Thursday, November 25, 2010

Are We About to Take the Biggest Step Yet in Reducing HIV Transmission?

Recently, I blogged about WHO's estimates for the number of people infected every year with HIV through unsafe injections and wondered why the number, 23,000, was so low. It was an error in the original reporting. In fact the number is 260,000 HIV infections. In addition, unsafe injections account for millions of transmissions of hepatitis B and C and a host of other diseases.

To put this in perspective, just under 10% of HIV in Uganda is transmitted via sex workers, their clients and their clients' partners, all together. The figure for Kenya is about 15%. But the contribution of unsafe injections is estimated at about 14%, and it could be a lot higher in some places.

The majority of HIV positive people in high prevalence countries did not engage in 'unsafe' sex, according to Modes of Transmission Surveys. But you'd never think that when you read articles about sexual behavior and commercial sex work. The percentage actually attributed to sex workers is less than 2%. It's the clients and partners of clients who make up the bulk of that 10% figure.

Despite sex playing a far smaller role in the AIDS pandemic than we are led to believe by most media and academic writings, the evidence that something else is playing a big part is all around. In South Africa, farm workers in two provinces have some of the highest rates ever found anywhere, almost 40%. Compare this to HIV prevalence among sex workers in India, which stands at about 7%. That's about the same as national prevalence in Kenya, Tanzania and Uganda. Are we supposed to conclude that some Africans engage in far more unsafe sex than Indian sex workers?

The Institute of Migration study, apparently, "could not pin-point a single factor causing this high rate of HIV infection on these farms but points instead to a combination of factors such as multiple and concurrent partnerships, transactional sex, irregular condom use, presence of Sexually Transmitted Infections (STIs) and/or TB and high levels of sexual violence". But these factors are present in many places in the world, in developing and developed countries, without giving rise to such astonishing HIV rates.

Dr Eric Ventura says that more research is clearly needed. But perhaps some different research is needed and even some investigation of the results of some already completed research. Not that there isn't plenty of research into non-sexual transmission, but UNAIDS and many others in the HIV industry choose to ignore it. Perhaps now that WHO have seen the light, UNAIDS will follow. But Ventura suggests, among other things, increasing farm worker acces to healthcare.

Perhaps access to healthcare is the biggest problem in South Africa and some of the surrounding high prevalence countries. Most of the very high HIV prevalence African countries have better access to healthcare than some of the medium prevalence countries, such as Kenya, Tanzania and Uganda. But what quality of healthcare? Increasing access to healthcare will be counterproductive if poor healthcare is contributing more to the pandemic than commercial sex, which has been such a popular punchbag up to now.

Very slowly, the issue of injection safety and other forms of non-sexual transmission of HIV is being raised and even being picked up by the media. The above figures about unsafe injections were supplied by Safepoint Tanzania, who have been trying to get this vital topic on the agenda. But when it comes to media attention, or even that of the HIV industry, sex always trumps boring old healthcare.

With all the interest in criminal HIV transmission (through 'unsafe' sex, of course), I wonder if we will ever look back on the days when UNAIDS and others tasked with reducing HIV transmission consistently refused to accept that a very significant proportion was coming from unsafe injections and ask ourselves how they could get away with this? Because what they are getting away with now constitutes professional negligence that far exceeds that of those who continued to use blood products contaminated with HIV long after they knew the risks.

As another World AIDS Day looms and the 'experts' drone on about what a brilliant job they have been doing, it's time to take what will be the biggest single step ever towards reducing HIV transmission in African countries. That is to recognize that HIV is not just about sex, unsafe or otherwise, and by acting to eliminate the most avoidable and preventable factors in the spread of the virus: unsafe injections and other healthcare procedures.


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.


Sunday, November 21, 2010

After Decades of Torpor, Is WHO Waking Up to the Problem of Unsafe Injections?

Recently, I wrote about condom manufacturers' apparent lack of concern that their products seem to get such bad press where clinical trials of HIV related medicines are concerned. I also linked to an article about a group of Nigerians  taking their government and various other state and non-state institutions to court because they used condoms correctly and consistently but still became infected with HIV. Several non-Nigerian institutions are also involved, including Family Health International (FHI).

Granted, numerous institutions have conspired to blame HIV transmission in Africa almost entirely on sexual behavior, when this is clearly not the whole story. But plaintiffs argue that they were used to test the efficiency of a particular brand of condoms, which were substandard. Perhaps there is evidence that this particular brand of condoms was faulty, in which case, they should indeed be withdrawn.

But the plaintiffs appear to want all condoms to be withdrawn from the market. It would be very surprising of it turned out that all condoms were faulty, despite the claims of the Catholic and other churches that this is so. There is plenty of evidence that condoms are effective in preventing the transmission of HIV and various other sexually transmitted infections. Condoms remain the most effective protection against sexual transmission of HIV.

What condoms don't do is protect people from non-sexual HIV transmission. This may sound too obvious a point to make, but there have been constant claims that abstaining from sex, only having sex with one, faithful partner and using condoms, are the only strategies for avoiding HIV transmission. Worse still, some claim that abstinence from sex is the only way. None of these claims are true.

Abstaining, being faithful and even using condoms will only protect from sexual transmission of HIV. They will not protect from non-sexual transmission, such as through intravenous drug use, unsafe medical practices or unsafe cosmetic practices.

Rather than admitting that they are wrong, the HIV hierarchy also claim that non-sexual HIV transmission is very rare in African countries. Such transmission happens in other countries, poor Asian countries, rich Western countries, Eastern European countries and everywhere else. But, it is claimed, it is too rare in African countries to merit more than about 1% of prevention funding. Never mind that health services range from appalling to non-existent in most African countries.

The WHO is relatively unenlightened when it comes to admitting that HIV prevention strategies are in need of review, given their almost total lack of success over the past few decades. But they do accept that unsafe injections are extremely common. Syringes and other injecting equipment are unsafe because single use equipment are being reused, without adequate (or perhaps any) sterilization.

According to the WHO, "in Africa alone, 20 million medical injections contaminated with blood from patients with HIV are administered every year". How they can also estimate that this results in only 23,000 HIV infections (also, a million hepatitis C and 21 million hepatitis B infections) every year is a mystery, given the efficiency of HIV infection through reused injecting equipment. But it gives an indication of the scale of the problem.

Apparently there is a campaign in Tanzania to have all single use injection equipment phased out and replaced with 'auto-disable' equipment, which breaks after use and therefore can't be reused. The sooner the better.

However, Tanzania's problem is not just with single use injection equipment being reused. They also have too few medical facilities, too few trained healthcare staff, too little equipment and various other things. It remains to be seen if the introduction of auto-disable syringes will be accompanied by improvements in supplies and all the other lacks. After all, there must be some reason why the health and lives of so many people are being put at risk for want of cheap equipment.

The Nigerian case is somewhat different because it appears to claim that a particular brand of condoms do not adequately protect against HIV infection. But the WHO findings, which probably seriously underestimate the problem, make it quite clear that sex alone is not responsible for HIV transmission in countries with sub-standard health services. Therefore, HIV prevention strategies should be extended to include the prevention of non-sexually transmitted HIV, especially nosocomial infections, those occurring in hospitals as a result of medical treatment.

[If you are interested in the question of whether people will be prepared to combine strategies, such as male circumcision, mcirobicides and pre-exposure prophylaxis with continued condom use, see my other blog.]


Wednesday, November 17, 2010

UNAIDS' Secret Weapon: Bait-and-Switch

On first hearing about self-testing HIV kits you might think that it's a brilliant idea. The result would be that more people know their status, their status information would be up to date and it could be kept up to date. Also, people might find out their status far earlier than otherwise, which would hopefully mean they are less likely to transmit the infection.

But then it might strike you that those who know their status need not tell anyone. They would be especially unlikely to tell anyone if they lived in a country where there is a law against having sex without revealing your HIV status, transmitting HIV despite knowing your status, etc. People might even be reluctant to reveal their status in countries where HIV is deeply stigmatized, which is most countries, especially in Africa.

Stigma is especially deep in Africa because the HIV industry, UNAIDS and others, insist that HIV is almost always sexually transmitted. Speculation about what people would or wouldn't do if self-testing kits were available are all influenced by the assumption that transmission is almost always sexual.

Therefore, people may test when they suspect they were infected sexually, but they may not do so if they have no reason to suspect this. If they are infected through medical treatment, or some other non-sexual mode, they are unlikely to think of getting tested.

However, if person A tells person B that person A has just tested positive, person B is very likely to assume that person A was infected sexually. If person B is HIV negative, and married to person A, they will then accuse person A of infidelity. If person B is positive, they will accuse person A of infecting them.

Whether there will ever be any reliable way of telling which party was infected first suddenly becomes a lot more interesting. That's if one party doesn't beat up the other party, drive them out of the family home or even kill them.

The behavioral paradigm, the assumption that almost all HIV transmission in African countries is sexual, is not supported by evidence. On the contrary, it is controverted by a large body of evidence. But it is so widely held that HIV is almost universally associated with something illicit, drugs and men having sex with men in non-African countries, heterosexual sex in African countries.

Before a self-test kit for HIV becomes widely available, shouldn't we deal with the problem of the behavioral paradigm? Unless we deal with this assumption, stigma will not just disappear of its own accord. Simply repeating a mantra about non-stigmatization will not make it disappear.

These questions are not raised because of any objection to technical solutions, where those technical innovations really are solutions and where they are appropriate. But HIV testing has always been controversial. The HIV industry has stoked this controversy, it's not completely clear why, and as a result, HIV testing is 'opt-in' rather than 'opt-out', unlike other medical tests.

If finding out people's HIV status is carried out in order to treat them and prevent further transmission, self-test kits may be very useful. But HIV has been characterized as a threat and a punishment for some kind of imagined transgression by various political and religious interests; the claim that the test would be purely diagnostic does not stand up to scrutiny. Many people are far more worried about being stigmatized than they are about knowing their status, to the extent that many don't wish to know their status.

The worry is mainly about HIV in African countries because the behavioral paradigm is only believed to hold true there. Despite the claims of UNAIDS and others, HIV is not only transmitted sexually, it may not even be mainly transmitted sexually. But as long as the orthodoxy is maintained, the resulting stigma will ensure that wider HIV testing will not address the problem of understanding what is driving the epidemic.

There is little justification for wider levels of HIV testing if no effort is made to find out how people were infected (which includes finding out when they were infected as accurately as possible). Making self-test kits widely available may even do a lot of damage if current assumptions about African sexuality are not re-examined.

The most absurd thing about purely technical solutions is that they don't have any impact on sexual behavior, the very behavior which has for so long been blamed for spreading HIV. Absurd because of the incorrect association of HIV infection with illicit sex. But also because this has created the stigma which resulted in almost all programs to reduce HIV transmission being total failures.

In the end, all this stigma could have been avoided by establishing exactly how HIV is transmitted. Now it looks as if these technical 'solutions', microbicides, pre-exposure prophylaxis, test and treat policies, etc, will also have to fail before anything is done that is likely to reduce HIV transmission. UNAIDS' latest HIV strategy appears to be good old bait-and-switch, widely considered to be fraudulent in the broader commercial world.

[There is a brief note about HIV self-testing and it's relationship with pre-exposure prophylaxis on my other blog.]


Tuesday, November 16, 2010

UN's IRIN Fluffs Issue of HIV Transmission in Medical Facilities

The issue of non-sexually transmitted HIV is rarely discussed in medical or official literature, or anywhere else for that matter. But there is a recent article on IRIN's PlusNews about the risk of accidental HIV transmission to health workers in Kenya. The article notes the need to provide health workers with proper safety equipment and education.

These are vital, not just to protect health workers, but to protect patients. If health workers don't have adequate equipment or if they don't adhere to strict hygiene practices, their patients face far higher risks than the health workers.

Unfortunately, the article botches the message in the second paragraph. They say that 2.5% of new HIV infections every year occur in health facilities. But this does not mean that 2.5% of the country's HIV infections occur among health workers. It means that the figure some epidemiologists have modeled, somehow, suggest that as few as 2.5% of HIV infections are caused by medical procedures, some of those being among health workers. There is no attempt to work out how many health workers are infected. And it's not as if such occurrences are properly recorded, that would be far too sensible.

In fact, the figure of 2.5% is just not credible. The WHO accepts that 70% of injections in developing countries are unnecessary and that almost 20% in some countries are unsafe. Why should Kenya, with it's deplorable health facilities, only have a 2.5% rate of medical transmission? The article even claims that "most government facilities adhere to safety guidelines" and blame "private practitioners in poor areas" for medical transmission.

Kenya's Service Provision Assessment suggests, on the other hand, that safety guidelines are not common. The assessment doesn't even question whether the guidelines are adhered to. They do assess how many facilities have the requisite equipment; not many.

The article seems to suggest that those living in rural areas are more at risk of unsafe health care. People in rural areas may face different risks that urban dwellers, possibly even high risks. But HIV rates are far higher in urban areas. People in rural areas are, however, far less likely to receive any kind of modern medical services. It's striking how the most isolated places of all have very few cases of HIV.

The article says that "patients themselves may not be knowledgeable enough to question unsafe practices", so it isn't a complete waste of space. Patients, Kenyans and other Africans, are quite unaware of the dangers they face, mainly because articles like this one seriously underestimate the level of risk.

A 'self-employed' health worker admits that they don't always have safety equipment, though they frequently give injections. Health workers are right to be concerned for their own health. But the government and those involved in improving medical safety should pay a lot more attention to patients. Health workers may receive the odd scratch or jab from a needle but patients receive much of whatever the equipment is contaminated with, under their skin, into their muscles or even into their veins.

Given the lack of training and equipment among health workers, any initiative to increase training and supplies should be commended. But this is not going to happen overnight, if it even happens at all. Everybody visiting a health facility should know about the risks they and their family members face so that they can take steps to protect themselves against nosocomial transmission of HIV, hepatitis and other blood borne diseases.

Yet again, an article touching on the issues of medical safety and the risk of HIV transmission through unsafe medical procedures completely fluffs the issue. Visiting medical facilities in African countries is extremely hazardous. An indication of how hazardous it is can be gleaned from the advice given by UNAIDS to UN employees:

"Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections."

This is great advice for UN employees (IRIN is part of the UN), even though they have access to UN approved facilities and the option to wait till they are in a country with better medical facilities. However, UNAIDS doesn't feel it is necessary to give the same advice to Africans. They, it appears, only face a very small risk of infection.


Monday, November 15, 2010

Is the 'War' on HIV/AIDS a War on Africans?

As in the broader field of development, who gets what in HIV funding depends more on their relationship with Western powers than on relative need. Certainly what is wanted, what is requested or what is appropriate are not considered. You might say that the market is supply driven, whether you are talking about HIV programs, services, commodities or even research.

A country run by a pretty undemocratic regime, like Uganda, is vaguely listened to and receives a lot of funding. Zimbabwe, which may also have questionable levels of democracy, is not considered particularly credible and receives a lot less funding. Yet it's hard to know which country is the better or worse off. The populations of both countries are infantilized, manipulated and patronized.

But both countries have little say in how HIV, people infected with HIV or people at risk of being infected with HIV are treated. The myth of 'individual responsibility' is pushed by vested interests, political, commercial and religious. All Africans are vilified by the HIV dogma, in particular, women. At best, women are seen as helpless victims of the reckless male, who is seen as violent, greedy and lazy. At worst, women are seen as sexually promiscuous, ignorant and unconcerned about their health or the health and welfare of their children.

Social problems are, rather tautologically, undesirable. Persecution, rape, poverty, disease, discrimination, deprivation and many other social problems are exacerbated in developing countries by poor health services, low levels of education, underdeveloped infrastructure, high unemployment, etc.

But many social problems in African countries have been associated with the spread of HIV. The truth is, no social problem is, on its own, responsible. HIV is not driven by any particular social problem, though many social problems may play some part in HIV transmission. HIV is a virus and, in common with other viruses, its spread relates to the nature of the virus itself, the virus host and the environments in which the hosts live.

Sometimes, the ostensible driver of HIV in African countries is given the name 'African culture', sometimes 'African sexuality' (assumed to be a subset of human sexuality, but very different), sometimes the 'African male psyche' (in the case of the Zimbabwean male). All the undesirable characteristics assumed to spread HIV are also assumed to make up whatever culture, sexuality or psyche is being described.

The fact that HIV epidemics vary considerably within and between countries, along with culture and sexuality, is generally ignored. As for psyche, the notion is woolly even by pop anthropological standards.

Kenya even had a special profile for members of the Luo tribe, who were historically deemed to be incapable of leadership for various reasons, including lack of male circumcision. And when HIV was recognized and found to infect far more Luo than members of any other tribe, this was conveniently added to the set of prejudices. Exactly why HIV prevalence is higher among the Luo population is not yet clear. Nor do the HIV research community seem particularly interested. Following the various prejudices, HIV policies are painted with broad brush strokes.

Zimbabwe may not receive the same level of Western favor as Uganda, but they (and a number of other African countries) are being 'favored' with a similar mass male circumcision program, funded by USAID. This program is not based on any demonstrated need for mass male circumcision, nor any demonstrated effectiveness of such a program in Zimbabwe (or any other African country). It simply assumes that the country is dominated by African males who conform to the stereotype, whatever set of undesirable characteristics that currently comprises.

One of the most studied HIV epidemics in Africa is in Uganda, where early HIV prevention campaigns have gained mythical status. But Uganda still has a serious HIV epidemic. If it was overstated in the 80s and 90s, it is probably understated right now. HIV has not been shown to relate to sexual behavior alone, and certainly not to any particular 'psyche', culture or sexuality. On the contrary, no single 'driver' has been identified in Uganda. It's almost as if the epidemic struck, increased, decreased and then increased again, independent of any prevention effort, national or global.

There may be people doing undesirable things in Zimbabwe, Uganda, Luo populated areas and certain other African countries. But this is true of every country in the world. Similarly, HIV may well be spread by sexual behavior, especially certain forms of sexual behavior. But sexual behavior, including sexual behavior considered to be 'unsafe', is universal.

On the other hand, in every country in the world, HIV is also known to be spread by certain non-sexual modes, such as through unsafe medical and cosmetic procedures. When virgins, people who are not sexually active, people who have only had 'safe' sex, infants whose mothers are not HIV positive and others in non-African countries are found to be HIV positive, the cause of their status is investigated. But in Africa, it is merely assumed that personal testimony is less reliable than it would be in non-African countries.

UNAIDS and the rest of the HIV community refuse to countenance suggestions that HIV in Africa has anything to do with, for example, medical facilities. This is despite the fact that medical facilities in some African countries are among the worst in the world. Nosocomial transmissions of HIV have probably been found (and investigated) in all wealthy countries, where health facilities are far better. But where such transmissions may have occurred in African countries, the authorities close ranks.

Zimbabwe, along with several other high HIV prevalence countries, is exceptional. These countries, including Botswana, South Africa, Swaziland, Lesotho, Zambia and perhaps others, have relatively good medical facilities, with high levels of access. And that may turn out to be one of the decisive factors in high HIV prevalence countries. Health facilities are better than in Uganda, Kenya, Tanzania and other medium prevalence countries, where access to health facilities is low.

If HIV programming is, as I have suggested above, supply driven, it seems like the Western countries who dominate development, health and HIV agenda are not really interested in any of those issues. Perhaps it's even naive to expect that Western countries would have interests that go beyond their own welfare. But HIV programming is often referred to as a 'war', or in similar terms, when it looks a lot more like a war against Africans. I'm not saying the West created HIV, just that they seem intent on making sure it is not going to be eradicated too soon.


Friday, November 12, 2010

Sterilizations of HIV+ Women May Not Be the Worst Thing Health Services Do

When HIV and AIDS started to hit the headlines in the 1980s, there was a lot of scaremongering that did little to help assess the extent of the pandemic and figure out what could be done to prevent its spread. Sadly, this has not changed completely. Headlines are often about revenge, punishment, criminalization and the like.

Even some of the so called prevention strategies sound a bit like a kind of punishment, aiming to place severe limits on sexual and other sorts of behavior. It's hard not to see mass circumcision campaigns, ardently championed by the HIV movers and shakers despite little evidence of their potential effectiveness, as being a kind of punishment.

Such attitudes towards a disease do little to stem its spread, as we have seen in the 25 or more years that have passed since HIV became universally acknowledged. Beatings, persecutions, murders and other travesties have occurred, and continue to occur. But states seem more anxious to create laws that risk punishing those who are HIV positive or who are at risk of being infected, rather than protecting them.

Pregnant women in many countries seem to be at exceptionally high risk and astonishing figures of rates among pregnant women in South Africa were the subject of yesterday's blog post. But I asked, and I ask again, how can we go on believing that HIV is almost always transmitted sexually? We appear to be accusing women of knowingly taking risks while pregnant, without regard for their own health, that of their babies and that of other family members.

Some countries, Namibia being only one, have taken the extreme step of forced and coerced sterilization of HIV positive women. This should not be tolerated and women should be protected from such treatment by law. Of course, it's far easier to identify women as the 'culprit'. Being pregnant means they are evidently sexually active. They are in need of medical care, often vital medical care. And they are unlikely to be able to escape if anyone, or any body, decides to 'punish' them for being infected with HIV.

The authors of the above article, Jennifer Gatsi Mallet and Aziza Ahmed, go on "Life is not that straightforward when it comes to reproduction, not for an HIV positive women, and not for many other women.  Women frequently face a lack of access to contraceptives, inability to access safe abortion services, lack of education and information about preventing pregnancy.  Further, social factors including sexual violence, pressure to bear children, and a woman’s fears around child survival can influence when and how a woman becomes pregnant."

These things may all be true and if so, they all need to be remedied. So, are we then going to blame men? Of course, many men may have views that are inimical to preventing HIV transmission; perhaps the actions of many even cause a good deal of HIV transmission. And if men are violent or if their behavior causes harm, this certainly needs to be addressed. But that's true regardless of whether it has anything to do with HIV transmission.

Rather than looking at individual sexual and social behavior, which may be very much in need of scrutiny, it would be a good idea to look at the weighty but relatively unexamined body of data suggesting that people face serious risks of HIV infection through unsafe medical procedures. Pregnant women are especially at risk because they can receive numerous injections, often unnecessary, usually in health facilities where there is a concentration of HIV positive people and far too few overworked, undertrained, badly supplied health professionals.

The ultimate danger of this blinkered view of HIV transmission is not that innocent people will continue to be punished, though that is bad enough. The worst aspect of clinging to the behavioral paradigm, the assumption that almost all HIV is transmitted sexually, is that the virus will be allowed to continue to spread.

If people are being infected in health facilities, HIV 'prevention' work could be doing more to spread the virus than any other mode of transmission. We don't know if that's true yet; but it's just the sort of thing that we should know after almost three decades of HIV.


Thursday, November 11, 2010

Would You Risk HIV While Pregnant or When Planning a Family?

South African's City Press has an article entitled 'Survey finds staggering HIV rate in pregnant women'. And the figures are, indeed, staggering. National prevalence among pregnant women is almost 30%. Rates have been stable for several years and the health minister wishes to see prevalence decrease to 17.3% by 2015. Of course, this is unlikely unless death rates reach equally spectacular levels.

But what is really staggering is how one could believe that so many women who intend to have children or who are already pregnant would risk contracting HIV and possibly passing it on to their child, in addition to having to live with a life-threatening disease themselves. Doesn't that strike anyone as odd?

Many African women are infected when they are already pregnant, often well into their pregnancy. Are we supposed to believe that so many people wish to have a child but don't really care whether that child will live or whether the child will lead a healthy life?

Frankly, I don't believe that South Africa, or any other country in the world, is populated by so many people who don't care whether they or future generations continue to suffer from this terrible pandemic, which is hundreds of times worse in some sub-Saharan African countries than it is anywhere else.

Try thinking about it: you want to get pregnant or you are already pregnant, intentionally or otherwise; and you take many risks and no precautions towards ensuring your own safety or the safety of your child. This would require total ignorance or total heartlessness. Are we seriously suggesting that so many people in South Africa are either ignorant, heartless or both?

Transmission rates among pregnant women in South Africa and other African countries cannot be explained by sexual behavior, no matter how much sex people are having and no matter how 'unsafe' it is. These rates could only be explained by some efficient mode of transmission, such as nosocomial transmission. This is where the disease is transmitted through unsafe medical practices.

I have mentioned it before but it's worth repeating: the WHO estimates that 70% of medical injections in sub-Saharan African countries are unnecessary. And almost 20% of injections are unsafe.

Pregnant women attending ante-natal clinics in African countries get a lot of injections. Often, their babies also get a lot of injections. There is ample opportunity for high rates of transmission in countries where HIV prevalence is high and safety standards are low.

To believe that HIV is being sexually transmitted among pregnant women at such high rates is to believe appalling things about African women (and probably men, too). In short, to believe such things is to be a racist, a sexist and probably much else that's not very pleasant.

Not only do Africans behave sexually much like other human beings, they also place value on human life, especially their own and those of their children. Just what are those who believe HIV is almost entirely sexually transmitted in African countries trying to say about Africans?


Wednesday, November 10, 2010

Correlation of 'Unsafe' Sex With HIV Transmission Does Not Prove Causation

A couple of HIV researchers have come up with a 'plan' to reduce HIV transmission: no sex for a month, or 100% condom use for a month. This plan hit the media some months ago because I discussed it in July, but it's definitely media friendly. The argument runs that a month of safe sex, or of no sex at all, could "help reduce the spread of HIV by skipping the period immediately after an individual acquires the virus when they are most infectious".

The researchers, Alan Whiteside and Justin Parkhurst, reckon 10-45% of infections result from sex with people during this brief period, when infected people are most infectious. Apparently these estimates are based on 'models'.

They bemoan the fact that nearly 50% of Swazi women aged 25-29 are HIV positive, despite past prevention efforts. However, these past prevention efforts included abstaining, being faithful to one partner and using condoms (without too much emphasis on the condoms in most instances). This was the much vaunted 'ABC' strategy, also considered media friendly in its day.

UNAIDS have coined the term 'Treatment 2.0' to refer to the sad bunch of 'strategies' they expect to use to reduce HIV transmission in the future. And, like 'Web 2.0' that inspired the name, there isn't really anything new about Treatment 2.0. It's just the same old stuff in slightly different packaging. This also seems to be true of the plan to advocate no sex for a month or 100% condom use for a month.

I accept that 'abstain for a month' sounds far more achievable than just 'abstain' and that 'use condoms for a month' sounds far more achievable than 'use condoms'. But Demographic and Health Surveys don't show that ABC and similar strategies didn't work very well: they suggest that there is little correlation between knowledge about safe sex, safe sex behavior and HIV transmission. In other words, behavior change communication (BCC) has been a total failure, in every country where it was implemented.

In common with the rest of the HIV prevention rhetoric, the insistence that transmission in African countries is all about sex seems to be mistaken. Some HIV transmission may be sexual, but not all. Therefore, HIV prevention strategies could include some that target sexual behavior. We would still be left with the problem of which ones, given that none have been particularly successful. But it's a start.

More importantly, though, a lot more attention needs to be paid to the question of how much HIV transmission is down to sexual behavior and how much is not. What are the other drivers of HIV transmission? There's clearly an issue with transmission through unsafe medical procedures, such as injections, because the WHO has reported that 70% of injections are unnecessary and 17-19% of them are unsafe in sub-Saharan Africa.

What about other medical procedures? Service Provision Assessments for African countries show that many health facilities lack trained staff, equipment, safety guidelines and the ability to carry out infection control measures. Many non-African countries have had huge levels of nosocomial HIV transmission, transmission as a result of health procedures. If it can happen in Western countries and Asian countries, why not in African countries?

Perhaps Whiteside and Parkhurst are right about selecting a specific time period, such as one month, but wrong about confining it to sex. Perhaps we could have a medical safety month, as well. This would be a good opportunity to estimate the effect such a measure would have on HIV transmission. The only problem is that health facilities don't have the capacity to provide safe healthcare for a day, let alone a month.

And that's a problem for a no-sex/safe-sex month, too. African countries don't have much capacity when it comes to national campaigns. They don't have the health facilities, the educational capacity, the infrastructure or anything else that would be required (though it has alway been a bit of a mystery as to what could ensure 'safe sex' in any country, for any period of time). There are many indications of how poor health services are, such as the number of people who suffer from and die from preventable and curable diseases, especially water borne and respiratory diseases.

Another indication, though, is the high rates of preventable and curable sexually transmitted infections. It is known that these can increase HIV transmission, in addition to causing a lot of poor health, misery and even death.

Perhaps Whiteside and Parkhurst are having a bit of a joke when they refer to Muslims 'abstaining' from sex during Ramadan, even though they only abstain during daylight hours. Does avoiding sex during the day constitute 'reducing risky sexual behavior'? HIV prevalence is often lower among Muslims than among non-Muslims and this may be related to sexual behavior, but it's unlikely to be related to sexual behavior alone. HIV, unlike many other sexually transmitted infections (STI), is difficult to transmit sexually but relatively easy to transmit through unsafe medical procedures.

Imagine this scenario: if high levels of unprotected sex were to give rise to high levels of sexually transmitted infections aside from HIV, this might result in a lot of people visiting hospitals and clinics for diagnosis and treatment. If those health facilities were inadvertently transmitting HIV, it would appear to be the sexual behavior that was driving the epidemic when, in reality, it was also unsafe medical procedures.

Populations that engage in unsafe sex are doubly at risk of being infected with HIV if transmission of other STIs is also high, or is thought to be high. Sex workers, men who have sex with men, intravenous drug users, perhaps even truck drivers, who have also been branded as 'risk' groups, pay regular visits to STI clinics to receive both preventive and curative measures.

So there's a bit of homework for Whiteside, Parkhurst and the extremely well funded bunch that make up UNAIDS and the HIV industry: are we assuming that correlation (of sexual behavior with HIV transmission) is equal to causation? When people are clearly at risk of being infected with HIV through sexual behavior, we are assuming that that's always how they are infected, so we are not looking for any other explanation. Perhaps it's time we looked at other possibilities.

If we don't look at other possibilities for HIV transmission, we may continue to think that it's all to do with sex. As a result, we may continue to fail to prevent the bulk of infections while patting ourselves on the back for appearing to prevent some. Ultimately, UNAIDS and the rest of them want to know the truth, right? Aids is not just about making money or careers, is it? It's unlikely that large numbers of people will abstain from sex for a month, or even use condoms consistently for a month. But even if they do, HIV transmission will remain high enough to maintain a serious epidemic.


Tuesday, November 9, 2010

The Insatiable in Pursuit of the Uneatable

For all the blubbering Western powers, such as the EU and the US, do over aid and development, they show their true colours when it comes to trade. Western trade policies with developing countries are designed to increase their own markets, increase their supply of cheap raw materials and labour, destroy anything that may create even the smallest bit of competition and, in general, retain their position of dominance and exploitation.

The EU is currently trying to push India into signing a trade agreement that will threaten the supply of cheap and affordable antiretroviral (ARV) medications to developing countries. India is one of the few countries in a position to produce generic equivalents of branded versions that demand extortionate prices. The issue is, ostenibly, over whether India should be allowed continued access to the data they need to produce the drugs cheaply.

The EU is happy to spend enormous sums of money on this kind of pursuit, far more than they spend on 'aid'. And even though EU and US money is going towards the purchase of a lot of ARVs used in developing countries, they seem content to pay more for, presumably, a lot less of an identical product in the future. And this is at a time when all sorts of crazy policies are being discussed to increase the number of people on ARVs to several times present levels. (There is some discussion of these policies on my other blog, which deals with Pre-Exposure Prophylaxis and other technical 'fixes' for HIV.)

The apparent contradiction in vastly increasing the cost of products that their own funding will be used to purchase in ever increasing quantities is not really a contradiction at all. So called 'aid' money is mainly used as a subsidy for their own industries, especially the pharmaceutical industries. And compared to the amount of money that goes into promoting the interests of Big Pharma, aid money is little to write home about, anyway.

Despite claiming to have the interests of developing countries, including India, at heart, the EU seems intent on destroying the Indian generic drug industry. If developing countries, especially African countries, cease to be a market for these affordable drugs, there will be no other viable markets large enough to sustain the sector.

You might think that this would mean the EU is scoring an own goal but it is just what Big Pharma would like. They have never really wanted a supply of affordable generic drugs, why would they? They couldn't care less who buys their drugs as long as they pay a price that keeps their profit margins at levels they are accustomed to.

A few million Africans may die but that's just collateral damage to the pharmaceutical industry. And the thought of millions of Africans dying could make for a great publicity campaign to increase the amount of money the EU and the US are willing to pay for overpriced drugs. With competition out of the way, top prices are guaranteed. That's how the free market works, it appears.

Just in case you thought all that free market (for developing countries), anti-subsidy (except for wealthy countries) liberalism had been entirely discredited by recent global financial crises, think again. Those who gained from the policies of the past are doing very well, thank you, it's ordinary people who are, as always, paying the price. According to an article by War on Want, the deregulation that has caused so many problems is to continue. Clearly it didn't cause any problems for some people.

And talking of maintaining policies that have caused devastation up to now, the EU is busy pushing biofuels as a 'green' alternative to fossil fuels. Not only is biofuel production not a green alternative in any sense, production of biofuel in large quantities requires even greater exploitation of developing countries than is seen at present.

Vast tracts of land in developing are currently being used to produce food and raw materials for Westerners. But these tracts of land are nothing to what is being grabbed to supply Western cars with cheap fuel. The question of whether there will be land enough left over for developing countries to grow enough food to survive is not really being asked by the land grabbers. Water, in short supply in many countries, will become even scarcer in the pursuit of 'green' biofuels.

Production of biofuels will involve large scale destruction of environments to make way for factory production methods needed to produce 'cheap' fuel. The process of grabbing land is already underway, has been for several years. Perhaps the EU hopes that any increase in carbon emissions will occur in countries too poor to measure the pollution or to do anything about it.

The extent to which Western powers exploit developing countries should never be forgotten when the subject of 'charity beginning at home' comes up. Rich countries may be looking for ways to reduce spending but what they spend on development is a mere pittance, much of it never reaching the supposed recipients. The best thing rich countries could do is reduce their levels of exploitation. Then, whether they continue providing aid and how much they provide may cease to be relevant.


Monday, November 8, 2010

NGOs Gagging for Sex

Spiked Online has an interesting article on NGOs in Asian countries who feel they are 'saving' people in the sex trade from exploitation. The problem is, those NGOs don't seem to want to know why so many adults would choose to do work that some consider to be inherently exploitative. The article points out that some workers came from far more exploitative industries, although the exploitation may have involved slave wages, a far lesser form of exploitation, it would appear.

There seems to be a lot of money available for NGOs who do this kind of work. On the other hand, there is not quite as much of the sort of headline-grabbing sexual exploitation going on as some would have us believe. Credible data is not one of the results of the large amounts of money being ploughed into the work these NGOs are doing.

The article finds that a lot of sex workers in Cambodia are former garment workers, people who choose to work in the sex industry rather than try to get by on impossibly low wages. So the NGOs are right, there is exploitation; it just doesn't involve sex. Perhaps the NGOs could redirect their efforts towards the garment factories, their rich owners, adequate legislation and enforcement or even the consumers in the rich countries that many NGO workers come from.

Here in East Africa, many people in the sex industry either tried working in highly exploitative export processing zones (EPZ) or various industries that pay so badly, there is little alternative but to find something to supplement incomes. In other words, sexual exploitation is not the only kind of exploitation they suffer. These EPZs are set up so that foreign industrialists can set up in developing countries and keep their costs as low as possible and thus provide Western countries with the cheap goods they crave.

Another exploitative industry is hospitality, where profits are generally unthreatened by high labor costs. Several sex workers I have met told me they tried to get work in hotels and it was made clear that they had to pay a bribe, using money or sex, to be considered for a job. Others had to pay, somehow, to keep their job, to get enough work to survive or to get promotion.

The Spiked article makes the point that people, adults, anyhow, can make up their own minds. They are not the mere victims they are often made out to be by some 'concerned' NGOs. This is quite true. But there also seems to be plenty of work that these NGOs could do if they are truly concerned about exploitation. Or does exploitation have to be sexual in order to be really worrying? The suggestion is that, no, it doesn't have to be sexual, but that's what the funders like.

A similar love for anything sexual also seems to dog HIV programing, with almost all prevention efforts being aimed at sexual transmission. Aside from this doing little or nothing to reduce non-sexual transmission, it doesn't appear to have had much impact on sexual transmission either. Billions of dollars have gone into programs that appear to target sex, rather than health. As a result, millions of people, particularly women and children, continue to be infected needlessly.

Objection to commercial sex work may be legitimate enough, but do those who object have an alternative in mind? Everyone can think of alternatives, but they are not viable in countries with very high levels of unemployment and underemployment, where the vast majority of people just get by and a lot don't even do that.

Every new, unemployed person, squeezing a few dollars out of some form of subsistance, results in less money for all those already struggling. Ironically, the effect of persuading a good many sex workers to give up their work and do something more 'conventional' would be to reduce the living that subsistence workers can make. And it will increase the amount of money that those still in sex work can make (unless sex work is supply drive, which seems unlikely).

If these NGOs don't address the real problems of lack of employment opportunities, exploitation in the work place, extreme poverty and the like, they will just be shuffling the problem from one group of people on to another. And addressing the real problems is no easy task. But things won't get any easier by wasting time with moral crusades and media titillation.

The Economist covers a similar theme and wonders why money is not spent on 'harm reduction', protecting sex workers from the risks they face, which are by no means limited to sexual risks. One of the main sources of stigma they face comes from the NGOs who claim to represent their interests. In addition to health services and condoms, sex workers need the protection of the law, especially from the police, who are among the many who stand to gain from the criminalization of sex work.

Again, this phenomenon is clear enough in East Africa, where people who think of themselves as 'clean living' fail to see that there are multitudes of people 'living on immoral earnings'. It's not just sex workers who do so. To evade exploitation by police, sex workers have to pay or otherwise bribe security people, bar, club and hotel administrations, 'minders' and anyone else happy to rely on the fact that sex workers are considered to be beneath contempt.

According to The Economist article, sex work tends to be conflated with human trafficking. This merely results in further exploitation of those involved in sex work, carried out in the name of 'zero tolerance', 'fighting crime', etc. NGOs operating like this are exploiting the very vulnerability of sex workers that they claim to be alleviating.

Much of the vulnerability of sex workers stems from the fact that the work is considered to be illegal, even where it is not outrightly prohibited by the law. NGOs would be far better advised to support sex workers than to oppose them, to help them gain the decriminalization they need. Without the protection of the law as a minimum, social problems relating to sex work will only get worse.

NGOs who wish to 'help' sex workers need to deal with the economic and social realities in developing countries. If they are opposed to exploitation, there is plenty of that, though it may not be sexual. And if these NGOs are motivated by some kind of moral repugnance towards sexual exploitation, they could direct it at those in the media and those in the donor community who appear to need sexual titillation in return for their support.


Sunday, November 7, 2010

Would You Buy a Second Hand Story From These People?

For some reason, the British TV station 'Channel 4' appears to see itself as a kind of defender of the rich, powerful multinationals who would do anything it takes to impose genetically modified organisms (GMO) on the world. I wonder how much it was worth to the channel and the stooges who contributed, unwittingly or otherwise.

I haven't been able to see the documentary. People in Africa are no more considered to have anything worth saying about their future now than they ever have been. Nor do mainstream media feel the need to let them know what decisions others are making on their behalf. But one thing is for sure, it is people in African and other highly impoverished countries that have the most to lose if GMOs take over.

And they will take over, if the multinationals succeed. GM is a case of either/or. Not only is it impossible for GMO and non-GMO crops to co-exist without the non-GMO crops becoming contaminated but the biggest seed companies in the world want to reduce supplies of non-GMO seeds until GMO becomes completely dominant. There will be no way to reverse this once it has been achieved.

The documentary, apparently, accepted the multinational's accusations of the green movement 'causing starvation' by opposing GMOs. Which GMOs would have been made available to Africans over the last ten years or so during which the seeds would have been available? There are no GMO foods available that produce higher yields or grow in sub-optimal conditions, except in the publicity of various interested parties.

On the contrary, to date, the only known crops with such traits are conventionally bred ones. Not only are conventionally bred and organic crops and methods safer and cheaper, they are also very successful. And this is exactly the problem for the multinationals. They don't want people in poor countries buying something without a patent, something that is not their 'intellectual property'. Such things are far too affordable.

So far, GMOs have only sold well in a few countries, all of which are regretting it now. The US has bought into GM more than any country and they are reaping the 'benefits' of dwindling yields, increased use of pesticides, contaminated land and superweeds. These are all things the multinationals have denied exist but you only need to read up on what's happening in what used to be the most productive places in the US.

The documentary was discussed online for some time before it was aired and one (former) environmentalist defended his stance by saying he was in favour of the work the Gates Foundation was doing in relation to the 'Alliance for a Green Revolution in Africa' (AGRA). Perhaps the poor fool thinks that Gates and his stacks of money is in some way different from the bunch of multinationals in question. But he is behind their work and always has been. Intellectual property is his specialty.

So the green movement, far from being behind mass starvation, has always, as far as I know, been opposed to the further impoverishment of Africa. Hopefully they have also been opposed to the antics of the great pseudo-philanthropist as well. But perhaps channel 4 wanted to pay the green movement a back-handed compliment by suggesting that they could prevent some of the most powerful and most ruthless institutions in the world from achieving the global monopoly on food production that they crave. Sadly, I don't believe the green movement is quite that powerful!

It's interesting what big, monopolistic technologies have got wrong over the years. Norman Borlaug, one of the architects of the first Green Revolution, probably thought that increasing technology, bigger farms, factory farming practices, massive reductions in labor, etc, would be all fine and dandy, that there would be no poverty or starvation any more. But it has long been clear that any benefits that might have come from the revolution are now a distant memory, that there is still an awful lot of poverty and starvation, even in India, where it was said to have been a success.

It's also interesting that articles about GMO, especially when they deal with opposition to the technology, always feel the need to use the term 'frankenstein foods'. This has never been anything other than a tabloid term, a straw man argument. Most environmentalists would not use the term and their objections are more based on the lack of evidence for the safety of GMOs and the lack of evidence that they will have any of the advantages claimed for them.

On the other hand, proponents of GMOs have been using the same claims about increased yields and numerous other 'advantages', even though none of them have materialized yet. It reminds me of the overused claim one used to hear about nuclear power, that it was 'too cheap to meter'. We know that was a lie, but many are now trying to increase dependence on nuclear power on the back of the claim that it is 'green'. Next they'll be telling us that it is clean, cheap, safe and whatever else.

If people are concerned to separate the claims and counterclaims reported by what is a heavily biased media, they need to do a very small bit of research while at the same time bearing in mind that many sources will lie. They need to ask why a person or institution would make certain claims, what the evidence supporting those claims are and what they think might be right or wrong from the point of view of those likely to be most affected, and perhaps most vulnerable, to the effects of something like GMOs.

I recommend a perusal of La Via Campesina's website and Wikipedia's article on food sovereignty as a good summary. The majority of working people in the world are either rural peasants or dependent on the work of rural peasants. Does a technology entirely controlled by a few rich multinationals really sound like something that contributes to food sovereignty?


Thursday, November 4, 2010

If Counselling and Condoms Are So Effective, Why Bother With Circumcision?

Male circumcision enthusiasts once worried that men who were circumcised as adults in order to reduce their susceptibility to HIV infection might subsequently engage in risky sexual behavior. This phenomenon is called 'risk compensation'. It was feared that men would only undergo the operation if they could then safely have sex without a condom, even though circumcision is only claimed to be 50-60% effective, at best.

While the evidence for the protective effects of circumcision are not very convincing, I'm surprised anyone would undergo the operation at all if they still have to use condoms afterwards. If you have no aversion to using condoms you'll probably still use them after the operation. But if you have an aversion, you are unlikely to lose it as a result of the operation.

Now the enthusiasts are claiming, on the basis of a survey of a handful of people (30, with a plan to circumcise over one million), that risk compensation is not occurring. They also claim that people are having safer sex after being circumcised because the counselling, pre- and post-operation, is so good. But then the question is, why could everyone not just receive counselling on its own?

If being circumcised gives little or no benefit unless you use condoms and avoid other risks, why not just advise everyone to use condoms and avoid other risks? The operation seems like an expensive and unnecessary burden on both clients and health services. Condoms on their own provide the highest level of protection against sexual transmission of HIV, whether you are circumcised or uncircumcised.

It's worth noting, those who were circumcised in traditional ceremonies do not receive the sort of counselling that those being circumcised in hospitals are getting. Yet there is no evidence that those circumcised in traditional settings are less well protected than those circumcised in hospitals. So it sounds as if the author of the study, Thomas Reiss, is going well beyond the evidence in making his claims about the effectiveness of both circumcision and the accompanying counselling.

Another article talks about risk compensation in connection with people on antiretroviral drugs (ARV). Again, it was feared that people would engage in 'risky' sex once they were on AIDS treatment. This would be tempting because they are said to be far less likely to infect others if they are responding well to the drugs.

This article is based on a study by Neil Martinson and it also puts low risk compensation behavior down to the experience of 'staring death in the face', in addition to 'counselling and safe sex messages'.

Treatment is a vital element in a country's overall AIDS strategy, as are counselling and other measures. But these two articles give the impression that sex, safe or otherwise, might not be as important a factor in African HIV epidemics as we are led to believe by the HIV industry mainstream. People may well be reacting to all the fuss about sex, but perhaps they were never as sexually incontinent as UNAIDS and their followers claim.

There is a proposal to test everyone in a population regularly and immediately put those found to be HIV positive on ARVs, called 'test and treat'. It has been found that the immune response in those on treatment can be so high that they can even have unprotected sex with a HIV negative partner without much risk of transmission.

If conditions are such that a test and treat strategy can be implemented in developing countries, perhaps in conjunction with various types of counselling, support and condom use, this may reduce sexual transmission of HIV considerably. Non-sexual HIV transmission may continue, unless it is reduced by appropriate measures. But the success of these efforts to reduce HIV transmission depend a lot on the accuracy of researchers and the extent to which policies are based on genuine findings, rather than on a political gloss.

HIV policy in African countries, up to now, seems to have been based more on wishful thinking and a completely unwarrented assumption that Africans are far more promiscuous than non-Africans. The two articles above don't give much cause for optimism. Evidence suggests that HIV is not solely, perhaps not even mainly, driven by sexual behavior. Technical fixes, like ARVs and mass male circumcision, only target sexual transmission of HIV. And they may not even be particularly effective in that respect.


Wednesday, November 3, 2010

African HIV Pandemic: Do Condom Manufacturers Worry About Bad Press?

I've asked the question a number of times, most recently on my other blog about pre-exposure prophylaxis (PrEP): why are condom manufacturers not worried about some of the bad press they are getting in one of their biggest markets in the world, sub-Saharan Africa?

Several microbicide trials that have shown the gels to be of little or no use have also shown that people who don't have sex very often, don't engage in much 'unsafe' sex and almost always use condoms, still become infected with HIV. Heterosexual sex is not a very efficient transmitter of HIV, so why do condoms seem to fail so badly during these trials?

For those who reject the behavioral paradigm, the claim (it's not a belief, those who make the claim know it's not true) that almost all HIV is transmitted through heterosexual sex in African countries, there is no conundrum. Those who become infected with HIV under the circumstances listed above were unlikely to have been infected sexually.

There are a number of other ways they could have been infected. They are unlikely to have been intravenous drug users, unless the trial screening process was highly flawed! But they probably received some kind of invasive medical treatment, such as injections.

Unsterile medical injections are a very efficient means of transmitting HIV and other blood-borne viruses, especially in high HIV prevalence areas, where these trials tend to be carried out.

The problem is that the trial protocol didn't involve investigating how participants became infected. The protocol could have attempted to determine the risks that people in the area faced because if people were being infected by any other route aside from sexual intercourse, that would invalidate the results of the trial.

This is where the condom manufacturers should be coming in. Trial results show that rates of HIV infection are very high, even among people using condoms. But if people are being infected via unsafe medical injections, cosmetic procedures such as tattooing, or anything else, this does not indicate that condoms have failed.

The denial that non-sexual HIV transmission could play a part in high prevalence countries leads to a lot of confusion. A group of people in Nigeria, along with a HIV research foundation, are suing the government for promoting condoms because they 'didn't work'. Members of the group used them but still ended up HIV positive. They are demanding $50 billion in compensation and an order against further promotion of condoms.

They should be demanding an investigation into how they might have become infected. Condom manufacturers should also be demanding such an investigation. Because every country in the world is, at least to some extent, promoting condoms as a means of preventing HIV transmission. Few seem to realise the non-sexual risks they face, even though they may be aware that condoms will not protect them from these.

As a result, HIV is still spreading quickly and will continue to do so for the forseeable future. Condoms are not the problem. They have a pretty high success rate when it comes to preventing sexually transmitted HIV. But they are not relevant when it comes to non-sexually transmitted HIV and it's important that this be made clear.

Condom manufactures should be very worried about the misrepresentation involved here. Their products are being promoted in circumstances where they are guaranteed to fail. Some day other people, like this small group of Nigerians, will start to ask why they are HIV positive even though they have not been exposed to any possibility of sexual transmission.

Of course, it's not the business of condom manufacturers to inform people that condoms won't prevent non-sexual HIV transmission; that should be pretty obvious already. But unless people are informed of the probability of their being infected non-sexually, the probably currently being unknown, it will continue to appear as if the billions of condoms being supplied to African countries are not having much impact.

Condoms are about the only hope that people in African countries have when it comes to preventing HIV transmission through sexual intercourse, whether vaginal or anal. They are vital in the overall public health goal of cutting transmission. But there is also a need to establish levels of non-sexual HIV transmission and to implement public measures to prevent it. If condom manufacturers wish to continue to receive billions of dollars of public money, they should help to make the distinction between sexual and non-sexual HIV transmission clear.

People need to know the whole story about HIV: it is not just transmitted sexually and they will not be protected if they think it is. They need to know that HIV can also be transmitted through unsafe health care and cosmetic procedures; they need to know how to avoid this sort of risk; and the risks people face in medical and cosmetic facilities need to be reduced. There is nothing to be gained from emphasizing sexual risks and completely ignoring non-sexual risks.


Monday, November 1, 2010

Are Mathematical Models of Human Sexual Behavior Constructed by Humans?

According to a BBC article, male inmates in a prison in KwaZulu-Natal are asking to be circumcised because they believe it will protect them from HIV. It sounds like they have been seriously misinformed. However prisoners may become infected with HIV, and however they may infect others, it is unlikely to be through heterosexual sex.

Figures for men who have sex with men (MSM) include prison populations in the Kenya Modes of Transmission Survey, so it's hard to tell which contributes more to the epidemic. The overall figure is an estimated 15%. However, it would be difficult to attempt to reduce transmission in these groups without really understanding exactly how transmission occurs.

In prison populations, if other countries are anything to go by, tattooing, forced or voluntary, may well play a significant role. If prisoners receive any invasive medical treatment, this may also play a part. Indeed, the very circumcision operation that is supposed to give them protection from HIV could be carried out under unsterile conditions. Prisoners may thereby increase their risk of being infected with HIV and other blood-borne viruses.

Intravenous drug use may also play a part in African prisons and access to adequate supplies of sterile injecting equipment is unlikely where such practices are forbidden. Condoms are also unlikely to be available on the grounds that sex of any kind is also forbidden.

If, as is often assumed, a large amount of HIV transmission in prisons is through men having sex with men, circumcision is unlikely to give any benefit. Circumcision has never been shown to give protection during anal sex. It might even increase risk of transmission. And circumcision will, of course, have no impact on non-sexual transmission whatsoever. This may seem obvious, but not that much is known about the extent to which HIV transmission is truly sexual, MSM related, non-sexual, etc; this is the case both in and out of prisons in African countries.

The BBC article seems to be unburdened by any research or any attempt at criticism. It's just another titillating article about HIV and its assumed associations with illicit sex. But it is particularly worrying that a health minister has said the prison hospital is overwhelmed. When a hospital is 'overwhelmed', do they cut corners, reuse equipment or take any other risks? The fact that the circumcisions are voluntary will be of little comfort to those who question the wisdom of circumcising as many men as possible because of some very dubious evidence that it reduces HIV transmission.

Despite the unconvincing arguments available for the effectiveness of male circumcision in reducing HIV transmission, the pro-circumcision brigade have produced 'evidence' that the operation will be even more effective than previously estimated. This evidence consists of some mathematical modelling, the likes of which has been used to justify all sorts of things, including the assumption that sexual behavior is responsible for almost all HIV transmission in African countries, though not in non-African countries.

That sounds like a pretty flimsy reason for having an invasive operation that may not work and that may carry more risks than it is expected to avert. But the pro-circumcision brigade is not averse to flimsy reasoning. After all, it's not their penises that are in question. They are not taking any risks themselves and are not considered to be the perpetrators of 'unsafe' sex, carelessly spreading HIV among their fellow Africans.

Interestingly, there is a rare voice of opposition to the mass male circumcision orthodoxy from Miriam Mannak. Unfortunately, Mannak seems to be persuaded by some of the pro-circumcision rhetoric that passes for evidence in the HIV world. But she raises a number of objections to the procedure and employs a rarely found quality in her thinking: compassion. The striking thing about adherents of the circumcision approach and the sexual behavior theory of HIV transmission is that they appear to have no compassion or sense of humanity.

As a result, a lot of HIV 'prevention' programing consists of what amount to punitive measures, designed to control an imagined animalistic attitude towards sex and towards sexual partners that only exist in African countries. Mass male circumcision is just one part of this set of punitive measures. It is likely to be as unsuccessful as previous measures to reduce HIV transmission. If epidemiologists fail to even think of people as people, their mathematical models will continue to be as useless as they have been in the past.