Tuesday, November 23, 2010

UNAIDS' Report: Prejudice, Wishful Thinking, Slick Marketing & a Veneer of Pop Science

World Aids Day is almost upon us, so the industry has to get its story together. It's clear that rich countries of the world have other things on their minds, such as money, so UNAIDS and their chums are not expecting them to be quite so generous in the near future.

But they have already adopted a new strategy: instead of constantly whining about the pandemic getting worse and the industry needing more money, they have started to whine about how the pandemic is getting better, so they need more money to keep things on the right trajectory.

"We have halted and begun to reverse the epidemic. Fewer people are becoming infected with HIV and fewer people are dying from AIDS", says the forward to UNAIDS' annual epidemic report. "But", it goes on, "we are not yet in a position to say 'mission accomplished.' Growth in investment for the AIDS response has flattened for the first time in 2009. Demand is outstripping supply. Stigma, discrimination, and bad laws continue to place roadblocks for people living with HIV and people on the margins."

Global press, observing the usual custom of repeating press releases without change, analysis, question or thought, are now busy saying what they are told to say. "HIV epidemic 'halted', says UN" says the BBC. The other news agencies I looked at appear to be in accord. But what UNAIDS are claiming is that the pandemic has been halted by their efforts; and there is precious little evidence that that is true.

HIV incidence in all the highest prevalence countries began to fall some 10 or 15 years after the virus started to spread. (Incidence is the annual rate of new infections, prevalence is the proportion of individuals in a population who have HIV at a speciļ¬c point in time.) This means that incidence in Kenya began to decline in the early to mid 1990s and in Uganda several years earlier. In Southern African countries, where HIV arrived later, the peak and subsequent decline was also later.

In fact, there are usually different sub-epidemics in countries and each one probably started, peaked and declined at different times. In Kenya, Uganda and Tanzania, national declines in incidence were followed by a peak in prevalence and then a rapid decline in prevalence as death rates started to climb. Once death rates peaked and declined, prevalence rates started to look as if they were going to go up again. So these three countries still have high enough rates of transmission to ensure that HIV will be endemic there for the foreseeable future.

But the most disturbing thing about this sort of epidemic dynamic is that we have no clear explanation of why HIV transmission peaked and started to decline long before anyone had got around to doing anything to reduce transmission.

Yes, we hear lots of triumphalist stories about what happened in Uganda, where HIV prevalence hasn't changed in years and is probably now increasing. We also hear that prevalence rates in some countries are static, or even climbing, because there are many HIV positive people being kept alive with antiretroviral treatment (ART). Some of the stories about Uganda may be true and there is little doubt that many people are being kept alive by ART.

But these don't explain why incidence peaked and declined. It also leaves the problem of why a disease that is difficult to transmit sexually is said to have suddenly started to spread at alarming rates in the 1970s, 1980s and 1990s without any apparent (and quite astonishing) increase in sexual behavior.

There is no evidence that rates of sexual behavior were ever high enough (or could ever be high enough) to give rise to such rates of transmission. Nor is there any evidence that rates of sexual behavior then declined as a result of some half baked behavior change programs, which few people still believe had any real impact.

In many non-African countries, where sexual behavior was never given as the entire explanation of how HIV became endemic, rates of transmission are rising. HIV transmission in these countries is more likely to be a result of intravenous drug use (IDU) and anal sex, homosexual and heterosexual. In non-African countries, HIV transmission rates correspond quite convincingly with levels of IDU and men having unprotected sex with men (figures for heterosexual anal sex are not so clear). Both IDU and anal sex are very efficient modes of HIV transmission.

The annual presentation of the industry orthodoxy as if it were infallible is bad enough. It's little more than a mix of prejudice, wishful thinking, slick marketing and a veneer of pop science. But it's insulting to people who suffer from HIV and AIDS, directly and indirectly, to be told that almost everything that can be done is being done. And it will be of little comfort to those who are at risk of becoming infected, either.

The 'hypothesis' about HIV arriving out of the blue, being spread by those highly sexually active Africans, then declining because some clever Western scientists told them to stop having so much sex doesn't work. But like any other lie, it requires more lies to shore it up until the liars come to realize that they are reaching the end of the credibility tether.

It remains to be seen how many people will be unnecessarily infected before UNAIDS and Co. tell the truth. Hopefully, they will then be abolished and replaced by an institution that is not entirely run by vested interests.


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