Wednesday, December 29, 2010

Academics Can Not Be Trusted to Tell the Truth About HIV

Until HIV academics lose their obsession with sex, HIV epidemic patterns will continue to be misrepresented, giving instead a seriously biased picture. This bias does not just have consequences for academic papers; it translates into biased policy, biased intervention programs and biased reporting. As a result, HIV continues to infect and kill millions of people, unchecked by those who are supposed be best placed to control the epidemic.

Doug Kirby had an article a couple of years ago entitled 'Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence'. The 'conclusion' that sexual behavior was behind all African epidemics is not really the issue here; that is something of a reflex.

The issue is about 'confirmation' from 'multiple' sources of evidence. In a nutshell, the paper does not lend confirmation to the behavioral paradigm, the belief that HIV is almost always transmitted sexually in African countries. Nor are the 'multiple' sources of evidence wholly independent of each other.

The fact that adherents of the behavioral paradigm have persuaded most of those working in the field to sing from the same hymn sheet does not have the effect of strengthening the evidence.

The reason all this talk about sexual behavior in Uganda does not confirm the behavioral paradigm, during the 1980s or any during other period,  is that it simply ignores non-sexual HIV transmission. People are rarely asked questions about anything but their sexual behavior, knowledge and attitudes. And yet it is thereby concluded that only sexual behavior, knowledge and attitudes are relevant.

Kirby's article even mentions that people were "more careful in general, avoided people with AIDS, were careful with blood, were careful with injections, etc." This glosses over what may be useful evidence about non-sexual HIV transmission.

But this was in 1989, when it was still acceptable to mention non-sexual HIV transmission. Not long after that it ceased to be acceptable. People were rarely asked about anything but their sexual behavior, knowledge and attitudes. Therefore, there is little data available. And this article, like so many others, skates over anything that is not about sex.

In fact, Kirby's point seems to contradict his thesis: the majority of people had made no change in their behavior or merely intended to make changes. Only a small minority had actually made changes. Not only is there little evidence that sexual behavior change was likely to have any impact on the epidemic, that relevant behavior change actually occurred and had any impact on the epidemic, or that it will ever have a substantial impact on the epidemic anywhere, but the whole paper assumes the truth of its conclusions, despite the paucity of evidence.

As for the 'multiple' sources of evidence, newspaper articles published whatever the going story was at the time. This would have been influenced by a mixture of half-baked policies, misinformed pronouncements and a handful of 'academic' papers that happened to suit the current buzz around AIDS.

The focus groups and other qualitative data is likely to have been heavily influenced by the same media buzz. In other words, most people would have been remembering what they heard, read and talked about as much as by what was happening, which was and continues to be largely misunderstood.

'Models' of what was happening, especially when the figures came from ante-natal clinics and STI (sexually transmitted infection) clinics tend to be somewhat circular. These facilities would have had very high figures for HIV infection because they were established to deal with the epidemic. In addition to the fact that figures from these facilities could not be generalized (although they were and sometimes continue to be), it is likely that many people were infected in health facilities through unsafe medical procedures.

It is not much talked about now and when it is, it is usually talked about as if it doesn't happen any more. But in the eighties especially, and sometimes in the 1990s, HIV was not just seen as an STI. It was also seen as a virus that was spread through various medical procedures. Blood transfusions were one of the most prominent medical procedures because the probability of transmission through contaminated blood was extremely high.

But most people don't receive blood transfusions. What most people do receive are injections and various other procedures which carry a high risk of transmission if equipment is contaminated. The risk is nowhere near as high as it is with transfusions but it is orders of magnitude higher than it is for sexual transmission, the probability of which is quite low per sex act.

Articles like Kirby's simply leave non-sexual transmission out of the picture. What proportion of various country epidemics are down to non-sexual transmission is unknown. What is known about sexual transmission is impossible to evaluate because we have little idea what proportion of overall transmission it accounts for.

Indeed, it is no secret that sexual behavior can not really explain why some countries and parts of countries have inordinately high HIV prevalence. But those who take the behavioral paradigm as their starting point still make up the majority among HIV academics.

Exactly why academics have continued to present this biased view of HIV epidemics is really not clear. Surely the desire to appear to be right, now that thay have been painting themselves into this corner for so long, cannot explain why so many millions of people are being condemned to avoidable sickness and death? But that doesn't really solve the problem of how to change this situation.

It appears that academics can not be trusted to tell the truth. They are not content to research, analyze and report unless their writings conform to what amounts to a dangerously biased orthodoxy. Will they continue to lie until their consequent irrelevance becomes widely recognised? Or will we simply let them get on with not doing their job while innocent people, women, men and children, suffer the consequences?

Kirby claims to have no competing interests but some of the funding was supplied by UNAIDS, that great bastion of the behavioral paradigm and attacker of anyone who suggests that HIV is not all about sex. Kirby also mentions help from Daniel Halperin, which would also have ensured that the conclusion wouldn't shock or offend anyone in the orthodox camp by reducing bias or acknowledging any of the more serious limitations of the study.


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