2.0' enough.
So the articles about UNAIDS' non-new new approach are all over the place, bureaucrat-speak for 'We've really screwed up, but hey, that's our job, right?'. UNAIDS need to get clear about where HIV is coming from, who is transmitting it, in which areas and exactly how it is being transmitted. They have got by on 'modeled' figures for too long, figures that depend on too many unwarranted assumptions. Many people have been warning for years now that the behavioral paradigm is a piece of racist, sexist clap trap. They have written articles and books demonstrating how deceitful and misleading it is but UNAIDS and the entire HIV industry still takes this flat-earthist line.
The trouble is that when you set up a cabalistic peer-review system it eventually starts to poke up its own ass. All the 'experts' get together to scratch each other's backs, a sort of mutual delousing, and they agree that their articles are very worthy and must be published at once. Anyone from outside the cabal is ignored. There are millions of people being infected with HIV every year and after 25 years of research, all we can come up with is the same regurgitated nonsense in a new package? Why does UNAIDS still exist, after falling stillborn from the prolific UN? Is this is all they can come up with? People in developing countries, both HIV positive and HIV negative, deserve a lot better.
Tuesday, July 13, 2010
Ribbon of Hope Projects
It's a delicate balance sometimes, when you are trying to support orphans and vulnerable children (OVC) and some other members of their family are even worse off than they are. Several of the guardians of the OVCs Ribbon of Hope Self Help Group are supporting face more immediate threats to their health than the children they are looking after. One mother is suffering from diabetes that appears to be very advanced. She is just recovering from TB and she has been losing her sight for some time. She is in her early twenties and is already having trouble caring for her daughter. If she was HIV positive, she could at least get antiretroviral drugs (ARV) for free. But as it's diabetes, the drugs are prohibitively expensive. Her own mother is on ARVs but she is old to be looking after a daughter and a granddaughter. The father of the child is absent.
Another HIV positive guardian is so sick that she has checked herself into a private hospital. Why she chose a private hospital when she can get the drugs for free is not clear. But she appears to be having trouble accepting that she is HIV positive and refuses to go to the local clinic, where she was diagnosed. You do hear stories of people preferring private hospitals but I doubt if this woman will benefit much from the care she gets there. And her life savings will not go too far, either. Maybe Ribbon of Hope can support one or two of her children but I think she has several others, who will all be vulnerable if anything happens to her. Her husband died some time ago, apparently of Aids.
Thankfully, some of the guardians are well enough to care for their own children, in addition to another child, usually a relative. They are all doing some kind of work but that usually involves long hours, low pay and a good chance that the employer will withhold the wages for as long as possible, months and even years. All the villages we are working in are sisal growing areas. These are vast tracts of land owned by a very small number of extremely rich business people and politicians. The villages are all isolated, several kilometers from the nearest tarred road. For people who live there, the main transport available is bicycle, motorbike, or hired bicycle or motorbike, for those who don't have their own.
We hope that each guardian will come up with some kind of income generation scheme, some way of making a bit of extra money. Ribbon of Hope will assist with loans, advice and perhaps other things. Some of the guardians already have a clear idea of what they would like to do and they have the skills and knowledge to start just as soon as the money is made available. Others are not so sure and are not quite ready. A couple of people seem unprepared to be completely honest or committed, but most had some kind of income generation activity up until the start of 2008. It's unbelievable how many people lost assets and businesses as a result of the civil unrest. Two and a half years later and many have not got back to where they were then and probably will not do so for some time yet. Some will be lucky just to get their land back but most have lost things they will never be compensated for.
After spending a few days visiting two of the villages where some of our clients live, we had to return to our fields, where the maize was in need of harvesting and the other crops, millet and sorghum, were in need of weeding. There has been terrible flooding in the last few months, since the maize was planted. Luckily, much of the maize has survived and the crop is looking good. The beans we planted between the maize plants were almost all washed away. The weeding is being done by some local people and in a few days we should have cleared the backlog and got back to the OVCs in the three other villages we work in.
I was very keen on demonstrating solar cookers and a couple of other simple technologies and I did some demonstrating a while back. But there has not been a lot of interest since. Ribbon of Hope has plenty of core activities to keep us busy and I wanted solar cookers and the like to be an additional activity that wouldn't take up too much time. I mentioned the ideas to the community volunteers whom we work with and they mobilized people. But after a few demonstrations, there were no requests for more. I'd like to do some refresher demonstrations but I'm not sure if it will be possible to drum up enough interest.
I think income generation schemes are good, especially when they work. But they often don't. Not everyone can be a business person. And as we have found from our own projects, mostly growing crops, there are a lot of things that can go wrong; too much rain, too little rain, diseases, pests, lack of market, poor infrastructure and downright dishonesty. That's why I try to persuade people to do some things that can save them money. If they spend a little less on cooking fuel, they will have more for food or other things. And you can save quite a lot, perhaps the equivalent of two or two and a half month's pay over a period of one year. I'd like to understand better why I have not been too successful in selling these technologies, which, by the way, are more or less free! It can be very hard to make money but it's not so hard to spend less.
But most of Ribbon of Hope's projects are going well at the moment. Some of the community based organizations are running themselves and we only visit now and again. One of the organizations that was doing badly at the start of the year, but turned itself around later, is now much stricter, which is a good thing. Too many times the work would be done by two or three people and the others would only turn up when the returns were coming in. A number of projects would have done well if the few workers just got on with it. But no one will work when they think others will help themselves to the results and many community based organizations fail because they are not strict enough about what people have to do in order to collect any of the group's winnings.
I think some people will do a very good job of supporting an extra child while continuing to look after their immediate family. Others may already be too overwhelmed by sickness and poverty. But then maybe we'll find additional ways of supporting them. So far, Ribbon of Hope has done very well keeping things ticking over. There have been challenges, some of which we have met, some of which have been too much. In the long run it's hard to say, but I'm optimistic about a lot of things. I'm just sorry I won't be able to stay here indefinitely to see how everything goes.
Another HIV positive guardian is so sick that she has checked herself into a private hospital. Why she chose a private hospital when she can get the drugs for free is not clear. But she appears to be having trouble accepting that she is HIV positive and refuses to go to the local clinic, where she was diagnosed. You do hear stories of people preferring private hospitals but I doubt if this woman will benefit much from the care she gets there. And her life savings will not go too far, either. Maybe Ribbon of Hope can support one or two of her children but I think she has several others, who will all be vulnerable if anything happens to her. Her husband died some time ago, apparently of Aids.
Thankfully, some of the guardians are well enough to care for their own children, in addition to another child, usually a relative. They are all doing some kind of work but that usually involves long hours, low pay and a good chance that the employer will withhold the wages for as long as possible, months and even years. All the villages we are working in are sisal growing areas. These are vast tracts of land owned by a very small number of extremely rich business people and politicians. The villages are all isolated, several kilometers from the nearest tarred road. For people who live there, the main transport available is bicycle, motorbike, or hired bicycle or motorbike, for those who don't have their own.
We hope that each guardian will come up with some kind of income generation scheme, some way of making a bit of extra money. Ribbon of Hope will assist with loans, advice and perhaps other things. Some of the guardians already have a clear idea of what they would like to do and they have the skills and knowledge to start just as soon as the money is made available. Others are not so sure and are not quite ready. A couple of people seem unprepared to be completely honest or committed, but most had some kind of income generation activity up until the start of 2008. It's unbelievable how many people lost assets and businesses as a result of the civil unrest. Two and a half years later and many have not got back to where they were then and probably will not do so for some time yet. Some will be lucky just to get their land back but most have lost things they will never be compensated for.
After spending a few days visiting two of the villages where some of our clients live, we had to return to our fields, where the maize was in need of harvesting and the other crops, millet and sorghum, were in need of weeding. There has been terrible flooding in the last few months, since the maize was planted. Luckily, much of the maize has survived and the crop is looking good. The beans we planted between the maize plants were almost all washed away. The weeding is being done by some local people and in a few days we should have cleared the backlog and got back to the OVCs in the three other villages we work in.
I was very keen on demonstrating solar cookers and a couple of other simple technologies and I did some demonstrating a while back. But there has not been a lot of interest since. Ribbon of Hope has plenty of core activities to keep us busy and I wanted solar cookers and the like to be an additional activity that wouldn't take up too much time. I mentioned the ideas to the community volunteers whom we work with and they mobilized people. But after a few demonstrations, there were no requests for more. I'd like to do some refresher demonstrations but I'm not sure if it will be possible to drum up enough interest.
I think income generation schemes are good, especially when they work. But they often don't. Not everyone can be a business person. And as we have found from our own projects, mostly growing crops, there are a lot of things that can go wrong; too much rain, too little rain, diseases, pests, lack of market, poor infrastructure and downright dishonesty. That's why I try to persuade people to do some things that can save them money. If they spend a little less on cooking fuel, they will have more for food or other things. And you can save quite a lot, perhaps the equivalent of two or two and a half month's pay over a period of one year. I'd like to understand better why I have not been too successful in selling these technologies, which, by the way, are more or less free! It can be very hard to make money but it's not so hard to spend less.
But most of Ribbon of Hope's projects are going well at the moment. Some of the community based organizations are running themselves and we only visit now and again. One of the organizations that was doing badly at the start of the year, but turned itself around later, is now much stricter, which is a good thing. Too many times the work would be done by two or three people and the others would only turn up when the returns were coming in. A number of projects would have done well if the few workers just got on with it. But no one will work when they think others will help themselves to the results and many community based organizations fail because they are not strict enough about what people have to do in order to collect any of the group's winnings.
I think some people will do a very good job of supporting an extra child while continuing to look after their immediate family. Others may already be too overwhelmed by sickness and poverty. But then maybe we'll find additional ways of supporting them. So far, Ribbon of Hope has done very well keeping things ticking over. There have been challenges, some of which we have met, some of which have been too much. In the long run it's hard to say, but I'm optimistic about a lot of things. I'm just sorry I won't be able to stay here indefinitely to see how everything goes.
Sunday, July 11, 2010
HIV Industry Withholding Vital Evidence
Some former sex workers in Uganda have set up an organization to represent sex workers , called the Women's Organization Network for Human Rights Advocacy (WONETHA). WONETHA believes that women who are involved in sex work should be supported as sex workers, rather than persuaded to change occupation. Trying to persuade sex workers to find another way of making money may be well intentioned (though it probably isn't). But in addition to not bothering to ask sex workers what they would like, such attempts fail to take into account the economic realities.
If you take a large number of women off the streets and give them other jobs, several things happen. Other women move into sex work, probably attracted by the higher price that sex work receives because there are fewer doing the work. Also, wages in the more conventional job market go down, as a result of more people looking for jobs and employers being able to pay even less than before. There are already lots of people doing some kind of subsistence or low paid work. It's often because they are so badly paid that they get into sex work in the first place.
People here have assured me that it is always possible to get a job or find some way of making money, that it is not necessary to resort to sex work. They don't seem to see that it is the fact that some people are not competing with them for these other jobs that makes it possible for them to find such work. Many other people, too, benefit from sex work, directly and indirectly. Police, security people in bars, clubs and hotels who get money from sex workers to allow them to do their work, other people who 'protect' sex workers or just bribe them, bar, club and hotel owners and various others.
Sex workers very often do look for alternative work, sooner or later. Many that I have spoken to have tried to work in the hospitality industry, to make money buying and selling things or by providing various services. But they often return to sex work, if they are not too old to do so, because there are already too many people trying to make money in these ways. The best thing civil society can do for sex workers is to advocate for better conditions for them, the protection of the law, access to safe medical services and full recognition of their human rights.
The motivation behind some of the efforts to persuade sex workers to give up sex work is the HIV epidemic, to which commercial sex work was said to have contributed greatly. Perhaps it did, though this is not clear. The most recent Modes of Transmission Survey for Uganda finds that sex workers, their clients and the partners of their clients contributed around 10% of new infections in 2008. Compared to this, over 40% of infections were from people in monogamous relationships. In other words, it is safe sex that is giving rise to a lot of HIV transmission, not unsafe sex.
The greatest contribution to HIV prevalence is said to come from people engaging in multiple partnerships and their partners. However, the percentage of people engaging in multiple partnerships is no higher in Uganda than it is in many Western countries and it is lower than in some. Very high rates of HIV transmission in Uganda are not explained by sexual behavior when the same behavior only results in very low transmission rates in other, more developed countries.
In the mid eighties, HIV prevalence among sex workers in Nairobi was found to be 81%. However, HIV rates, along with rates for other sexually transmitted infections (STI), began to fall over the next few years and continued to fall thereafter. And this happened in the absence of any HIV prevention programs. Whether earlier STI prevention vaccination programs had spread HIV among sex workers is debatable but such high rates among sex workers are unusual. In some countries, sex workers are unlikely to be HIV positive unless they are also intravenous drug users. So there is still a problem explaining why HIV rates are so much hither in developing countries than in developed countries.
Sex workers may face high risk of being infected with HIV and other STIs through their work. But they also face other risks that are much easier to avoid than sexual risks. For example, sex workers (and others) often use injectible contraceptives. They also regularly visit clinics for checkups and vaccinations against various STIs. If any of these clinics are reusing needles, syringes or any other equipment, a lot of infections could be transmitted by such unsafe practices. The Modes of Transmission Survey finds that 0.06% of HIV infections are transmitted in this way. But this figure is questionable in a country that has ongoing shortages of medicines, contraceptives, equipment, trained personnel and clinics.
Non-sexual HIV risks could be avoided but no one is going to avoid them if they don't know they exist. Sex workers are constantly being told about the risks they face through unsafe sex. But they are never told about the risks they face in clinics. Yet, they are being sent to these clinics in ever growing numbers. Sex workers have a right to know that HIV is not just transmitted sexually. Telling them about condoms and unsafe practices will not help them avoid non-sexual risks. And people who are not sex workers also need to know about non-sexual risks. They are quite mistaken in their belief that sex workers play a big part in transmitting HIV.
The most disgusting thing about the belief that HIV is almost always transmitted sexually in African countries is that it emanates from the HIV industry, which goes on about reducing stigma. There is no better way to promote stigma than to label people as 'most at risk', especially when they are known not to be most at risk. The HIV industry is well aware that unsafe medical practices can be far more efficient transmitters of HIV than unsafe sexual practices. And while they warn their own employees about these risks when they are visiting developing countries, they tell people who have to live in those countries that they needn't worry about injection safety or anything else that may result in exposure to contaminated blood.
Much of the stigma that sex workers and HIV positive people face is manufactured by the HIV industry, who know that non-sexual HIV transmission plays a part in the epidemic. They just don't want to admit that this phenomenon exists or to carry out any research that could reveal the exact contribution it makes to HIV epidemics in developing countries. Sex workers, HIV positive people, HIV negative people in developing countries and anyone concerned about human rights should be advocating for the right to know about something that represents such a huge threat to people's health and welfare. Until people know, they will not be able to protect themselves.
If you take a large number of women off the streets and give them other jobs, several things happen. Other women move into sex work, probably attracted by the higher price that sex work receives because there are fewer doing the work. Also, wages in the more conventional job market go down, as a result of more people looking for jobs and employers being able to pay even less than before. There are already lots of people doing some kind of subsistence or low paid work. It's often because they are so badly paid that they get into sex work in the first place.
People here have assured me that it is always possible to get a job or find some way of making money, that it is not necessary to resort to sex work. They don't seem to see that it is the fact that some people are not competing with them for these other jobs that makes it possible for them to find such work. Many other people, too, benefit from sex work, directly and indirectly. Police, security people in bars, clubs and hotels who get money from sex workers to allow them to do their work, other people who 'protect' sex workers or just bribe them, bar, club and hotel owners and various others.
Sex workers very often do look for alternative work, sooner or later. Many that I have spoken to have tried to work in the hospitality industry, to make money buying and selling things or by providing various services. But they often return to sex work, if they are not too old to do so, because there are already too many people trying to make money in these ways. The best thing civil society can do for sex workers is to advocate for better conditions for them, the protection of the law, access to safe medical services and full recognition of their human rights.
The motivation behind some of the efforts to persuade sex workers to give up sex work is the HIV epidemic, to which commercial sex work was said to have contributed greatly. Perhaps it did, though this is not clear. The most recent Modes of Transmission Survey for Uganda finds that sex workers, their clients and the partners of their clients contributed around 10% of new infections in 2008. Compared to this, over 40% of infections were from people in monogamous relationships. In other words, it is safe sex that is giving rise to a lot of HIV transmission, not unsafe sex.
The greatest contribution to HIV prevalence is said to come from people engaging in multiple partnerships and their partners. However, the percentage of people engaging in multiple partnerships is no higher in Uganda than it is in many Western countries and it is lower than in some. Very high rates of HIV transmission in Uganda are not explained by sexual behavior when the same behavior only results in very low transmission rates in other, more developed countries.
In the mid eighties, HIV prevalence among sex workers in Nairobi was found to be 81%. However, HIV rates, along with rates for other sexually transmitted infections (STI), began to fall over the next few years and continued to fall thereafter. And this happened in the absence of any HIV prevention programs. Whether earlier STI prevention vaccination programs had spread HIV among sex workers is debatable but such high rates among sex workers are unusual. In some countries, sex workers are unlikely to be HIV positive unless they are also intravenous drug users. So there is still a problem explaining why HIV rates are so much hither in developing countries than in developed countries.
Sex workers may face high risk of being infected with HIV and other STIs through their work. But they also face other risks that are much easier to avoid than sexual risks. For example, sex workers (and others) often use injectible contraceptives. They also regularly visit clinics for checkups and vaccinations against various STIs. If any of these clinics are reusing needles, syringes or any other equipment, a lot of infections could be transmitted by such unsafe practices. The Modes of Transmission Survey finds that 0.06% of HIV infections are transmitted in this way. But this figure is questionable in a country that has ongoing shortages of medicines, contraceptives, equipment, trained personnel and clinics.
Non-sexual HIV risks could be avoided but no one is going to avoid them if they don't know they exist. Sex workers are constantly being told about the risks they face through unsafe sex. But they are never told about the risks they face in clinics. Yet, they are being sent to these clinics in ever growing numbers. Sex workers have a right to know that HIV is not just transmitted sexually. Telling them about condoms and unsafe practices will not help them avoid non-sexual risks. And people who are not sex workers also need to know about non-sexual risks. They are quite mistaken in their belief that sex workers play a big part in transmitting HIV.
The most disgusting thing about the belief that HIV is almost always transmitted sexually in African countries is that it emanates from the HIV industry, which goes on about reducing stigma. There is no better way to promote stigma than to label people as 'most at risk', especially when they are known not to be most at risk. The HIV industry is well aware that unsafe medical practices can be far more efficient transmitters of HIV than unsafe sexual practices. And while they warn their own employees about these risks when they are visiting developing countries, they tell people who have to live in those countries that they needn't worry about injection safety or anything else that may result in exposure to contaminated blood.
Much of the stigma that sex workers and HIV positive people face is manufactured by the HIV industry, who know that non-sexual HIV transmission plays a part in the epidemic. They just don't want to admit that this phenomenon exists or to carry out any research that could reveal the exact contribution it makes to HIV epidemics in developing countries. Sex workers, HIV positive people, HIV negative people in developing countries and anyone concerned about human rights should be advocating for the right to know about something that represents such a huge threat to people's health and welfare. Until people know, they will not be able to protect themselves.
Friday, July 9, 2010
Will a New HIV Boss at WHO Make a Difference?
The World Health Organization (WHO) has a new head of HIV called Gottfried Hirnschall and he gave an interview recently to IRIN. Apparently he feels that, as a prevention message, abstinence is unrealistic. That's good, but not good enough. Abstinence didn't just fail because it's unrealistic. There's no reason why the option of choosing not to have sex under certain circumstances shouldn't be part of a comprehensive sex education program. It's just better if it's not called 'abstinence' and if it isn't the only trick in the box.
There are probably many reasons why HIV prevention programs have failed in African countries but the one reason that WHO, UNAIDS, CDC and all the main HIV institutions refuse to countenance is that not all HIV is transmitted sexually. They go as far as admitting that a small amount is transmitted non-sexualy, but not enough for them to bother spending money or time on. And sure enough, Hirnschall mentions male circumcision and 'treatment as prevention'.
But what does treatment as prevention involve? Because HIV positive people who are responding to antiretroviral treatment (ART) eventually have a low viral load, they are very unlikely to transmit HIV to their partner. If it were possible to test every sexually active member of a population regularly, say once a year, anyone found HIV positive could be put on treatment.
There are just two small flaws. One is that persuading the majority of sexually active people to be tested even once, even to save their lives, has proved elusive. The second is that the majority of people who are currently in need of treatment are not yet receiving it. Much of the funding for HIV treatment that was so fothcoming in recent years has been cut or flatlined. Just as the WHO released new guidelines that would put more people on ART, there isn't even enough money to keep some people already on treatment in drugs.
People on ART need to take the drugs every day for the rest of their lives. If they miss their dose too many times, resistance builds up and they need to move to a different drug regime, a far more expensive one. It is very difficult to get credible figures on what percentage of people in African countries are adhering to ART. But numbers of people dying from Aids is suspiciously high in some countries. It would be one thing if those providing people with the drugs could afford the second or third line drugs for those who develop resistance. But some countries are in the position of not even being able to afford first line drugs.
Hirnschall is asked about the shortage of money and he mentions 'task shifting', things like training nurses to do what doctors have been doing up till now. For people who don't mind being seen by a doctor or who really don't need to see a doctor, that's fine. Most people in developing countries don't get to see doctors anyway, they are too scarce. But even nurses are scarce and they are pretty stretched already. Perhaps more nurses will be trained and these ones will not be poached by rich countries.
So much for treatment, though it's not very much. But will those advocating putting more people on treatment get around to preventing new infections? Ok, they like to say that treatment is also prevention, but from a practical point of view, this will not work. People are becoming infected faster than others can be put on treatment and if money for treatment becomes scarce, where will prevention be then?
First of all, not all HIV is transmitted sexually. It needs to be established how much is coming from non-sexual routes, such as unsafe healthcare and other things. And this needs to be dealt with because it sure as hell won't stop by handing out condoms, circumcising men and telling people how to run their sex lives. Hirnschall thinks that a HIV vaccine would be ideal. But what would be ideal would be to establish where most HIV infections are really coming from so that, even if there were a vaccine, we wouldn't need to waste so much money on it.
Second of all, if Hirnschall is worried about where all the money is going to come from if donors are thinking of pulling out he should get on to the issue of generic drugs. He talks about negotiating with big pharma. What's the point of negotiating with them? They want the highest price they can get, they know people in developing countries can't pay it but they think donors can. They will never reduce their prices to a reasonable level. The only way to ensure that drugs are made available at an affordable price is to open up the market to generic producers.
Of course, big pharma don't want that, they don't want to compete, they want to hide behind the protectionism of intellectual property 'rights'. There are companies well able to produce enough generics to supply everyone who needs ART, to scale up treatment and to continue treating people who go on to need second and third line drugs, as many people eventually will. This has to happen some time. It should have happened a long time ago. Will Hirnschall just drag his heels the way all the others are doing?
Is the WHO's new head of HIV just going to give us more of the same? Or is he going to question the behavioral paradigm that says that most HIV is transmitted sexually? And is he going to stop 'negotiating' with the blood suckers in big pharma and open up the drugs market to competition? If his aims are to reduce HIV transmission and eventually eradicate it, and to treat as many HIV positive people as possible, he will have to take both these steps.
There are probably many reasons why HIV prevention programs have failed in African countries but the one reason that WHO, UNAIDS, CDC and all the main HIV institutions refuse to countenance is that not all HIV is transmitted sexually. They go as far as admitting that a small amount is transmitted non-sexualy, but not enough for them to bother spending money or time on. And sure enough, Hirnschall mentions male circumcision and 'treatment as prevention'.
But what does treatment as prevention involve? Because HIV positive people who are responding to antiretroviral treatment (ART) eventually have a low viral load, they are very unlikely to transmit HIV to their partner. If it were possible to test every sexually active member of a population regularly, say once a year, anyone found HIV positive could be put on treatment.
There are just two small flaws. One is that persuading the majority of sexually active people to be tested even once, even to save their lives, has proved elusive. The second is that the majority of people who are currently in need of treatment are not yet receiving it. Much of the funding for HIV treatment that was so fothcoming in recent years has been cut or flatlined. Just as the WHO released new guidelines that would put more people on ART, there isn't even enough money to keep some people already on treatment in drugs.
People on ART need to take the drugs every day for the rest of their lives. If they miss their dose too many times, resistance builds up and they need to move to a different drug regime, a far more expensive one. It is very difficult to get credible figures on what percentage of people in African countries are adhering to ART. But numbers of people dying from Aids is suspiciously high in some countries. It would be one thing if those providing people with the drugs could afford the second or third line drugs for those who develop resistance. But some countries are in the position of not even being able to afford first line drugs.
Hirnschall is asked about the shortage of money and he mentions 'task shifting', things like training nurses to do what doctors have been doing up till now. For people who don't mind being seen by a doctor or who really don't need to see a doctor, that's fine. Most people in developing countries don't get to see doctors anyway, they are too scarce. But even nurses are scarce and they are pretty stretched already. Perhaps more nurses will be trained and these ones will not be poached by rich countries.
So much for treatment, though it's not very much. But will those advocating putting more people on treatment get around to preventing new infections? Ok, they like to say that treatment is also prevention, but from a practical point of view, this will not work. People are becoming infected faster than others can be put on treatment and if money for treatment becomes scarce, where will prevention be then?
First of all, not all HIV is transmitted sexually. It needs to be established how much is coming from non-sexual routes, such as unsafe healthcare and other things. And this needs to be dealt with because it sure as hell won't stop by handing out condoms, circumcising men and telling people how to run their sex lives. Hirnschall thinks that a HIV vaccine would be ideal. But what would be ideal would be to establish where most HIV infections are really coming from so that, even if there were a vaccine, we wouldn't need to waste so much money on it.
Second of all, if Hirnschall is worried about where all the money is going to come from if donors are thinking of pulling out he should get on to the issue of generic drugs. He talks about negotiating with big pharma. What's the point of negotiating with them? They want the highest price they can get, they know people in developing countries can't pay it but they think donors can. They will never reduce their prices to a reasonable level. The only way to ensure that drugs are made available at an affordable price is to open up the market to generic producers.
Of course, big pharma don't want that, they don't want to compete, they want to hide behind the protectionism of intellectual property 'rights'. There are companies well able to produce enough generics to supply everyone who needs ART, to scale up treatment and to continue treating people who go on to need second and third line drugs, as many people eventually will. This has to happen some time. It should have happened a long time ago. Will Hirnschall just drag his heels the way all the others are doing?
Is the WHO's new head of HIV just going to give us more of the same? Or is he going to question the behavioral paradigm that says that most HIV is transmitted sexually? And is he going to stop 'negotiating' with the blood suckers in big pharma and open up the drugs market to competition? If his aims are to reduce HIV transmission and eventually eradicate it, and to treat as many HIV positive people as possible, he will have to take both these steps.
Wednesday, July 7, 2010
Don't Just Repeat the Mantra; Follow it!
One of the people who came up with the idea of a 'no sex month' to reduce HIV transmission by 10-45% (for that month) has published a paper which finds that neither poverty nor wealth drive the HIV epidemic. The no sex month idea suffers from what could be a major flaw: it will only reduce sexually transmitted HIV infection. That may sound obvious but this researcher assumes that most, perhaps even all HIV, is transmitted sexually. So his analysis of the finding that neither poverty nor wealth drive HIV is similarly flawed.
This latest paper may be more comprehensive than previous ones. But the suggestion that wealthy people are often more likely to be HIV positive than poorer people has been made a number of times over quite a few years. It has also been noted that higher levels of education can be correlated with higher rates of HIV. And it has been clear that these trends can change, with the correlation becoming less pronounced and even reversing over time. Whereas earlier in an epidemic, wealth and education may correlate with higher HIV rates, they may correlate with lower rates later on.
It has been clear also that HIV rates differ strongly among men and women, with prevalence among women being far higher than that among men at later stages in epidemics. Correlations between wealth and education are often stronger for women and less pronounced for men. And correlations can be stronger in poorer countries than in wealthier countries. So far, so good, these findings are all interesting and revealing. Before they were established, many pronouncements were made about connections between HIV and poverty and HIV and education which resulted in ineffective strategies.
But the paper's author links all these findings to the unspoken assumption that HIV is mostly transmitted through heterosexual intercourse, that the 'behavioral paradigm' is true. The extent to which HIV is transmitted sexually is not clear because the extent to which it could be transmitted non-sexually has never been properly investigated.
Many poor African countries have high HIV rates. But many richer African countries have even higher rates. Even within Kenya, the highest HIV rates are not found in the poorest areas. North Eastern province is by far the poorest province, with the worst education indicators, yet HIV prevalence is very low. Higher rates are found in Nairobi, whose population is richer and better educated, on the whole. But no matter how you slice up the population, high HIV prevalence does not correlate with wealth, poverty, inequality, education or anything else that is obvious.
If you assume that HIV is mostly transmitted sexually, you wonder why infections among women can be four times as high as those among men. Just who is infecting these women and under what circumstances? You could assuage these doubts somewhat by pointing out that women are more susceptible, for various different reasons. But then you find the richest women with the highest levels of education in Tanzania are far more likely to be infected than the poorest. This changes over time, but the trend certainly doesn't reverse. And the pattern among men is completely different. With the behavioral paradigm, you have to tie yourself in knots to understand just what sort of sexual behavior is going on here.
It helps if you are quite racist, which is lucky for UNAIDS because as an institution, they are racist through and through. It also doesn't do any harm to be sexist and UNAIDS also ticks that box. You then make up various different (and fairly improbable) hypothetical scenarios and you come up with this:
It doesn't mean very much but it sounds good, especially as there are some citations in the original article, giving the whole thing a veneer of authenticity. But there is no evidence that Africans, rich or poor, male or female, engage in large enough amounts of the sorts of behavior considered risky enough to explain the devastating epidemics found in Sub-Saharan African countries. Sexual behavior varies from place to place, but not in the way UNAIDS and the author in question would like. Most Africans do not have lots of risky sex, only some do. But some Europeans do, as do some Americans. You just don't find HIV epidemics in Europe and America like the ones in Africa.
The author goes on :
This may all be true but it is only true of sexually transmitted HIV.
If you don't assume the truth of the behavioral paradigm and you accept that some HIV is transmitted non-sexually, they you can consider less improbable and more testable scenarios. For example, you could look at the different behaviors of males and females relating to health care. Women could be exposed to more of the kinds of medical procedures and cosmetic procedures that might carry a risk of HIV infection. Richer women could be exposed to more of these procedures than poor women. Earlier on in the epidemic, education and wealth may have had little influence on women's attitudes towards health and cosmetic treatments but this could have changed as more became known about the epidemic.
If it is assumed that all or most HIV is transmitted sexually then you will end up with HIV prevention programs that aim to change people's sexual behavior. That's what we have ended up with, even worse, most of the programs don't work. Unless we also target non-sexual transmission, which means establishing its contribution to the HIV pandemic first, we will never 'know our epidemic', in the words of UNAIDS. And if we don't know our epidemic we will never 'know our response', either. The key to a mantra is not just to repeat it, you also have to follow it.
This latest paper may be more comprehensive than previous ones. But the suggestion that wealthy people are often more likely to be HIV positive than poorer people has been made a number of times over quite a few years. It has also been noted that higher levels of education can be correlated with higher rates of HIV. And it has been clear that these trends can change, with the correlation becoming less pronounced and even reversing over time. Whereas earlier in an epidemic, wealth and education may correlate with higher HIV rates, they may correlate with lower rates later on.
It has been clear also that HIV rates differ strongly among men and women, with prevalence among women being far higher than that among men at later stages in epidemics. Correlations between wealth and education are often stronger for women and less pronounced for men. And correlations can be stronger in poorer countries than in wealthier countries. So far, so good, these findings are all interesting and revealing. Before they were established, many pronouncements were made about connections between HIV and poverty and HIV and education which resulted in ineffective strategies.
But the paper's author links all these findings to the unspoken assumption that HIV is mostly transmitted through heterosexual intercourse, that the 'behavioral paradigm' is true. The extent to which HIV is transmitted sexually is not clear because the extent to which it could be transmitted non-sexually has never been properly investigated.
Many poor African countries have high HIV rates. But many richer African countries have even higher rates. Even within Kenya, the highest HIV rates are not found in the poorest areas. North Eastern province is by far the poorest province, with the worst education indicators, yet HIV prevalence is very low. Higher rates are found in Nairobi, whose population is richer and better educated, on the whole. But no matter how you slice up the population, high HIV prevalence does not correlate with wealth, poverty, inequality, education or anything else that is obvious.
If you assume that HIV is mostly transmitted sexually, you wonder why infections among women can be four times as high as those among men. Just who is infecting these women and under what circumstances? You could assuage these doubts somewhat by pointing out that women are more susceptible, for various different reasons. But then you find the richest women with the highest levels of education in Tanzania are far more likely to be infected than the poorest. This changes over time, but the trend certainly doesn't reverse. And the pattern among men is completely different. With the behavioral paradigm, you have to tie yourself in knots to understand just what sort of sexual behavior is going on here.
It helps if you are quite racist, which is lucky for UNAIDS because as an institution, they are racist through and through. It also doesn't do any harm to be sexist and UNAIDS also ticks that box. You then make up various different (and fairly improbable) hypothetical scenarios and you come up with this:
Poor people in some settings undertake particular risky practices – e.g. earlier sexual debut or reliance on transactional sex – whereas wealthy individuals may engage in other risky practices, such as participation in broader social and sexual networks or sex with higher numbers of (voluntary) regular partners.
It doesn't mean very much but it sounds good, especially as there are some citations in the original article, giving the whole thing a veneer of authenticity. But there is no evidence that Africans, rich or poor, male or female, engage in large enough amounts of the sorts of behavior considered risky enough to explain the devastating epidemics found in Sub-Saharan African countries. Sexual behavior varies from place to place, but not in the way UNAIDS and the author in question would like. Most Africans do not have lots of risky sex, only some do. But some Europeans do, as do some Americans. You just don't find HIV epidemics in Europe and America like the ones in Africa.
The author goes on :
Effective action requires unpacking the black box of behaviour by recognizing that HIV infection in poorer groups may arise from certain lifestyles and risky behaviours related to poverty, whereas HIV infection in wealthy groups may be due to different lifestyles and risky behaviours related to their wealth.
This may all be true but it is only true of sexually transmitted HIV.
If you don't assume the truth of the behavioral paradigm and you accept that some HIV is transmitted non-sexually, they you can consider less improbable and more testable scenarios. For example, you could look at the different behaviors of males and females relating to health care. Women could be exposed to more of the kinds of medical procedures and cosmetic procedures that might carry a risk of HIV infection. Richer women could be exposed to more of these procedures than poor women. Earlier on in the epidemic, education and wealth may have had little influence on women's attitudes towards health and cosmetic treatments but this could have changed as more became known about the epidemic.
If it is assumed that all or most HIV is transmitted sexually then you will end up with HIV prevention programs that aim to change people's sexual behavior. That's what we have ended up with, even worse, most of the programs don't work. Unless we also target non-sexual transmission, which means establishing its contribution to the HIV pandemic first, we will never 'know our epidemic', in the words of UNAIDS. And if we don't know our epidemic we will never 'know our response', either. The key to a mantra is not just to repeat it, you also have to follow it.
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