Sunday, October 31, 2010

Has HIV Prevention Programing Been Distracted by a Moral Red Herring?

A recent article in The Lancet about discordance predictably fails to discuss the possibility that a substantial proportion of HIV is transmitted non-sexually. After all, non-sexual transmission is not something that the HIV orthodoxy, UNAIDS and a few other over funded institutions, like to discuss. Instead, the article concludes with a brief paragraph dismissing non-sexual transmission without argument.

The main thrust of the article is that the "proportion of HIV-positive women in stable heterosexual serodiscordant [where one partner is HIV positive and the other is not] relationships was 47%". I'm not sure why the authors are so surprised because much of their data has been around for five or more years. But this "shows that women are as likely as men to be the index partner [the first to be infected and therefore the one that is assumed to infect the other partner] in a discordant couple".

The bulk of HIV prevention programing assumes that HIV is almost always transmitted sexually in African countries. This includes the assumption that men are far more likely to be the index partner because men are far more likely to engage in 'risky' sexual behavior. However, both of these assumptions are unsupported by evidence. These 'findings' about discordance are more of an indication that the orthodox view of HIV transmission is not correct. There simply doesn't seem to be a close correlation between 'unsafe' sex and HIV transmission.

Sexual transmission of HIV is not particularly efficient. Rough estimates of transmission probability suggest that the probability of a HIV positive man infecting a HIV negative woman may be about 1 in 500. The probability of a HIV positive woman infecting a HIV positive man may be about 1 in 1000. Certain things can make either partner more susceptible to infection and more infectious, but even in discordant couples, transmission rates are only about 10% per year. And even then, the partner infected later is not always infected by their partner. Either way, both may be infected non-sexually!

Transmission through non-sexual modes is many times more efficient. HIV contaminated blood and blood product transfusions may not be very common now, though they still occur. But reuse of injecting and other invasive equipment is probably very common and it is also hundreds or even thousands of times more efficient.

Aso, although HIV transmission doesn't appear to have much to do with sexual behavior, it does appear to have a lot to do with marriage. The paper finds that "marriage as a potential risk factor for HIV infection in 13 African countries showed that previous marriage (average of 16·9% of all HIV-infected people across 13 countries) or remarriage (average of 14·5% of all HIV-infected married people in 13 countries), whether attributable to divorce, separation, or widowhood, were significantly associated with HIV infection risks."

But marriage, and HIV risk as a whole, is much more of a threat to women than it is to men. Assuming the self-attested rates of sexual promiscuity among men are true (though they are no higher than rates found in many rich countries), women must be even more promiscuous and extremely dishonest, to boot. Because, despite engaging in relatively low levels of 'unsafe' sex (according to the surveys the article authors use), women are far more likely to be infected than men in all high prevalence countries.

In some parts of Kenya, the ratio of female to male infection is striking. Among the Luhya of Western Kenya, 10 women are infected for every 1.6 men. Among the smaller tribes, 5 women are infected for every one man. Among the Kikuyu, one of the biggest tribes, 5 women are infected for every 1.5 men. Only in a minority of tribal groups, and a minority of Kenyans, are men as likely as or more likely to be infected than women.

Every week I find new research showing that the orthodox view of HIV transmission is in serious need of review. But rarely do I find an admission that the reason why most HIV prevention programs have failed might be because of a faulty theory of transmission dynamics. The authors of the paper conclude "Our study shows the need to focus on both sexes in HIV prevention strategies, such as promotion of condom use and mitigation of risk behaviours." How about broadening the scope to include prevention of HIV transmission, regardless of whether it is sexual or non-sexual? Isn't the ultimate aim of prevention programing to reduce HIV transmission and work towards eradicating the virus altogether?


Friday, October 29, 2010

HIV Institutions Need to be Frank About How Discordance Occurs

Some time back, a Ugandan woman who found out she was HIV positive shot dead her husband, who was HIV negative. This incident introduces an article about the urgent need to focus on HIV discordance, where one partner is positive and the other is negative. Sadly, the article doesn't shed any light on how discordance could occur.

There has been some research into discordance but much of it has gone no further than estimating numbers. Discordance occurs in about half of the couples where at least one partner is infected. And even among non-discordant couples where both partners are infected, there are quite a number where partners did not infect each other. This data is not collected very much, but it should be. How could it occur?

For a start, someone needs to be HIV positive to infect someone else through sexual intercourse. This may sound obvious, but I wonder if the woman who murdered her HIV negative partner knew. In Kenya, half of all married HIV positive women have a partner who is HIV negative. Far more women than men are infected with HIV and in Western Kenya there are more than five HIV positive women for every HIV positive man.

If you go along with the oft repeated orthodoxy, that most (some say 90%) HIV infection is sexually transmitted, you may wonder why women are so much more likely to be infected than men when plenty of data shows that men are far more likely to engage in 'unsafe' sex than women. Or you may simply dismiss this by saying that women are more 'susceptible' to infection through sexual intercourse.

This doesn't really explain differences between genders, especially in Western Kenya, where a large number of women must be having sex with a small number of HIV positive men. After all, as I've just said, 'unsafe' sexual behavior is higher among men. But you could, along with the orthodoxy, dismiss that with some other, equally unconvincing, argument.

Currently, guided by the orthodox wisdom, people who find out that they are HIV positive and their partner is not tend to be told that they must have had unsafe sex with someone other than their partner. There isn't really any other possibility, given the orthodox view. They could object that they have only ever had sex with their partner but the assumption is still made that they are probably mistaken or lying. Very often, that's the end of the partnership. Some people remain with their HIV positive partner, many don't.

It would be so much easier to admit that the figures suggest that a lot of HIV infections are probably not caused by 'unsafe' sex. Most women are not promiscuous. Nor are most men, despite all the spoken and written attestations to the sexual behavior of Africans, especially African men. Some men and some women are promiscuous, but that's true in every country in the world.

The assumption that high HIV rates can be put down to sexual behavior at levels that are not possible for human beings is institutional racism, because it informs most HIV policy and programing. The assumption is only made of Africans. In non-African countries, it is not assumped that most HIV transmission is sexual. There is more scope for actually believing what people say about their own sex lives.

It is also institutional sexism. The attested behavior of women, which makes up data collected by HIV institutions, is not used to inform policy and programing. On the contrary, the data is assumed to be lies because it does not accord with the current orthodoxy.

Bizarrely, the article concludes without mentioning non-sexual HIV transmission, the one mode of HIV transmission that might explain prevalence patterns but is rarely discussed by UNAIDS or any other HIV institutions. These institutions are tasked with preventing HIV transmission, yet they choose to ignore the possibility that appalling health services in countries like Kenya, Uganda and Tanzania could result in accidental transmission of HIV.

Another article goes through a similar process of describing some of the problems of discordance and also fails to say how such discordance could occur.

It is difficult to explain discordance without mentioning non-sexual transmission. But it is also unethical, for two reasons. Firstly, everyone has a right to know how they were infected, or how they may have been infected. Secondly, everyone has a right to know how to protect themselves and others from infection, whether it's sexual or non-sexual infection.

Africans are being denied their right to know how they were or may have been infected with HIV and they are being denied the knowledge they need to protect themselves. And it's not just adults that are at risk, infants and children are also at risk. Parents need to be aware of risks that their children face in order to mitigate those risks.

Where infants and children are found to be HIV positive, it vital to establish the source of their infection. It needs to be clear that they were not necessarily infected by their mother, who may not even be infected or may be infected with a different strain of the virus. This phenomenon has often been documented but it has yet to be investigated in African countries.

HIV discordance is a lot easier to explain when it is frankly accepted that not all HIV infection is a result of sexual intercourse. The many non-promiscuous people, virgins, infants, children and no longer sexually active people who find they are HIV positive have a right to know this. And we all have a right to know how HIV is transmitted and how to protect ourselves, especially in high prevalence countries with failing health systems.


Wednesday, October 27, 2010

Unethical and Invalid Vaginal Microbicide Trial Receives Fast-Track Status

It was recently reported that the massively hyped microbicide gel that might reduce HIV transmission from men to women by 39% failed to attract enough funding to run further trials. They had only managed to raise $40 million of the $100 million they needed.

Well now it's back, they hype, that is. The funding is not mentioned, though I assume it has been raised. I wrote two posts about this issue a few months ago. The first was about how unconvincing the whole trial was, along with the media coverage it received. The second was about how the trial was likely to be both invalid and unethical.

None of the worries that I and others have expressed about the trial, known as CAPRISA, have been answered by any subsequent publications. But now the gel has been 'fast-tracked' by the FDA.

The most worrying statement in this article about the 'fast-tracking' is: "most new cases are among women infected during sex with men". Most new cases are among women, but there is little evidence that most of them result from sex with men.

The CAPRISA trial itself gives numerous indications that HIV is not spread solely by sex. Most of the participants didn't engage in much sex and most of them used condoms most of the time. In other words, the sex involved was not predominantly 'unsafe' sex. But, despite this, HIV transmission rates were appallingly high. Why? The trial did not attempt to establish why.

This trial was indifferent as to whether people were infected sexually or non-sexually. Data about how many male partners were HIV positive, and how many had the same viral strain as their female partner, were not collected.

The assumption that HIV is almost always transmitted sexually (in African countries, not in non-African countries) informs most HIV prevention programming. Evidence of non-sexually transmitted HIV is often ignored or even suppressed. It is never investigated.

But even though the CAPRISA trial demonstrated the irrelevance of sexual behavior in very high transmission scenarios, apparently trials are going to continue. Worse still, all sorts of plans are being made about commercial production of the gel, as if its effectiveness has been demonstrated!

Almost all the money currently being spent on HIV prevention (as opposed to treatment, which receives far more funding) goes to programs that assume that sex is the problem. The result is that hardly any money goes into preventing HIV transmission that doesn't result from sex. Yet, medical services in African countries are of such low quality that UNAIDS warns UN employees about the risk of being infected with HIV from medical treatment.

If there are risks of medical transmission of HIV for UN employees, there are medical risks for everyone. The refusal of the CAPRISA trial to warn participants about non-sexual risks renders the trial unethical. The failure to investigate how participants were infected renders it invalid. This vaginal gel is just one more travesty being committed by the HIV industry.

(For discussion of pre-exposure prophylaxis (PrEP), see my other blog.)


Tuesday, October 26, 2010

HIV, Individual Responsibility and Blame in a Neoliberal Agenda

Yesterday, I argued that there can be a tendency to make diseases of poverty seem like matters of personal responsibility, lifestyle decision and behavior. Some diseases, such as diabetes, may occur in poor and rich countries. Whether people in rich countries suffer from diabetes because of their irresponsible dietary choices may or may not be true. But people in developing countries usually do not have a great deal of choice about what to eat. High starch staples may fill a person up as cheaply as possible, but they can also contribute to chronic health conditions.

Similarly, poverty and unemployment can be painted in terms of individual responsibility. An article about the Grameen Bank and its founder, Mohammad Yunus, traces the desire to attribute development problems to individual responsibility back to neoliberal rhetoric.

In the past, I have also argued that HIV is not solely transmitted through individual sexual behavior. Sexual behavior can be relevant, but so is individual susceptibility, the health environment in which people live, levels of equality and empowerment, etc. Indeed, HIV is not solely transmitted through sexual behavior, either. It can also be transmitted through unsafe medical and cosmetic practices.

The fact that health seeking behavior can often be elective and that cosmetic practices may almost always be elective does not mean that HIV transmission through these routes is avoidable. Many people are unaware of the risks involved and know little about how to reduce their exposure to them. Others are just not in a position to ensure that medical and cosmetic instruments and processes are hygienic and risk free. They may be too sick, very young or otherwise unable to do anything about it.

The country that spends more per head on health, the US, sometimes experiences nosocomial outbreaks of certain diseases, that's outbreaks that are caused by medical treatment or processes. Actual HIV transmission is now rare, though it does still happen. But many people have, on several recent occasions, been exposed to risk of infection with HIV, hepatitis and perhaps other diseases. And other recent instances of infection have occurred.

In contrast, African countries only spend a few dollars per head of population. Out of 450 HIV positive children in Mozambique, 22 (nearly 5%) were found to have HIV negative mothersUnsafe healthcare is 'suspected'. The fact that many of the children were infected with the same strain of HIV as their mothers does not mean they were infected through the usual mother to child routes. In other words, the number infected through unsafe healthcare could be a lot higher. But, despite many such findings in African countries, investigations are few and far between.

An article that mentions the outbreak in Mozambique concludes:

These neglected routes of HIV acquisition need due attention urgently. Education of staff in health-care services must be continuously pursued to reduce nosocomial risk, and a sufficient supply of disposable needles and syringes and maintenance of high-quality screening of blood donors must be top priorities.

You may think that it's a straightforward matter to reduce nosocomial risks. However, the typical allocation of funding to this area of HIV prevention is about 1%. Given how poor and inaccessible health services are in African countries, even this 1% is unlikely to have any noticeable impact on nosocomial transmission.

So, where HIV is transmitted sexually, there are many reasons why this is not just a matter of 'individual responsibility'. We have long been aware that many people don't know their HIV status or their partner's status and that even when risks could be avoided in theory, it is not always possible in practice. But we must also recognize the fact that many HIV positive people, perhaps a substantial proportion, are not infected with HIV through sexual intercourse. If people don't recognize the possibility they will not see the need to protect themselves.

The HIV industry has gorged itself on HIV prevention programs that, predominantly, assume individual responsibility. There is, and always has been, plenty of evidence to show that this assumption is wrong. The pitifully low success rates of these programs over many years should have been taken as a warning sign. Like poverty and poverty related diseases, HIV is probably very rarely a matter of individual responsibility. HIV prevention programing needs to be developed accordingly.


Monday, October 25, 2010

Don't Blame the Poor for Diseases of Poverty

Diabetes is often referred to as a disease of the relatively affluent because it can be caused by some of the habits that are common in better off, urbanized areas. It can be associated with foods that have high levels of sugar, often highly processed foods, along with a sedentary lifestyle.

However, it can also be a disease of the very poor, those who have little choice over which staple food they rely on for almost all of their nutritional needs. In Tanzania and Kenya, for example, many people rely on staples that are high in starch, and little else. Maize, white rice, white bread and a small number of other foods can make up the bulk of the daily diet of most people.

An article in the New York Times may give the impression that there are lots of Africans suffering from diseases of affluence. I'm not sure why this article is about such a small sector of the East African population, though it may well be true that there are more wealthy people now than before. But diabetes is far more common than affluence.

I accept that the article is quite clearly about the African middle class, but the association of diabetes with increasing wealth is disingenuous. There are people suffering from diabetes who are neither affluent, urbanized nor sedentary. Are we supposed to see people in such circumstances as being responsible for their suffering from the disease?

The same article mentions lung cancer. One of the biggest killers in developing countries is acute respiratory conditions. This is not because most people smoke cigarettes, live close to a polluting but highly lucrative (for them) industry, live in a city or do anything else that relates to affluence. It is because they are exposed to living conditions that render them susceptible to serious lung problems. It is also because health facilities are poor and inaccessible.

In fact, if any generalization can be made about diarrhea, water-borne diseases in general, nutritional deficiencies and acute respiratory conditions, it is that they affect more babies and infants than adults. In adults, respiratory conditions affect women more than men. Also women and children are far more likely to be living in poverty than men.

The majority of people do not have access to private transport, some don't even have access to public transport. Most do not work in offices, most don't even have formal jobs of any kind. Most still have to walk to health facilities and social services, or even do without them. There are, presumably, risk factors for cancer, heart disease and strokes that relate to poverty as well as to affluence.

Urbanization has been a trend for a long time but it is unlikely to contribute that much to diseases of affluence in East Africa. Urban dwelling poor people are probably even more deprived than rural dwelling poor people and they face additional health hazards that those in rural areas don't face. These hazards include air quality, pollution, road traffic accidents, occupational hazards, violence and others.

I don't wish to belittle common health conditions, regardless of who suffers from them. But it is poor people who need better and more accessible health services, whether urban or rural dwelling. And many people are suffering from preventable and curable conditions that relate to their diet, their environment, their economic circumstances and adverse social conditions, not just from their 'lifestyle'.

An article about health in Zimbabwe illustrates the point: "70% of diseases and deaths in the country, caused by malnutrition, diarrhea, malaria and pregnancy-related complications, are preventable." Similar figures can be found for Kenya and Tanzania. It's a popular game in the press, in development and in politics to deflect attention from the problems people face that are beyond their control and to concentrate on issues that are, ostensibly, a matter of individual responsibility. There is a lot of public health work that needs to be done. Poor countries are not 'like' rich countries when it comes to health.


Friday, October 22, 2010

Human Rights Are Not a Matter of Mix and Match

Following the recent calls from a senior member of the government for greater recognition of rights for homosexuals in Kenya, the former leader of Botswana, Festus Mogae, has argued against the introduction of laws that criminalize same sex relationships. He is also opposed to laws that criminalize sex work. Both of these moves could help reduce discrimination and persecution.

Mr Mogae was discussing these issues in relation to reducing HIV transmission. The combined contribution of men having sex with men, sex workers and their clients to HIV epidemics may be as high as 20%, perhaps even higher. Although both same sex relationships and sex work should be decriminalized for reasons independent of HIV transmission reduction, Mogae's frankness is a big step in the right direction.

Unfortunately, the president of Zambia, Rupiah Banda, doesn't agree. Nor do a large number of current African leaders. But many people are afraid to even campaign or express an opinion about same sex relationships or sex work, especially if they are involved in such relationships or depend on sex work for their income. Whether Mogae is speaking for them or clearing the way for them to speak for themselves, the issues should no longer remain in the hands of extremists.

Despite the relatively small contribution that same sex relationships and sex work make to HIV epidemics, perhaps it doesn't matter why governments discuss the possibility of decriminalizing or avoiding criminalizing these activities. Perhaps the important thing is that the issues are discussed openly and fairly, with the hope that leaders will make decisions based on human rights principles, rather than on tabloid whim.

On the subject of tabloid whim, a Ugandan newspaper is calling for gay people to be hanged. The article has even named people it claims are gay. Uganda's government is not known for discussing homosexuality sensibly, or even for discussing it, and a lot of 'information' on homosexuality in the country is thought to have been disseminated using money from a US Christian church.

Such campaigns are always based on misinformation and hatred. Things associated with homosexuals are suspiciously like things associated with other monorities, such as albinos. Here in Tanzania, literature about albinism often has to explicitly point out that you will not become an albino by touching one, that they are not some kind of mysterious type of human. And there are numerous other myths that need to be dispelled, over and over again.

Homophobes like the public to think that gay people 'recruit' others, adults and children, and somehow make them gay. There are many myths and they are easy to propagate, especially as so many of them are familiar. Stigma that associates HIV transmission with 'unsafe' sexual behavior and some kind of vague 'immorality' also eases the propagation of prejudice. As a result people are persecuted, attacked and often killed.

The belief that Africans have some kind of unusual sexuality, or that they are more sexually active than non-Africans, also feeds the prejudice against same sex relationships. It's all part of a form of human behavior that results in people believing things that couldn't possibly be true solely because they confirm other things that also couldn't possibly be true.

This is dangerous behavior. What Uganda and other African countries need is legislation that prevents such myths being propagated in any way, especially in newspapers and other media. Lying may be common in the media, but the sort of fabrication that goes on in relation to same sex relationships and other sorts of behavior that are said to be 'wrong' has been responsible for many acts of violence. It is likely that there will be more violence.

Failure to recognise the human rights of one minority is a failure to recognise the human rights of all minorities. Because human rights are granted to all humans, arbitrarily selecting one minority and denying them their rights is a denial of the concept of human rights. So it is not only those who engage in same sex relationships who should be rejecting the current rash of homophobic nonsense we are being subjected to by many national media in Africa; everyone who cares about human rights should be concerned.


Wednesday, October 20, 2010

Catholic Bishop Confuses Religion, Morality, Science and 'Nature'

A study carried out in Tanzania in 2004 found that about 47% of observed medical injection practices were unsafe and that 50-90% of curative injections were unnecessary. In a country with HIV prevalence standing at about 8% in 2003, this means that a lot of people are at risk of infection through medical procedures. Especially considering that a large percentage of people receiving invasive medical care are pregnant women, among whom HIV is particularly high.

This kind of finding makes the prouncements from the head of the Catholic Church in Belgium, Archbishop Andre-Joseph Leonard, very difficult to understand. He is said to have described the AIDS epidemic as an "inherent justice" resulting from the "mistreatment of the profound nature of human love", that "nature is taking revenge". If the man seriously believes this, then he must also think that such mistreatment takes place to a far greater extent in certain African countries and specific parts of some countries.

Whatever the explanation for the bishop's comments, they need to be retracted by both him and the church he is perceived to represent. A lot of instances of HIV are transmitted by accident, whether sexually or otherwise. If HIV mainly infected people who were sexually promiscuous, or even people who are guilty of 'immoral' behavior, quite a lot of Catholic priests from Belgium, Germany, Ireland, France, the US and many other countries would also be infected by now.

But most rational people know that HIV can be transmitted by and to those who are simply exercising their normal reproductive rights; it can be transmitted to people through unsafe medical care; also mothers, whether they are infected sexually or non-sexually, can pass the infection to their children, during pregnancy, during delivery or during breastfeeding.

The bishop, like others who don't appear to think or speak rationally on the subject of HIV, seems quite confused about whether he is referring to religion, morality, science or 'nature' (calling something natural or unnatural is a value judgement). As to his "sympathy" and "solidarity", I imagine these would be of little comfort to the victims of his airing of these extremely prejudiced views.

The article about Leonard concludes with a quotation from him on homosexuality: "homosexuality is not the same as normal sex, in the same way that anorexia is not a normal appetite." But he must wonder why only some homosexuality results in illness and death, whereas all anorexia is illness and often results in death. Indeed, if he often has these contemplative moods, he should consider why so many African women are being punished for something that a lot of European men have not been punished for.

The bishop is not just wrong, what he is saying about HIV is dangerous. There are people who believe the sort of things that he says, perhaps others who want to believe them. HIV is also transmitted non-sexually, this is widely accepted (though not widely enough). It is despicable to pretend that it is purely sexually transmitted and to use the phenomenon as a 'moral lesson' to humanity. Even if the Catholic Church were some kind of shining beacon of goodness and leadership, their representatives do not have the right to punish people who are sick, suffering and dying.


Monday, October 18, 2010

Concurrent Relationships: the Latest Stick for Beating Africans

Almost all HIV prevention programs that have taken place in African countries for the last twenty years, and most of the programs that are taking place now, assume the truth of the 'behavioral paradigm'. This is the belief that HIV transmission in African countries is primarily a result of unsafe heterosexual sex. It's important to realize that the behavioral paradigm is applied to African countries, not to most Western countries, where HIV prevalence is low and most of it is not transmitted heterosexually.

In fact, it is not so much of a paradigm, more of a 'foundation myth'. UNAIDS and other proponents of the HIV orthodoxy fully realize that not all HIV is transmitted sexually; they just don't wish to discuss that fact with Africans. They are happy to warn UN employees and associates to avoid African health facilities because of the risks of infection with various blood borne diseases. But when it comes to estimating the number of Africans infected in health facilities, they insist that the figure is negligible. Funding for prevention of such non-sexual HIV transmission is, as a result, also negligible.

Adherence to the behavioral paradigm has always been a matter of loyalty (presumably to funding) rather than evidence. And over the years even some adherents have found reason to question the foundation myth. In a sense, many of them are questioning the behavioral paradigm itself. However, they are not ready to replace it with a view of HIV epidemics that is supported by evidence. Instead, they accept that sexual behavior, per se, may not be that much different in African countries than it is in non-African countries. But they add that Africans have more 'concurrent relationships' than non-Africans and that this sort of relationship explains the very high levels of transmission found in some countries.

Eileen Stillwaggon and Larry Sawers have always opposed the behavioral paradigm in their writings but they have recently published a paper which examines the arguments for the 'concurrency' theory. They conclude that:

Promoters of the concurrency hypothesis have failed to establish that concurrency is unusually prevalent in Africa or that the kinds of concurrent partnerships found in Africa produce more rapid spread of HIV than other forms of sexual behaviour. Policy makers should turn attention to drivers of African HIV epidemics that are policy sensitive and for which there is substantial epidemiological evidence.

The lengths that advocates of the concurrency theory go to are extraordinary. They are reduced to selecting the data that fits the 'hypothesis', leaving out anything that doesn't fit, including data of poor quality and even making up or imagining data to fill in some of the gaps. Stillwaggon and Sawers' paper is long but it is a demonstration of the state of the art of the current HIV orthodoxy.

IRIN, one of the UN's news services, has covered the debate, such as it is. And to be fair, they have accepted that there is a debate, something UNAIDS don't do. But this is not just an academic dispute. The HIV orthodoxy has always presented HIV in African countries as a matter of African sexual behavior which, we are supposed to believe, is completely different from non-African sexual behavior.

This is odd because many African countries have low rates of HIV transmission, as do many parts of countries where HIV transmission is high, nationally. Odder still is the fact that most people, academics and non-academics, are happy to embrace a theory of HIV transmission that is, in a word, racist. Even worse, many people in Africa also embrace the theory!

As with the behavioral paradigm, we are supposed to believe that in some parts of Africa, concurrency is extremely common. In other parts, it is clearly not so common. For example, in North Eastern Province in Kenya, concurrency must be very low because HIV prevalence is low; even though polygamy is higher than anywhere else in the country. But in the parts of Nyanza Province where the Luo live, concurrency is very common. After all, HIV prevalence there is many times higher than it is in North Eastern Province.

Sawers and Stillwaggon refute the claim that rates of concurrency are higher in African than elsewhere, but rates differ greatly between and within African countries, also. Trying to prove an 'African' sexuality is as futile as trying to prove an Aryan sexuality. But those who are trying are no less enthusiastic, despite the lack of evidence!

Yet Halperin, Epstein, Mah and others, who have championed the evidence-free concurrency hypothesis, respond to Stillwaggon and Sawers by branding them as 'denialists'. This is ironic because it is the behavioral paradigm and it's illegitimate sibling, concurrency, that require denial of all that is known about HIV transmission. Sawers and Stillwaggon are not denying that sexual transmission occurs, nor even claiming that it is rare. They are just pointing out that non-sexual transmission must play a far larger part than the orthodox view would allow.

Halperin really reveals something about his thinking when he says "If you go out to shebeens [informal taverns in South Africa] and talk to people about sexual behaviour, I’m sure you’ll find out what’s going on. Everyone will tell you that strict mutual monogamy is the exception not the rule." If you go to pick-up joints in any country in the world you'll find out what's going on: they're pick-up joints. People don't go there to pray. But you can't build a theory about HIV transmission on a few anecdotes about what happens in shebeens.

What Epstein says about needing better scholarship is particularly poignant following Halperin's remarks. If, as she claims, donors are 'backing away' from behavioral approaches, that is good news. Most of them haven't worked. But if they think that a purely biomedical approach is what's required they are simply making the same mistake as before, concentrating on one possible mode of infection when there is more than one mode involved.

The IRIN article is certainly not balanced. But at least it mentions a few issues that the behavioral paradigm obsessed orthodoxy would prefer not to discuss. This is a start, though we should not still be making a start on an epidemic that has been around for nearly three decades. After all, HIV is not the first epidemic ever.


Sunday, October 17, 2010

Why Do UNAIDS Only Wish To Eliminate Some HIV Infections, And Not All?

Writing in the Huffington Post last month, Susan Smith Ellis paints a rosy picture for the future of prevention of HIV transmission from mothers to their children. Ellis's claim that this form of HIV transmission can be eliminated entirely by 2015 may well be true. But it is very unlikely that the goal will be achieved in high prevalence countries. And most of the 430,000 children a year, either born with HIV or becoming infected with it in their first few months of life, are from sub-Saharan African countries.

The HIV orthodoxy, led by UNAIDS, assumes that almost all HIV infection in African countries, around 90%, is a result of (unsafe) heterosexual sex. This assumption is not supported by evidence. Rather, mathematically modeled figures are used to support a set of prejudices that deny the possibility that non-sexual transmission occurs to any great extent in African countries.

It would be very foolish to claim that HIV is never sexually transmitted, or is hardly ever sexually transmitted. But it is no more foolish than claiming that HIV is never transmitted non-sexually. The virus is almost certainly transmitted both sexually and non-sexually. What is in question is the contribution that each mode of transmission makes to HIV epidemics in high prevalence countries.

There is evidence that sexual behavior differs greatly between high prevalence countries (or high prevalence regions in high prevalence countries), but the evidence is weak and doesn't stand up to scrutiny. In contrast, the evidence that health services in high HIV prevalence countries are poor, and could be responsible for some of the highest rates of HIV transmission, is more difficult to refute.

Rather than attempt to refute evidence that HIV may commonly be transmitted through unsafe healthcare, UNAIDS and others simply deny its existence. Occasionally, they refer to non-sexual transmission, either to stress how low it is in high prevalence countries or to warn UN employees to avoid using health facilities in high HIV prevalence countries. But their mantra is one of personal responsibility, of avoidable HIV transmission through unsafe sex.

If a woman is infected with HIV on or around the time of conception, her HIV status can be confirmed by a test some time round the end of the first trimester. If infection occurred before the time of conception, the test will confirm the woman's HIV status, but it won't confirm when infection took place. Yet the woman may not have been sexually active before the time of conception, or she may have taken precautions against both conception and infection. However, because she is pregnant, it will probably be assumed that she was infected sexually.

Perhaps it sounds reasonable to assume that the woman was infected sexually, but was her partner HIV positive? It is not routine in most health facilities to check. It can happen that the partner is tested but it very often doesn't. And given how much lower HIV rates are among men, there is a good chance that most HIV positive pregnant women were not infected by their partner (and it appears to be common for women to give birth to a child fathered by their partner). In fact, in Kenya, around 50% of married HIV positive women have a HIV negative partner.

Do we just assume that all these women also had sex with some HIV positive man, despite the fact that he was not their partner and despite the fact that most or all of them say they have only ever had sex with their partner? If we work for UNAIDS and many other organizations, that is pretty much what we assume. We assume that she is not only promiscuous, but that her word is not reliable. (There is also the mystery of how she became infected with HIV by someone who managed not to impregnate her. It's an awful lot easier to get pregnant than to be infected with HIV through unsafe sex.)

For many women, things are more complicated. They are infected in their second or even third trimester. They may be tested and found to be positive, which makes treatment, or at least precautions against mother to child transmission, more likely. But they may be infected so late in their pregnancy that their positive status is not detectable until after they deliver. In such cases, the need for treatment may not be discovered until it is too late, it may not even be discovered at all.

There are many other aspects to this area of HIV prevention but the aspect I wish to draw attention to is the assumption that most HIV transmission is sexual. Where this assumption is made, other modes of transmission are ignored. Pregnant women and babies receive a lot of medical procedures that men do not receive. One would hope that these medical procedures are safe and hygienic, that they do not pose any risk of infecting either the mother or the child.

But there is no such guarantee in many countries. Conditions in health facilities may be better than conditions in people's homes, but where conditions have been evaluated, they can be very poor indeed. Hospitals often lack personnel with the requisite training, equipment, hygiene procedures and other things that eliminate or reduce the risks of transmission of HIV or other blood borne diseases. Conditions at home are less likely to include the risk of infection with a serious virus, such as hepatitis or HIV. But equipment that is contaminated with these viruses could be common in health facilities. After all, sick people tend to go to hospitals if they can.

We don't need to assume that HIV is almost always transmitted sexually. Sexual behavior, indeed, should be irrelevant to health facility safety. Even mothers who are, or whose partners are, 'promiscuous' or engage in 'unsafe' sex, is not really the issue. The issue is whether the health care they receive is likely to expose mothers and babies to the risk of nosocomial HIV transmission, transmission through unsafe medical procedures. What countries with high HIV prevalence need is greater vigilance in health facilities and an admission that blood-borne infections can occur, just like they can, and often do, in rich countries.

And that's why Susan Smith Ellis is wrong in claiming that, because mother to child transmission of HIV could be eliminated, that it will be eliminated. As long as the assumption is made that the risk is almost all sexual and hardly ever non-sexual, and especially health care related, mothers and their babies will continue to be exposed to risks; many will be infected. Probably the biggest demographic group in high prevalence countries, sexually active women who are having children, are currently facing an avoidable risk, a risk that UNAIDS insists does not exist.


Wednesday, October 13, 2010

Could a Nosocomial HIV Outbreak Occur in Kenya?

One of the most horrifying examples of a nosocomial HIV outbreak occurred in Romania in the 1980s. According to a recent article in Time:

"Unlike in the rest of Eastern Europe, the majority of people living with HIV in Romania did not become infected as adult drug users or sex workers, but as children living in orphanages. In 1987, nurses hoping to cure Romania's orphans of their anemia started injecting them with whole-blood transfusions daily, reusing syringes on multiple children. Some of the blood turned out to be contaminated and at least 10,000 orphans contracted HIV. By 2000, Romania claimed 60% of all the pediatric HIV infections registered in Europe."

There have been many other nosocomial outbreaks, before and since, the majority of them remaining relatively undocumented. However, the basic details of some of the worst are listed in various places on the web, in particular, in David Gisselquist's book 'Points to Consider', available online, free of charge.

In many countries where nosocomial HIV (and other blood-borne diseases, such as hepatitis) outbreaks occurred, they were related to blood transfusions and the use of other blood products. Such occurrences in Western countries are now far less likely to happen, perhaps extremely unlikely. And even in developing countries there is greater awareness of the risks associated with blood transfusions. Most blood is screened, but it is unlikely that all countries take all precautions necessary to ensure that these risks are completely eliminated, especially developing countries.

And when it comes to unsafe injections, it is particularly difficult to quantify the risk. The WHO estimates that about 70% of injections are unnecessary and that a high percentage are unsafe, maybe close to 20%, maybe higher. The figures they cite usually lump countries together in regions and sub regions, so it's hard to know what figures apply to which countries.

UNAIDS is usually silent on the issue of non-sexual transmission of HIV, and nosocomial transmission of HIV, in particular. There are two notable exceptions; the first is when they publish figures denying that nosocomial transmission contribute more than about 2.5% of infections to epidemics in countries such as Kenya; the second is when they warn UN employees to avoid medical facilities in countries such as Kenya because of the risk of nosocomial infection with HIV or other blood borne diseases. It would be truly a medical miracle if only non-Kenyans (and non-Africans) were susceptible to such risks.

Evidence that HIV has been transmitted in African countries is  not hard to find and 'Points to Consider' is a good place to start. But the HIV orthodoxy remains, that HIV transmission is almost all heterosexual in African countries. It appears that evidence to the contrary is being systematically ignored. Why this is so is very unclear.

But rather than constantly drawing together the evidence (a quick search for 'nosocomial' on my blog links to plenty of citations where evidence can be evaluated), it is time for the issue to be investigated. The investigation needs to assess how much HIV has been transmitted nosocomially in the past and to ensure that it no longer happens in the future. At present, most 'official' figures, are modeled. These models first assume, without adequate evidence, that almost all HIV transmission is through heterosexual sex. Then these 'officials', in their infinite wisdom, allocate a small percentage that is nosocomial.

Given what is known about probabilities of heterosexual HIV transmission, it is not possible for the virus to spread as quickly as it has in some African countries (though not all). But given what is known about nosocomial infections, the Romanian instance being just one, it is possible for HIV to spread rapidly in countries that have very poor health services.

Kenya has very poor health services but a lot of people don't have access to health facilities. However, many of the countries with the highest rates of HIV transmission have poor health services to which a large percentage of the population have access. There is an opportunity to investigate and possibly eliminate a substantial percentage of HIV transmission.

Perhaps it's a matter of professional pride or academic pigheadedness that prevents UNAIDS and other parties from even admitting the possibility that they are wrong. But, whatever the reason, the possibility must be acknowledged. Otherwise, many more people will be infected with HIV and other viruses, leading to a lot of unnecessary and preventable suffering and death. What happened in Romania in the 1980s could happen in many African countries in the 2000s. It could happen in Kenya.

(To read about pre-exposure prophylaxis (PrEP), see you other blog.)


Monday, October 11, 2010

Which Way is the Gay Rights Discourse Going in Kenya?

The UK Guardian carries an article arguing that there is a lot of good news for gay people in Africa, that many things are changing for the better. I hope it's true. I hope that, even though several countries are passing legislation that seems to go in the opposite direction, these bills are being rendered obsolete even as they are being discussed.

Of course, what a journalist says one day, despite being repeated my many others the next day, can tend to be rather ephemeral. The very fact that a journalist is discussing something often indicates that it is already old hat. When something as sensitive as gay rights is an issue, some hack with a superficial understanding is the last person you want to be your spokesperson.

I was quite surprised at one of the articles I read about the minister for special programs, Esther Murugi, and her call for greater acceptance of gay people in society. But it was perhaps more surprising that the article was republished by Mars Group Kenya, a human rights organization. The article was so preposterous in its claims and so inept in its arguments that I wondered if Mars Group only posted the article to make the author look like a fool, except that the article was anonymous.

An article in The Standard attempted to use argument rather than bluster. The fact that the argument was patently fallacious means that even people who were convinced by the conclusion, that homosexuality is wrong, may see that the means used to reach the conclusion was highly suspect, at best. I don't believe the author wished to defend homosexuality by raising easily defeated arguments against it; just that those arguments have the load bearing capacity of a wet paper bag.

And a third argument, in The Nation, simply called for a bit of calm and common sense, a bit of compassion, even. Perhaps the author found it difficult to raise arguments against the homophobic outbursts because there was nothing to argue against. I don't have a link to the article but the author, Makau Mutua, makes many interesting points on the subject in another article, including a refutation of the sort of arguments that appear in the Mars Groups article mentioned above.

There's no doubt that Minister Murugi has sparked off a lot of discussion. It's just hard to see where that discussion is going to lead. She hasn't resigned, nor has she been sacked, despite the reactions from some groups, especially religious groups.

On balance, I think good could come from these open discussions, especially where they are genuine exchanges of views rather than the political equivalent of schoolyard rows. But I don't know if it's always safe to discuss sexuality, in particular homosexuality, anywhere and everywhere. I think one still needs to be careful. Ordinary people don't have the levels of protection that politicians and even journalists often enjoy. But I also think arguments can have little impact and I follow Mutua by calling for people to be humane.


Saturday, October 9, 2010

Meaningless HIV Hypotheses Result in Meaningless Predictions

The Lancet has published a report on the "aids2031 project" which "modelled long-term funding needs for HIV/AIDS in developing countries with a range of scenarios and substantial variation in costs: ranging from US$397 to $722 billion globally between 2009 and 2031, depending on policy choices adopted by governments and donors." The world's press has dutifully repeated choice bits of the report without comment, question or (God forbid!) criticism.

Indeed, the report has the usual veneer of confidence that you find with long term predictions, lots of big figures, a range of scenarios, a typology of country epidemics and some pretty diagrams. If this was about bailing out a handful of rich bankers, the amounts of money would be far higher, the period of time would be shorter and the money would be handed over without much fuss. But as there are tens of millions of people involved and they are mostly living in poor countries, serious questions need to be asked about which spending scenario is 'best'.

The figures are, of course, entirely meaningless. HIV was discovered at a time when it had probably only infected a few million people. It is not known why the virus spread so rapidly in a few countries, all in sub-Saharan Africa, yet it only infected people in very specific risk groups in other countries. In many countries, transmission of the virus peaked around about ten or 15 years after it arrived and then declined. Therefore, in some countries the virus may well be peaking now, in some countries transmission rates continue to drop and in others it has already dropped to a low level.

But the question of why HIV struck, spread, peaked and declined has never been answered. As a result, the virus appears to have waxed and waned independently of what any country did to reduce its spread, which was in most cases nothing, anyhow. In countries like Kenya, Uganda and Tanzania, prevalence is stuck at between 6 or 8%, suggesting a steady stream of new infections. Many are being treated, but how many and how successfully is anyone's guess. Body counts are good for fundraising but not for reassuring funders that everything that can be done is being done.

The four spending scenarios all assume that a steady stream of new infections may continue in some countries and that transmission rates in higher prevalence countries, such as South Africa, Namibia, Botswana, Swaziland and others, will continue to decline. And this may be true, new infections may decline in every country. If, as is assumed by the HIV orthodoxy, HIV is mostly transmitted sexually, rates could never go particularly high anyhow. There is a limit to how much sex people can have. The fact that sexual behavior seems to have only a small effect on HIV transmission rates is irrelevant to the orthodox view.

But the authors of the report don't seem to consider the possibility that HIV transmission rates in some, perhaps many countries, could suddenly spike. Of course, there is unlikely to be a spike in sexual activity, especially a level of activity that goes beyond what is humanly possibly. But such a spike must have occurred at some time, if HIV is almost always transmitted sexually (and I'm talking about African countries).

If you don't accept that HIV is almost always transmitted sexually, a spike of non-sexual transmission, perhaps many spikes, are always a possibility. Such spikes, perhaps occurring in health facilities, involving unsafe injections and other procedures, could occur at any time and are the most reasonable explanation for rates of HIV transmission that has never been accounted for by levels of sexual activity that are beyond what humans are capable of.

The problem with the four different scenarios discussed in the report is that they are not based on any real epidemics, instead they are based on a very faulty paradigm. One can easily generate an infinite number of equally meaningless scenarios based on that same paradigm. None of the scenarios deal with improving health systems or health infrastructure, which could reduce transmission considerably.

Poor conditions in health facilities, which can quite easily explain otherwise inexplicable rates of transmission, remain in all high prevalence countries (or ones that once had high prevalence). As long as they remain, planning for the future is a shot in the dark. But as the HIV industry have long been demonstrating, you don't develop a better aim by practicing shooting in the dark. It's only advisable if you don't know what you've hit, or don't much care.

The authors argue that "substantial reductions in incidence (≥50%) will only occur with introduction of a vaccine or curative treatment." I disagree. Substantial reductions in incidence can be achieved by ensuring that nosocomial transmission is eradicated in every country, especially those which have ever had high rates of transmission. As long as health facilities and services remain underdeveloped and inaccessible, further serious outbreaks of nosocomial HIV transmission can not be ruled out. The authors of the report are not even in a position to diagnose what has been happening in the past, let alone make predictions 20 years hence.

(For discussions of Pre-exposure Prophylaxis (PrEP), see my other blog)


Friday, October 8, 2010

A Vote For Minister Murugi is a Vote for Human Rights

There are senior people who still hold powerful positions, despite facing trial in the International Criminal Court; there are some who have stolen money intended for internally displaced persons; others who have stolen food intended for the starving. Education, health and infrastructure funds have gone missing, having passed through the hads of the most powerful leaders in Kenya. Yet calls for the resignation of these powerful individuals are rarely heard.

But one minister calls for greater acceptance of gays by society and religious leaders want her to resign. The part that religious leaders have played in various scandals in Kenya is often quite unclear and it is alarming to hear that when someone in authority advocates greater tolerance, it is religious leaders who protest the loudest. Condemnation precludes the tolerance that they only seem to preach when it suits them.

The word 'promote' is often used in these contexts. In this instance, Minister Murugi is said to be promoting 'un-African' acts. Do people think the minister is recommending that everyone should try having sex with someone of the same gender? If the minister is promoting anything, it is that people accept that there are others who are different from them. And you don't have to be gay to be different. Difference can refer to gender, tribe, religion, politics, wealth and much else.

And there is another message I am hoping Ms Murugi would like to spread and that is the message of thinking independently. Since when have churches and religious leaders adequately represented the interests of ordinary people? Religious leaders are apart from ordinary people, they are often rich, pampered, treated with deference and hold themselves aloof from everyone else. Ordinary people need to get by on their own resources, or what's left after the religious leaders have got their share.

Kenyans pay dearly with their hard earned cash, and in countless other ways, to keep religious leaders comfortable. But these religious leaders are not in those comfortable positions so that they can tell people how to live their lives. They are, from an ethical point of view, on a level with other people. Some may fall far below, some may live admirable lives. But it is not their place to judge, nor to command, only to advise, support and nurture.

This may even be a good time to renegotiate, or at least reconsider, the role that religious leaders play in people's lives and in the running of their country.

Minister Murugi has done what she was elected to do. What would people prefer? That they sack her and replace her with someone else, who will usurp a role of arbiter of good behavior and executioner of punishments for those who fall out of line? It's almost as if Kenyans want leaders who behave as they wish to but expect their electorate always to fall in line and never, never criticize what their leaders may get up to.

The current situation leads to a lot of fear, violence and discrimination. Is that what Kenyans want? There are few leaders in this country who have made any change for the better and, I agree, change for the better is difficult. But Minister Murungi has tried to make a change that might, eventually, make things better for a very significant minority. And in standing up for one minority, a precedent will have been set for other minorities. Causes that once seemed lost may be won, in time.

Every Kenyan should be calling for Minister Murugi to hold firm in her advocacy of greater acceptance of gays in society. People should be telling their religious leaders that they are overstepping their authority. Indeed, they are perverting their authority by failing to uphold tolerance and instead, spreading intolerance and possibly fanning violence and crime. Every Kenyan stands to gain from greater tolerance. Nor need one be gay to benefit from recognition of the legitimacy of difference, whether that difference be sexual, racial, political or anything else.


Wednesday, October 6, 2010

Kenyan Health Care Suffers From Underfunding and Corruption

Following recent remarks by Kenya's Health Services Minister, Professor Anyang' Nyong'o, to the effect that there major problems with health care provision in the country, there have been a couple of other articles on the same subject.

One of them calls for greater investment in the health sector and suggests that problems in the sector are common knowledge. The article is not very specific and doesn't cite the study it purports to be referring to but it mentions inadequate staffing, drug shortages, lack of equipment and paucity of facilities.

The article claims that conditions are worse in rural than in urban areas, which is debatable, but it says that the rural, slumdwelling poor "simply lack access to quality health services". Indeed, I'd say that in some places people lack access to any health services, quality or otherwise. Staff shortages, the article goes on, leads to the use of shortcuts, longer procedures are avoided and quick fixes are widely used.

Apparently corruption is also a problem in the health sector and "Provisions to public health facilities end up in the hands of crooks, who sell them to private hospitals." The article concludes by calling for more investment, but perhaps any finance or resources involved need to be more carefully monitored as well.

Another article deals specifically with corruption and mismanagement in the sector. Both the Medical Services and the Public Health ministrys are mentioned (there are two on account of the power sharing agreement made following the post-election disputes in 2008). This article also mentions shortages of drugs and poor supervision.

According to the article, the report by the Kenya Anti-Corruption Commission "found absenteeism by medical staff, flawed procurement processes, theft of drugs and other medical supplies, and unnecessary referral of patients to private clinics as major forms of corruption." There is also, apparently, a lack of clarity about fees that patients are charged.

Minister Nyong'o specifically draws attention to the possible contribution that unsafe health services could make to the HIV epidemic and various other blood borne viruses. But the health problems that Kenyans face are numerous. In addition to greater awareness about these there should also be far more spending on safe health care that is accessible to everyone.


Monday, October 4, 2010

Storymoja Hay Festival 2010, Nairobi

The Storymoja Hay Festival 2010, held in Nairobi at the weekend, was billed as an arts festival that would include poetry, literature, debate, discussion and other events.But what I took away from the festival owed a lot to the free copy of 'Living Memories', by Al Kags, that was included in the ticket price.

This was a collection of stories from older Kenyans, what they could remember from earlier times. These stories were disturbing, but also very moving. Some of the memories were from the thirties and forties but most were from the fifties, specifically, the Mau Mau years. I have read about the vicious treatment meted out by the British before, but these stories all added something to knowledge of the period that no amount of academic writing could.

I hope Al Kags and others manage to collect and publish lots more oral accounts, not just of bad times, but also of ordinary times, good times and things that have been forgotten by some and were never known by others. Occasionally I hear stories myself, but there is no substitute for oral histories being collected while it's still possible.

Sadly, there were not that many visitors on Saturday, the only day I was there. But I wouldn't be surprised if people were put off by the 500 shilling ticket price. This is not the way to make arts and literature more accessible.

This high cost is quite a contrast with the Maker Faire exhibition that took place at the end of August. This had no entry fee and was very well attended, despite coinciding with the promulgation of the new Constitution.

For people interested in poetry reading, storytelling, debate and discussion, there were certainly opportunities at the Storymoja Festival. And perhaps it seems negative to ignore these and complain about the cost.

But the lack of interest in literature and reading in Kenya, as well as arts in general, is disappointing. Children are brought up seeing reading as a chore, never as a form of entertainment. Even if it can't compete with TV and the rest, it should appear somewhere on the list.

However, there is one particular factor which ensures that most children will not be exposed to much literature in the near future, and that is the costs involved. The few bookshops in most cities sell a small range of books at exorbitant prices, most of them being published abroad. The choice for children is even more limited than that for adults. At the festival, much of what was on offer could as easily be bought in a Nairobi bookshop.

There was clearly plenty of sponsorship for the festival. I spoke to some people who had been involved in the lead-up to the event and a lot of things took place that might not have been obvious to visitors. The free book of living memories is just the sort of thing that should have been subsidized, rather than expensive VIP entertainment. But that book is a great example of how much more could be done.

If money is availabe for such events, perhaps some of it could be spent making literature and the arts in general more accessible to people, and more relevant. Most books were being sold at European prices, even many of the books by African authors. And the locally published books, at several hundred shillings, are still too expensive for most Kenyan people.

For those who went to the festival, what can they take away? If they have developed a desire to hear more poetry or stories, where will they go next? Other events are similarly priced and usually held in expensive Nairobi venues. How many people were, as a result of attending the festival, signed up for a mailing list so they can be kept informed of such events and anything else related to literature and the arts?

There was another exception to the high cost of most of the items that people could buy. An educational publisher, the name of which I don't remember, was selling indigenously produced comics. They were comic versions of folk tales, very simple, but very beautiful. It may be because they were published in the 1980s that they were only priced 5 shillings. But even 25 shillings or more might have attracted a lot of buyers. The series is called 'Pichadithi' (from 'picture' and the Swahili for story, hadithi).

My views of the festival are somewhat mixed. I can see clearly, just as I could after the Maker Faire, that there is a lot on offer in Kenya, but that there could be a great deal more. Similar to the inventions and creative items being exhibited at the Maker Faire, there are incipient stories, poems, novels, plays and much more. But a lot of work needs to be done to allow them to become real and more still to make literature and the arts accessible to everyone.


Sunday, October 3, 2010

Testing the HIV 'Test and Treat' Strategy

A 'Test and Treat' strategy, also referred to as 'Treatment as (or 'is') Prevention', has not shown very good results in a study in China. Such strategies were the most hyped item on the agenda just under two years ago in the HIV/AIDS world. The claim was that HIV positive people responding to treatment usually have a very low viral load so they are far less likely to transmit the virus to their sexual partners; therefore everyone in a population could be tested regularly, perhaps every year, and immediately put on antiretroviral (ARV) treatment if found to be positive.

The study in China looked at discordant couples, couples where only one partner is HIV positive. HIV transmission rates were relatively low, at 4.3% over a three year period (a seroconversation rate of 1.7 per 100 person years), though the rate increased over time.

Risk was higher where sexual activity was higher and where condoms were not always used. Risk was also higher among those who had lower scores in a psychological test. But the ARV treatment itself did not lower the risk of transmission.

Another piece of research could lend some corroboration to the Chinese research. Though not looking at Test and Treat specifically, it does suggests that such strategies may not be very effective outside of the very closely monitored trial conditions that applied to earlier randomized controlled trials.

This piece of research investigated the effects of $6 billion of PEPFAR funding (President's Emergency Plan For Aids Relief) on AIDS related deaths and prevalence in recipient countries. While the fund may have had some success in lowering death rates from AIDS, it did not significantly lower prevalence over its first four years in operation. The authors and speculate that four years may be too short a period.

It is estimated that death rates were reduced by 10.5% (an estimated 1.2 million deaths). However, the number of people put on treatment could be as much as 100 times higher than in the Chinese research. If mass treatment had much effect on transmission, one would expect some detectable effect on prevalence, even after just four years.

But unless you believe the UNAIDS orthodoxy about HIV being mainly transmitted sexually in African countries, the low rates of sexual transmission found in the Chinese research will not be very surprising. The area where the research took place, Zhumadian, has higher than average HIV prevalence because of the use of infected blood products from paid plasma donors in the 1990s.

Perhaps the investigators in the PEPFAR research should not have been so surprised that the $1.2 billion allocated to prevention, about one fifth of the total, had little impact. Because most PEPFAR prevention 'strategies' assume the truth of the UNAIDS orthodoxy, that most HIV transmission in African countries is sexual. Maybe they will now start to see that the orthodoxy needs to be challenged.

In addition to casting doubt on the completely untenable and highly racist assumptions that make up the orthodox view of HIV transmission in African countries, the above research could also question the medicalization of HIV and other diseases. This is the implicit assumption that health is just a matter of treating diseases with drugs, as opposed to ensuring that the conditions under which diseases spread are dealt with.

If high rates of non-sexual HIV transmission can occur in China, they can occur in African countries. And if low rates of sexual transmission can occur in China, they may also be occurring in Africa. Low rates of sexual transmission may be the norm in Africa and it is late in the day to start investigating the contribution that non-sexual transmission plays. But we have a duty to investigate this if we want to have any impact on African epidemics. We can no longer allow prejudices to determine what should and should not be asked about the massive rates of HIV transmission found in a handful of countries in Africa.


Friday, October 1, 2010

Nosocomial and Iatrogenic HIV Transmission in Kenya

I have mentioned non-sexual HIV transmission, and especially transmission through unsafe health care, on a number of occasions. However, some people have interpreted such phenomena in very different ways. Though I have never claimed it, some people seem to think that I am saying that most HIV transmission in Africans countries is non-sexual. I am not claiming this, only that a lot of HIV transmission could be non-sexual and a lot of the 'evidence' for sexual transmission is being manipulated, even though it points to something other than sexual behavior as being behind very high rates of transmission.

Nor am I claiming that every person who visits a health facility is at the same risk of being infected. Even in countries with very high prevalence of HIV and other blood-borne viruses, this doesn't mean that HIV transmission in health facilities is common. Safety and hygiene may be a priority most of the time. Even if the odd procedure is missed now and again, this doesn't mean someone is likely to be infected through a medical procedure. For a start, equipment used needs to be contaminated. And even then, the probability of being infected might only be a few percent.

Most health professionals may follow guidelines religiously. The worry is when there is a shortage of equipment, a lack of clarity about roles or procedures, a temporary drop in vigilance. The fact that such events don't often occur might make them even less likely to be spotted in time. But even when such things go wrong, they still might not give rise to a high risk of people being infected with HIV or anything else. It depends on many circumstances.

I argued recently that sexual transmission of HIV, being quite inefficient, cannot give rise to infections quickly enough or in high enough numbers to explain very serious HIV epidemics like those found in many Southern African countries, or even those found in East Africa and other countries with medium epidemics. I used the terms 'Mediocristan' and 'Extremistan' from Nassim Nicholas Taleb's book The Black Swan and suggested that sexual transmission of HIV is a phenomenon of Mediocristan but that transmission in health facilities is from the realm of Extremistan.

In other words, medical transmission of HIV may not happen all the time, it may not even happen very much. But when it happens, it can affect large numbers of people. Some events may not affect many people, they may just peter out without anyone noticing. Perhaps a few infections will be found, of HIV, hepatitis or something else. But they may never be identified as medically transmitted. This sort of event is still one of Mediocristan. But if the conditions are right and some unsafe procedure results in HIV being transmitted, the number infected could be very high. Inordinately high rates of transmission are possible in health settings that are not possible through unsafe sexual behavior, no matter how much of it may take place.

There have been quite a number of documented (though mainly uninvestigated) outbreaks of HIV that have taken place in medical facilities. These have taken place in both rich and poor countries. The only difference is that in rich countries it is possible to recall and attend to tens of thousands of people. And the risk of infection is not too high if HIV and prevalence of other blood-borne diseases is low in the population. But in poor countries, even if the possibility of an outbreak is noticed, it is unlikely that their health services will have the capacity to investigate, let alone identify all those infected.

So, I am not saying that most HIV infections in Kenya, for example, come from some kind of medical treatment, possibly unsafe injections. I'm saying that in a medium prevalence epidemic, such as Kenya's, some non-sexual transmission must have occurred, especially in areas like Nyanza. There, prevalence is exceptionally high among members of the Luo tribe. Also Western province, where prevalence is exceptionally high among Luhya women. There are probably still plenty of medical transmission events occurring and, if not, there probably will be some in the future.

In countries with the highest HIV transmission rates, such as Swaziland, Zimbabwe, Namibia, Botswana, South Africa and others, medical transmission is likely to contribute a far bigger proportion of infections than in lower prevalence countries. Access to health services is also quite high in these countries. But some of the lower prevalence countries, such as those in East Africa, have lower levels of health services, accessible to far fewer people. And there are many low prevalence areas that also have low access to health services and high prevalence areas with high access to health services. So this connection, if it really is a connection, needs to be investigated.

There are other non-sexual risks relating to HIV transmission, such as through cosmetic practices, head, face and body shaving, manicure, pedicure, tattooing and others. These probably happen, but the question of how often is an empirical one. In countries where most people don't attend medical facilities very much, an epidemic could bump along at a relatively low prevalence for years, much as it has done in Kenya, Uganda, Tanzania and various other countries, with all modes of transmission contributing a steady proportion.

An increase in medically transmitted infections could have quite a profound impact on prevalence, but there's no reason why such an outbreak should be noticed. Or rather, the effects of the outbreak might only be noticed little by little and might not seem like an event with a single, identifiable cause. Especially if no one is looking for the cause or they assume there was a sudden spike in 'unsafe' sexual activity, the extent of which surpasses credibility, if anyone was worried about what is and is not credible about African sexuality.

This is why I have drawn attention to the comments of the Kenyan Medical Services Minister, Professor Anyang' Nyong'o. He has alluded to the state of Kenya's health services, shortages of personnel, overuse of injections, unsafe practices and the consequent risks of nosocomial transmission of HIV, hepatitis and other blood-borne diseases. Now that the country is aware of this risk, it's time to take steps to improve safety in health facilities and rethink the approach to HIV that limits itself to lecturing people about what they should and shouldn't do in their private lives. People need to be aware of the serious non-sexual risks that exist and they should be made aware of how to avoid such risks.

The yearly rate of new HIV transmissions in Kenya may presently be low. Sexual transmission, I would argue, is always low; cosmetic and other practices may also contribute very little. But in a country with health service provision as poor as Kenya's, it's only a matter of time before a significant outbreak occurs. Some significant outbreaks may have already occurred, surveillance is far to low to detect such an event. Unless UNAIDS and others with control of finance and policy are prepared to, like Minister Nyong'o, accept that nosocomial transmission takes place, has always taken place, and will continue to take place, HIV epidemics in African countries will never be reduced, let alone eradicated.