Are UNAIDS Really Giving Good Advice to Malawians?

This could be a good time for condom manufacturers to get involved in large scale HIV prevention campaigns in African countries. After all, it must represent a huge market. But the figures for HIV prevalence among condom users are not always very encouraging. In fact, reported condom use often seems to be associated with far prevalence than those who claim not to use them.

The latest Demographic and Health Survey for Malawi is a case in point. Among women who had ever used condoms, HIV prevalence was 20.3%, whereas among those who never used them it was only 13%. Among men who had ever used them, prevalence was 11.8% but among those who never did was only 5.8%. Those are substantial differences.

Similar trends are found among men who have paid for sex in the last 12 months. Among those who ever used condoms, prevalence is 11.5% but among those who never did it was 4.1%. Even those who did not pay for sex in the last 12 months had far higher prevalence than those who did pay for sex and did not use condoms (or did not have sex in the last 12 months), at 9.3%.

Why does condom use seem to be associated with far higher HIV transmission rates in many African countries? We know they work to reduce sexual transmission of HIV and other sexually transmitted diseases, so what could be going on in Malawi? It seems surprising that condom manufacturers are not taking a careful look at these figures.

The report also finds that: "Among respondents who have never been married, the HIV prevalence [...] 2 percent for those who have never had sex. This suggests that some women and men incorrectly reported that they were not sexually active, or that there is some degree of nonsexual HIV transmission occurring (e.g., through blood transfusions or non-sterile injections)."

Granted, some people forget, lie, or misreport, in Malawi and everywhere else. But even those who have reported high levels of 'unsafe' sexual behavior are just as likely to have been infected through some non-sexual mode of transmission as those who have never had sex. After all, sexual transmission is less efficient than many non-sexual modes.

HIV rates by circumcision status also appears to be very mixed. In almost every age group, HIV prevalence is higher among circumcised men and overall prevalence stands at 10.3% for circumcised men and only 7.6% for uncircumcised. Given that a lot of Malawian men are not circumcised, let's hope the circumcision enthusiasts figure out exactly what's going on here before rushing in and carrying out an operation that doesn't decrease transmission and may increase it. There are already claims that about 250,000 Kenyan men have been circumcised to 'reduce' HIV transmission.rends

There are also the trends that you will find in other high prevalence African countries. For example, prevalence is far higher among women, roughly a 60-40 split. When you consider that most of the high risk groups that don't involve sexual transmission, intravenous drug users, men who have sex with men and prison populations, are almost all men, it makes you wonder how women can face such high risks.

Prevalence is twice as high in urban areas and varies a lot between different regions and different tribes. Prevalence also varies considerably among religions, with Anglicans having the highest prevalence, Catholics the lowest and Muslims somewhere in between.

Higher or lower levels of education are not clearly associated with HIV prevalence, with almost the same rates among those with no education and those with higher than secondary level. Employment status is a lot clearer, with rates being far higher among employed people than unemployed people.

As is often the case in high prevalence countries, wealth appears to be highly positively correlated with HIV prevalence. This is especially the case for women, where prevalence among the lowest quintile is 8.9%, rising steadily to 19.7% among the highest quintile. For men, the figures are 5.6% rising to 10.8% in the highest wealth quintile.

I'm all for promoting interventions that work and condom use is one that certainly does work to reduce sexual transmission of HIV. But there are always figures in Demographic and Health Surveys that make one wonder what proportion of HIV really is transmitted sexually and what proportion is transmitted through other routes. Many of the figures for Malawi, though, seem to suggest that a lot of HIV industry advice is really not very effective.

AgriSol in Tanzania: Land-Grabbing or Outright Theft?

Tanzanians and other Africans seem to be worrying a lot about reductions in foreign aid and what conditions will need to be met in order to receive whatever is available. But they don't seem to be paying much attention to the fact that land is being grabbed by foreign multinationals at a rate that involves far higher sums of money than foreign aid.

The Oakland Institute has investigated AgriSol's dirty deals in Tanzania and though they have been found wanting, they appear to be going ahead. Many Tanzanians suffer regular food shortages and poor diet but Agrisol intends to use huge tracts of land and substantial amounts of water to produce biofuels and genetically modified crops for export.

Aside from needing land and water to produce food and other things, Tanzania is not yet prepared for genetically modified organisms. Even if they have some kind of regulation, probably regulation that suits the likes of AgriSol more than it does Tanzanians, the country is unlikely to have the capacity to enforce appropriate regulation any time in the near future, which should suit the GM industry.

AgriSol and others involved in these land-grabs like to claim that the land is marginal and/or underutilized, even uninhabited, none of which are true. Biofuels and genetically modified crops, despite claims to the contrary, need water and fertile soil. So AgriSol want to bribe (or whatever the current nomenclature is) their way into 800,000 acres of fertile land which is inhabited by over 160,000 people.

Of course, AgriSol also claim they will be enriching Tanzania and the local communities who will be effectively dispossessed and displaced. AgriSol will not allow such matters to get between them and hundreds of millions of dollars profit. So they need the assistance of public relations experts, legal experts and, of course, political allies. And with that amount of money to be made, this assistance should be readily available.

The Oakland Institute have published eight myths they have identified about land-grabbing, and in particular about this current AgriSol intrigue. The first is that the land is not being used, which most land-grabbers claim. The land is inhabited by displaced Burundians, some of whom have been there for nearly 40 years, having been originally displaced by war.

AgriSol also claim they are not involved in the displacement of Burundians, which they say started independently of their efforts. This claim does not stand up to scrutiny. Their claims about cooperating fully, consultations, transparency and the like are also untrue. All the big land-grabbers claim that Africans will benefit, AgriSol being no exception, even taking steps to ensure that they can export food crops at times when there is a lack of food security in the country involved.

Indeed, AgriSol will be looking for a tax exemption and they will want to receive input subsidies that are currently destined for Tanzanians. So much for private enterprise eschewing subsidies! AgriSol go through the usual sanctimonious posturing about environmental responsibility, which simply doesn't add up for either biofuels or genetically modified organisms, which are both extremely destructive to the environment.

Very small numbers of people will be employed by AgriSol's scheme and fewer still are likely to be Tanzanians. And the amount of 'rent' they will be paying is a derisory one tenth of a dollar an acre for a 99 year lease. Good agricultural land costs in the region of millions of dollars, so it's not clear how rental revenue will even cover the costs of the paperwork.

The Oakland Institute unearths many disturbing things about AgriSol and the various well connected people involved, who seem to be more scrupulous about maximizing earnings than anything else. Sadly, there will be a few in Tanzania who will be able to pick up a nice fee for selling their friends and families. But Tanzania as a whole and ordinary Tanzanians will lose a lot more than they stand to receive in donor funds, no matter what conditions they agree to.

Why Are Westerners So In Love With Circumcision For Africans?

Daniel J Ncayiyana, the editor of the South African Medical Journal, presents a rarely heard view in a professional medical journal: he is critical of mass male circumcision campaigns that make claims to reduce HIV transmission, by widely varying amounts. In fact, it is rare to hear someone in such a position criticizing anything to do with theory (and hence programming) relating to HIV in Africa.

Despite the often vast claims of Western proponents of voluntary (so they say, anyhow) male circumcision, Ncayiyana opposes this as a strategy, finding the evidence mixed, sometimes exaggerated and never completely convincing. Perhaps the claim that "'Male circumcision is the most powerful intervention we have at this point in time" should be interpreted as reflecting the lack of success in other areas of HIV prevention, rather than the effectiveness of circumcision?

Enthusiasts of circumcision seem to forget that if they diminish the potential effectiveness of other prevention strategies, people may get the impression that circumcision on its own is effective, which it is not. All trials of male circumcision consisted of a combination of prevention strategies, including condom use. If circumcision results in a reduction in use of other prevention strategies, sexual transmission of HIV from females to males could increase.

Of course, male to female transmission, which is far more common in African countries, will not be reduced by male circumcision; it may even be increased. This operation, which is ostensibly aimed at couples who tend not to use condoms (and other groups), sounds like it will fail to reduce transmission in the very contexts where reduction is most needed. So far, the various pronouncements about circumcision seem to have produced little but confusion.

Ncayiyana mentions the fact that prison services in South Africa report a "near-stampede" by inmates demanding circumcision (though this may be another exaggeration), who seem to think the operation will protect them against non-heterosexual, perhaps even non-sexual HIV transmission. There is simply no evidence that circumcision protects against male to male transmission, or even male to female transmission where anal sex is involved.

One of the most puzzling things about female to male sexual transmission of HIV is that it occurs so much in African countries. Counterintuitive as it may seem for a virus that is claimed to be almost entirely sexually transmitted, female to male transmission hardly ever occurs in most Western countries. The bulk of transmission is from men having sex with men and intravenous drug use. Even the percentage of female to male transmission estimated in Western countries may fail to exclude cases where people were not altogether frank about the risks they have faced, or where health professionals failed to report all the risks.

While criticizm of circumcision is not often cited, there is some published criticizm, some of which Ncayiyana alludes to. He even alludes to the lack of certainty about the relative contribution of heterosexual transmission, as opposed to other sexual and non-sexual modes of transmission. And he notes that arguments for adult male circumcision have been used as arguments for new-born babies, which is simply ridiculous.

Van Howe and Storms put it succinctly: "It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection)." It is not hard to see, but the calls for tens of millions of men (and perhaps even more babies) to be circumcised to reduce HIV keep coming in. Even Bill Gates has forked out $50 million for circumcision.

One of Ncayiyana's main worries is that all this attention for circumcision will take attention away from HIV prevention strategies that work, at least to some extent, such as condom use. If sexual behavior needs to change, circumcision is unlikely to have much long term impact on this. If men's attitudes towards women need to change, as we are so often told they do, circumcision is not going to bring this kind of change about. And the list goes on.

I don't have as much faith as Ncayiyana seems to have in condom use, however combined with partner reduction and the like. I think they may all be useful when it comes to reducing sexual transmission or HIV, but this will not shed light on non-sexual transmission. Non-sexual transmission through unsafe healthcare, cosmetic practices, traditional medicine, tattooing, scarification and oathing may be rare, as UNAIDS claims. But UNAIDS may be wrong, they haven't checked yet. However, circumcision seems like more of an unwise leap of faith than a genuine HIV transmission prevention strategy.

What the US Presidential Commission for the Study of Bioethical Issues Doesn't Say

The Presidential Commission for the Study of Bioethical Issues (PCSBI) has just published a report commissioned as a result of the 'discovery' of the Guatemala syphilis experiment in the 1940s, which involved infecting unsuspecting people with syphilis and other diseases for the purpose of scientific research. A lot of people were infected and many died as a result. Some of those running the Guatemalan study later took part in the Tuskegee Syphilis experiment, which continued into the 1070s.

The PCSBI wanted "assurance that the rules governing federal research today adequately guard against the abuses perpetrated by the U.S. Public Health Service" and "that current rules protect people from harm or unethical treatment, no matter where in the world U.S.-supported research occurs.". The assurance is forthcoming, in a rather limited sense, and there are many recommendations that still need to be met.

As a Public Library of Science blog notes, the report is about federally funded research, not research carried out by Big Pharma or other industries, nor even that carried out by NGOs, which probably constitute the biggest proportion of trials involving human subjects. Therefore the report is not really very reassuring at all. Outrages such as those that occurred in Guatemala and Tuskegee might occur elsewhere; they could even be occurring right now, with the knowledge of the US and other governments.

I attended part of a training course to teach rural albinos and carers of albinos about income generation schemes, planning, budgeting, etc, and becoming involved in community level savings and loans schemes. It's interesting how much effort the trainer needed to put into starting off with very basic concepts and repeating them throughout the week. Many had only a few years of primary school and had rarely used their reading or writing skills since leaving school.

So I always wonder when I hear terms like 'informed consent' and how they work in such a setting. What level of understanding do people have of complex drug regimes and other matters if they have little or no basic literacy? Many drugs come with instructions that presuppose a level of literacy that may not have been attained by all, or even most participants in some types of research. Is it enough to have a set of signatures from people involved, even if the form they are signing is written in their mother tongue?

I have blogged elsewhere about the Rebecca Project, which has published a damning report on non-consensual research in African countries, showing that such things may not happen in the circumstances described by the PCSBI report but they do still happen. David Gisselquist of the Don't Get Stuck With HIV website and blog has also written a comprehensive review of unethical and illegal research that has taken place in African countries.

It's a pity the PCSBI kept their brief so narrow because now we have no idea who, if anyone, will carry out similar research into non-federally funded research and when this might happen. The last thing we need is for the industry to fund the research itself. Given what is available to us about their ethical standards, we can be forgiven for not expecting much better from that which is unavailable.

Kenyan Doctors Worried About Safety in Health Facilities

A doctor working in the South West of Kenya finds conditions in health facilities very difficult and says that "Basic provisions like gloves and syringes are constantly out of stock". While this sort of thing is attested in reports such as Kenya's Service Provision Assessment and Tanzania's Sikika reports on levels of supplies and personnel, it's often unclear how health professionals cope with such shortages. Do they send patients home, reuse what is available to them or what?

Dr Lucy Ngina says that "We are always sending patients to buy their own syringes, needles and even bags for intravenous fluid." But she sometimes has to make do with gloves that are too large, for example, risking her own safety and that of her patients.

Although billions of dollars have flowed into HIV related services in African countries, spending on health in general has not increased in the last ten years and the number of healthcare personnel has remained static, although the population has increased at a rate of 2.5% per year or more in Kenya.

Apparently the Kenyan health system is "one of the most dangerous in the world, producing the worst outcomes as measured by mothers and babies who die during childbirth." It may be dangerous in other respects but more attention is paid to certain indicators than others. It is likely, for example, that TB, hepatitis B and C and other transmissable diseases are commonly transmitted in health facilities. But it is less likely that anyone is collecting much data on these phenomena.

One of the problems mentioned is the way big donors, such as the US aid agency (USAID) and the Gates Foundation, tend to concentrate on the 'big diseases', which already receive a lot of attention from other quarters. Many other diseases, often treatable and preventable, are ignored.

Another problem is 'brain drain', which can refer to health personnel qualifying in developing countries and choosing to work in wealthy countries; trained personnel being recruited into the ever-expanding private health sector; or it can refer to wealthy countries' going to developing countries to recruit the best qualified candidates they can find and persuading them to work in the West. Recent calculations may exaggerate how much this costs developing countries in monetary terms but it's probably impossible to calculate how much it costs in terms of human sickness and death.

Doctors currently on strike in Kenya are not just demanding better pay, they are also demanding better working conditions for the sake of their health and the health of their patients. Modern medicine is great when it is properly funded and safely administered. But poor and unsafe conditions can render health facilities even more dangerous than no health services at all.

In countries with serious HIV epidemics, outbreaks in hospitals could infect hundreds, even thousands of people over relatively short periods of time; partcularly when none of the various HIV institutions are actually looking out for hospital associated HIV transmissions.

Neglected Tropical Diseases: Neglected for a Reason

It's good to hear calls for 'neglected tropical diseases' to be addressed, rather than taking the sort of vertical (single disease at a time) approach that is favored by big institutions and by countries who allocate large amounts of money to health related development. But even some of those calling for this move are still pegging vital broader health issues to the extremely narrow HIV agenda.

People living in areas with a high disease burden, poor nutrition, poor living conditions and the like, are going to be infected with many diseases during their life, HIV being just one. This is not a recent discovery, nor is it very surprising. It is also not a surprising discovery that HIV positive people are more likely to transmit HIV if they are also suffering from other, easily treatable and preventable diseases.

So, the big missed opportunity is not one for HIV prevention and treatment alone, it is for health and development in general. Picking off a few headline diseases is little better than concentrating almost all attention on HIV. But making lasting improvements to living conditions, nutrition, water and sanitation, infrastructure, health systems and education are the real missed opportunities, without which HIV prevalence will remain high for a long time to come.

I hope the American Society of Tropical Medicine and Hygiene succeed in getting more general, non-HIV related health issues some attention and funding. But addressing health more generally, avoiding the 'silo' or 'vertical' approach, is probably the best way to treat and prevent HIV, also. Doing things the other way around has not worked and never will. If you see HIV as the problem and set up a parallel health infrastructure you will fail with most or all of the other health issues and this is unlikely to have much impact on HIV either.

But Walson and others put their finger on the very difference between HIV and other diseases they now hope to deal with, ones they refer to as 'diseases of poverty'; HIV is not a disease of poverty, at least, not to the extent that intestinal and other parasites, malnutrition related conditions, waterborne diseases and acute respiratory diseases are. HIV in African countries tends to concentrate to a disproportionate extent in urban dwelling, wealthier, better educated, more mobile populations.

From a commercial point of view, there just isn't much money in 'diseases of poverty', whereas there is a huge amount of money available for HIV; that's what makes HIV an entire industry, and diseases of poverty a mere development issue. In wealthy countries enough people can afford HIV drugs, despite the fact that they are grossly overpriced.

But even in developing countries, donors, up to now anyhow, have been interested in funding HIV. They're mostly interested in funding treatment because that's a lot more lucrative than prevention. But the word on the street now is that 'treatment is prevention', so even more money may end up being spent on this single disease. Though HIV treatment is not, in any useful sense, prevention, this is unlikely to worry those whose income comes from treatment.

Waterborne diseases, respiratory diseases and the like, those that kill more people than all the headline diseases put together, do not involve lifelong treatment with expensive drugs, which need to be replaced, eventually, with even more expensive drugs as resistance builds up. Some of the most ignored drugs are ones for which the treatment is a once or twice off occurrence and the treatment is dirt cheap. What self-respecting pharmaceutical multinational corporation wants to bother producing such drugs?

There is mention of the Gates Foundation but this institution has only shown token interest in anything but wealthy institutions and industries, with pharmaceuticals and genetically modified organisms receiving massive amounts of funding. Gates himself is not shy about promoting vaccines, preferably one for each disease, but he's a lot less interested in, for example, water and sanitation, provision of which could take care of a whole spectrum of diseases. Which is not to say he spends nothing on water and sanitation, just comparatively little.

People and institutions who wish to address various health issues because they reduce the quality of life and the life expectancy of hundreds of millions of people are to be encouraged, particularly if their 'success' is not going to be judged entirely by HIV related indicators. But HIV is not just highly funded because it threatens the livelihood, health and lives of so many people; just about all diseases fit into that  category. There's long been an obsession with HIV that may not be so easy to dislodge by a few public calls for change.

Gay Footballs: Obama and Cameron Aiming to Destabilize African Development Sectors?

The COP17 climate talks are taking place at the moment in Durban, presumably to create the illusion that the climate industry sees Africa as having a part in the negotiations. Natural resources continue to be plundered from any country unlucky enough to have discovered them, and the searches are still on for oil and anything else the West can get hold of cheaply. Land is being grabbed at an unprecedented rate so that multinationals can produce food and biofuels in countries that are also recipients of poverty reduction funding, and even food aid, to be sold in rich countries.

The Global Fund (to fight AIDS, TB and malaria) has suspended operations for two years, which will affect a lot more than just HIV programming; the HIV dominated development sector will see former recipients of Global Fund monies scrambling to 'reposition' themselves as big players in health systems, reproductive health, family planning, gender based violence, LGBT and gender issues and whatever else will save their skin. Some will probably even present themselves as experts in poverty reduction, education and climate change; they gotta go where the money is.

The development sector faces huge challenges, not just from issues like the ones listed above, but because many working in the sector are not wholly convinced that their aims are being met. Recognizing that something needs to be done about human rights, poverty, health, education, infrastructure and the like in developing countries is an important first step, one that most, perhaps all working in development have made. But I have met few who have found out exactly what needs to be done; I certainly haven't.

Having said that, I work with people who are involved in projects which, ostensibly, 'make things better', in the fields of health, education, water, vulnerable populations, etc. So I expect them to be concerned about development related issues, especially the ones that threaten development funding or that risk reversing any gains they might achieve through their work. But I haven't found a colleague who knows anything about genetically modified organizms (GMO), land grabbing, biofuels or climate change, except to the extent that they involve funds. Mention certainly needs to be made of 'sustainability', 'risk', 'environment', 'inclusiveness', 'equality' and the like, but that's the responsibility of the grant proposal writer (who happens to be me).

But recently my colleagues have started to talk about development funding, and not surprisingly, because all the newspapers are running the story; a particularly wealthy individual from a wealthy country has said his government (he is the prime minister) is considering withholding development funding to countries who have punitive homosexuality laws. This is a stupid and childish thing for a prime minister to say and he has been back peddling ever since. But the damage is done; all my colleagues can talk about is gays, and how they are being 'forced' to allow gay marriages and do all sorts of things that are against 'their culture'.

Now the US government is making similar noises. I heard one of my colleagues saying that we don't need their money, neither the US's nor the UK's. There's a sense in which he is very wrong, the obvious sense. But there is an important sense in which he is right; Tanzania does not need Western countries to set their agenda in return for relatively small amounts of money that don't seem to benefit the most needy anyway. Aid money already comes with strings, so adding some more strings is not going to suddenly allow some people to benefit, for example, gay people. In fact, these moves are likely to make things a lot worse for gays. It's as if the US and UK governments are using the issue of gay rights to goad African countries into stirring up anti-gay prejudices, knowing exactly the effect their 'threats' will have.

This is only partly about African homophobia. It's also about Western homophobia, in the sense that any mention of homosexuality is highly reportable and guaranteed to polarize views (and curiously distract attention from other issues?). It is such a powerful political tool that the most experienced spin doctor couldn't invent it. But why is this tool being wielded with such force right now? Is it because foreign aid is falling anyway and Western donors need something to hide behind, to deflect the inevitable blows? I'm no pundit and I can't answer those questions, but I would bet on one thing: these moves by the UK and US are themselves homophobic, are totally inimical to gay rights, globally, and they will only make things worse for gay people in African countries.

Absence of HIV Does Not Equal Health

The issue of health conditions stemming from intestinal parasites, such as schistosomiasis (bilharzia), and their connection with HIV, has come up a number of times on this blog. There has been research into how these conditions may increase susceptibility to HIV in populations where they are endemic, and how they may increase the likelihood of HIV positive people transmitting the virus, sexually.

Much of what has been written on the subject is not particularly new, and even a recent review of the literature may yet receive as little attention as all the papers reviewed therein. But perhaps one day those concentrating on sexual behavior will realize that it is mostly ordinary, everyday sexual behavior, not rampant and risky sexual behavior, that is behind the bulk of transmissions in countries like Kenya, Uganda and Tanzania.

In addition to the hotly disputed (but grossly underresearched) contribution of non-sexual HIV transmission to serious epidemics, the contribution of non-risky sexual behavior also raises questions for the HIV industry. It has been apparent for a long time that the largest sexual transmission contribution to HIV epidemics comes from monogamous, heterosexual couples. Why should penile-vaginal sex result in so many infections when the probability of such transmission is quite low?

The HIV industry invented some red herrings that suited their penchant for salacious theories, all of which turned out to have little impact on HIV transmission, or to be too uncommon to explain any more than a fraction of transmissions (which is not to say that they didn't contribute anything at all). Examples are female genital mutilation, vaginal douching, multiple partnerships, concurrent partnerships, etc.

So, the review in question looks specifically at urogenital schistosomiasis, which is widespread in many African countries. Despite being common, this disease is also easily and cheaply treated. Some might wonder why prevention and treatment have not been made available decades ago, but that is another long story.

It is possible that the best chance schistosomiasis has of being eradicated now is if the HIV industry thinks it might help reduce HIV transmission easily and cheaply, given that they have spent billions on expensive and relatively ineffective interventions, and are quickly running out of money. But they may find (relatively) cheap ineffective interventions, such as mass male circumcision, that are more to their taste, and genital schistosomiasis may yet remain common, however implicated in the spread of HIV.

Much of the research into intestinal parasites and HIV show that the two are associated, but does not show causation. But why should people with these diseases have to wait for a causal connection with HIV to be proven before they receive treatment, or before attempts are made to eradicate the disease? The same question could be asked about other diseases that either make people more susceptible to HIV or more likely to transmit it.

Besides, causation has not been demonstrated for male circumcision/lack of circumcision either, yet half a million operations are claimed to have been carried out in the name of HIV prevention (many of them among the Luo of Kenya's Nyanza province, where schistosomiasis is also endemic). Some association between circumcision and lower HIV prevalence may have been shown, but a similar association may exist between female genital mutilation and lower HIV prevalence without anyone advocating for FGM as a viable HIV prevention intervention.

People have a right to health. We don't need economic arguments about cost effectiveness or proof of a causal connection between genital schistosomiasis and HIV before implementing eradication programs for all the parasitic and other neglected diseases for which preventive and curative measures have long been available.

Global Fund: It's Not Time to Give Less, It's Time to Take Less

Paul Boateng and Aaron Oxley argue that "Now is not the time to cut funding for HIV and Aids" in the English Guardian's Global Development section, which is prominently sponsored by Bill Gates (and who isn't these days?). The authors argue that cancellation of the Global Fund will reverse gains in combating HIV (TB and malaria). But first, is the Global Fund riding on a publicity wave that taps into gains that can not all be attributed to the Fund itself? And second, does Britain really give a damn about HIV or any other social issues in developing countries?

It is true that new HIV infections have declined over the last decade. But this trend was already well established when the Global Fund got going. The Global Fund and others, such as PEPFAR and the World Bank's MAP, may have hastened the trend, but it's difficult to say by how much. In addition, aids related deaths have dropped, which can be partly (only partly because death rates peaked as a result of epidemic dynamics, often before the big funds were established) attributed to large funds like the Global Fund paying for 6 or 7 million people (depending on your source) to receive life-saving antiretroviral drugs (ART); but at what cost?

The cost of providing 6 or 7 million people with ART, and that's a fraction of the people who need or will need the drugs, is far higher than it should be. These drugs are grossly overpriced under the protectionist policies of the World Trade Organization. The real beneficiaries of big HIV funding have been pharmaceutical companies. If the Global Fund and other big funders really wanted as many people to be treated as possible, they would divert some of their attention to getting genuine competition into the generic HIV drug industry. If ART was more affordable, bug funders could spend some money on effective prevention measures (if and when they get around to finding any).

But the big question is not really about how much donor countries 'put into' HIV, but how much they extract from recipient countries. The article authors point out that 2 billion dollars are needed, from all donor countries, not just from Britain, to meet current requests up to 2014. But just one example of how much is being extracted can be found in an article that appears in the British Medical Journal. The country that benefits most from poaching skilled medical personnel from African countries is Britain, at an estimated 2.7 billion dollars, with the US a distant second, at 850 million.

The value of getting your doctors trained abroad is many times the amount donated to the Global Fund, and that's just from poaching in the health services. Britain is also one of the biggest land grabbers; they receive a large share of the continent's natural resources and leave little behind; they grow many of their luxury crops in countries that they also send food aid to, thereby extracting water, food production potential and cheap labor, not to mention damaging local markets and denying people the right to determining the use of their natural resources and food supply.

I certainly wouldn't advocate reducing spending on HIV, or on development, but I would question how all this money has been spent. Firstly, systematically stigamitizing all Africans as promiscuous, while at the same time calling for a reduction in stigma, is self-contradictory. It's time to look at non-sexual HIV transmission; we know it occurs, we just haven't yet bothered to estimate its relative contribution to the most serious epidemics. Secondly, we will never be able to afford enough drugs at the grotesque prices demanded by pharmaceutical companies; their part in bankrupting the Global Fund needs to be recognized.

So Boateng and Oxley might be better advised to campaign for less to be extracted from African countries, rather than for more token payments to be made to the rather phallic Global Fund. The amount of money extracted from these countries is many times what they have ever received, albeit in the form of highly publicized, magnanimous acts. The few million who benefit from antiretroviral drugs is nothing compared to the hundreds of millions who suffer as a result of what Western countries take, rather than what they fail to give. The authors are right, now is not the time for giving less, it's the time for taking less.

[More about the 'extractive' tendencies of Western countries who make ostentatious payments to well publicized development funds.]

World Aids Day: How is the Orthodoxy Faring Under the Stress of Evidence?

A recently published survey shows that national HIV prevalence in South Africa has hovered at just under 30% since 2004. The authors suggest that a lot more people are living longer with HIV because they are accessing antiretroviral treatment. This may be so, but not many South Africans were accessing treatment until fairly recently. What the figures also suggest is that a few hundred thousand deaths every year are also being matched by a few hundred thousand new infections.

There's a massive variation between provinces, ranging from just over 20% in Kwa-ZuluNatal to 3% in Northern Cape. There's also a huge variation among age groups, with highest rates among 15-29 year olds, but peaking among 20-24 year olds at just over 30%. Still, the 19% prevalence figure is astonishing for 15-19 year olds and is in need of explanation.

From less than 1% in 1990, HIV prevalence has increased rapidly, exceeding 20% in 1998 and reaching 25% in 2001. Prevalence has not fallen below 25% in the last 10 years. Rates in antenatal clinics are even more astonishing, reaching over 40% among 30-34 year olds. The highest rate of all, 46.4%, was found in Uthukela, Kwa-ZuluNatal.

It's something of a conundrum that so many more women than men are infected in South Africa and other high HIV prevalence countries, all of which are in sub-Saharan Africa. It's a conundrum because hardly any women are infected in Western countries, compared to men. One of the few female risk groups in Western countries is intravenous drug users. Even sex workers are unlikely to be infected unless they are also drug users.

So why is it that the opposite is true in Africa? Western women are infected through heterosexual sex, but in very low numbers. Yet in South Africa, most of the women infected are not intravenous drug users or sex workers. According to the HIV orthodoxy, they are infected through heterosexual sex, apparently penile-vaginal sex.

And most Western men are infected through receptive anal intercourse or intravenous drug use. Some may be infected through heterosexual sex, but not many. Far more men than women are infected because far more men than women face the most serious risks.

Indeed, in African countries, it could be asked how many men are really infected by women through penile-vaginal sex. Because the lower percentage of men infected also includes those who engage in receptive anal sex and those who are infected through intravenous drug use. Few women engage in intravenous drug use, though they face the same elevated risk of infection through anal sex as men who engage in receptive anal sex.

It could make one wonder just how many men are being infected through heterosexual sex, and how so many women are being infected by what amounts to a relatively small number of HIV positive men. Of course, you can add in the HIV orthodoxy special African spice of dry sex, concurrency, rampant levels of partner change, etc. But you might still wonder...

Then there are, in the same report, the figures for syphilis. From a high of just over 11% in 1997, when HIV prevalence was just under 20%, syphilis fell steadily to a quarter or even a sixth of that rate after 2000, and stayed there. Syphilis rates do not correspond with HIV rates, not even a little bit. Kwa-Zulu Natal has the second lowest rates and Northern Cape has the highest. Also, syphilis prevalence does not vary much by age.

You might be forgiven for thinking that the virus that is difficult to transmit sexually, HIV, must also be transmitted non-sexually, perhaps to a very great extent, since the relatively easy to transmit syphilis dropped at the same time as HIV was increasing, and stayed low, while HIV stayed high. Or you might immediately dismiss that idea, since it flies in the face of so much UNAIDS propaganda.

Either way, you might wonder if the same virus, HIV, could only infect those who take the biggest risks in Western countries, yet it seems to infect more of those who take the smallest risks in African countries. Or you might be a member of the mainstream press, and not wonder at all, not once in thirty years.

Once the Stereotypes Have Gone, What Goes in Their Place?

Francois Venter makes a number of interesting comments in his article in the Cape Times, which starts by criticizing Helen Zille for her recent public outburst about criminalizing 'unsafe' sexual behavior, which only served to show how little she knows about HIV, health, sex and the law (and how much she knows about pseudo-morality, petty politics and mainstream media). But Venter goes a lot further, taking on the mantra that has launched a thousand careers: HIV is spread through promiscuity.

Venter recognizes something that UNAIDS and the HIV industry have yet to understand, that Africans are people. Shocking as that may sound, even HIV positive Africans are people. They are not sex machines, engaging in levels of coital activity that would leave little time or energy for anything else. They have jobs and families and lives that don't allow for 24/7 sex.

The HIV industry have never actually calculated how high levels of sexual behavior would need to be to account for the notoriously high levels of HIV transmission found in countries like South Africa to even be feasible. They just went ahead and informed the world that Africans are weired when it comes to sex and that if they could just stop being so irresponsible, everything would be OK.

Venter is unlikely to be a recipient of HIV industry controlled funds, or he won't be for long, because he even goes so far as to point out that "HIV is actually not terribly transmissible when looking at risks per sex act measured in developed countries, when compared to other viruses like herpes." He contrasts this with the fact that "a young woman in KwaZulu-Natal has an almost 1-in-3 chance of being HIV positive by the age of 21 years."

There is clearly something different going on in South Africa, and it is not just sexual behavior. So Venter suggests the possibility of some biological factor that makes sexual transmission of HIV more efficient in certain places.

While I am in sympathy with him, I'm not sure I go for his contention that "the geography" could be more significant than the behavior, not in the way he seems to mean, anyhow. Africans in the US are far more likely to be infected, even if they are heterosexual and not intravenous drug users. The geography is very important in some ways, also in South Africa, when you look at those living in urban as opposed to rural areas; those in rural areas are far less likely to be infected.

Venter vaguely suggests more susceptible genes, a more virulent strain of HIV or some undiscovered environmental factor. These may all be relevant in some way, but there is a more likely possibility, given the considerations he mentions, and that is the relative contribution of unsafe healthcare and perhaps cosmetic services. In South Africa, even people living close to roads are more likely to be infected than those further away. In Malawi, those living close to health facilities are more likely to be infected than those further away.

Various co-factors Venter mentions may play some part, some co-factors almost definitely do. But Venter still reverts to the behavioral paradigm, concluding "It’s sex, sure, but high risk sex largely independent of how or with whom you have it." This is a pity as Venter even presents some of the evidence that shows that sex can't play as big a role as the HIV industry would have us believe. Sex plays a part, perhaps a big part, but it can not explain entire epidemics, such as the one in South Africa. The question is, what are the relative contributions of sexual and non-sexual transmission in high prevalence African countries?

I applaud Venter for going as far as he does, however, I don't think he goes far enough. But there is good news. Venter mentions costs. Well, campaigns to warn people about blood contacts, such as in healthcare and cosmetic facilities, along with efforts to properly investigate infections that are unexplained by sexual behavior would not cost much. They are even things he could do as part of his own work as a GP.

And most importantly, genuinely competitive pricing for generic antiretroviral drugs, without the connivance of Big Pharma and their friends (such as Bills Clinton and Gates), produced in high prevalence countries, would also reduce the ever increasing amounts of money thrown into the pockets of various multinationals. This may hurt, Dr Venter, but it won't hurt your patients.

[For more about non-sexual transmission of HIV through unsafe healthcare and cosmetic services, see the Don't Get Stuck With HIV site and blog.]

Global Fund Cuts: Callous Disregard for HIV Industry

The Global Fund for AIDS, TB and Malaria has dried up. Perhaps not for ever, but for long enough for us to realize that providing increasing numbers of people with increasingly expensive drugs for decades may not be wholly sustainable.

If any effort had been made to reduce transmission of HIV (or even TB or malaria, although they do seem like a bit of an afterthought) over the last 10 years, the costs of 'universal access' to antiretroviral drugs might have gradually become achieveable. But with more people being infected than being put on drugs, the Fund has presided over ten more years of missed opportunities in the field of HIV prevention.

There's lots of talk about treatment being prevention, on the grounds that those on treatment are less likely to transmit HIV. But that is still just talk, and the levels of testing, treatment, support and monitoring required to effect such a program are probably beyond the means of all HIV funding put together. Treatment is vital, and greater access to treatment may help prevent some infections, but it will never obviate the need for effective prevention strategies.

So Kenya is being advised to "Seek Alternative Ways of Funding Healthcare", as no new programs will be funded for the next two years. Ten years of ignoring health systems and diseases that were not considered sexy enough now means there is a lot of catching up to do and no money to do it with. For all the billions that have gone into HIV, African health systems have little to show for it. It's late in the day for a decision to start to see HIV for what it is, a disease, one among many. It's also late to decide that "it is time to dismantle the many parallel HIV programmes created mainly to compete for donor funding but which are unsustainable".

Uganda finds that the "Aid Cut [will] Affect One Million HIV Positive Citizens". Apparently the country had massive plans to eradicate HIV, even more massive than the ones that didn't eradicate it over the last twenty years. There were plans to put most people on treatment, especially mothers and children. But the virus appears to be making a comeback in certain sectors of the population, and has been doing so for some years. Exactly what have they been doing?

The Ugandan Government is also "Advised to Use Local Resources to Fight Aids", which would probably be good advice if such local resources exist. But African governments might also be well advised to form their own health strategies, with HIV fitting appropriately into those strategies, rather than remaining apart from health and other social services and completely dominating most agenda, as it has done for so many years. The various organizations and institutions that have been sucking on the HIV nipple will need to diversify, downsize or disappear.

None of this sounds like a reason to celebrate. But it is a good time to change, if African governments decide to do so. It may now be up to them to identify the main drivers of the virus, to assess the relative contribution of each mode of transmission and to decide on the most appropriate ways of preventing the further spread of HIV. If the donor community is no longer paying, perhaps Africans will notice that their sexual behavior is not that different from that of non-Africans. Perhaps the way will be open for programs that rely less on expensive technologies and an unwarranted assumption that HIV transmission all a matter of sex.

Because currently, things are great for the pharmaceutical industry and the HIV industry in general. Not without some serious lobbying, I'm sure, but everything has been going their way for years. Donor funding has poured into their coffers and every year a new scheme is dreamed up to increase the tonnage of drugs shipped to poor countries, where far more people are dying for lack of clean water and decent levels of nutrition than HIV.

Perhaps now, the 'experts', the ones that African countries couldn't do without, will have to go home and find a job in healthcare, with the appropriate retraining, of course. I believe it's called 'task shifting'. Africans will not suddenly start losing out as a result of Global Fund cuts, they have been losing out for years. But the HIV industry will lose out. Expect a lot of emotive pleas, ostensibly for 'dying Africans', but hear those pleas for what they really are: self interest.

[For more about non-sexual transmission of HIV through unsafe healthcare and cosmetic services, see the Don't Get Stuck With HIV site and blog.]

UNAIDS 'Getting To Zero'; Zero Lies?

The Nairobi Star has just noticed that HIV prevalence is far higher among employed people than unemployed people, according to the Demographic and Health Survey, 2008-09. They don't cite the correct figures (see graph for corrected figures), but this is not a new trend. So why would employed people be more likely to be infected? According to the Star, it's because they have "disposable incomes which provide the ability to support multiple sex partners and even buy sex, living away from spouses because of employment, drug and alcohol use and abuse of recreation" [sic].

(Source: Kenya Demographic and Health Survey 2008-09, Table 14.5)

If the author is right, and she certainly holds the orthodox view, then women must be buying a lot of sex too, perhaps more than men. But the same survey also shows that levels of 'unsafe' sexual behavior are far higher among men than women. Men are also more likely to abuse drugs and alcohol. Yet HIV prevalence is consistently higher among women. Prevalence is also higher among people with more education, people with more money (whether employed or not) and people in urban, as opposed to rural areas.

Tempting as it must be for a journalist to present sex as the 'obvious' answer to higher HIV prevalence among employed people, perhaps they should look at another possibility, the possibility that sex is not responsible for all HIV transmission. Most HIV transmission in Kenya (Uganda and Tanzania) occurs between people who do not take many risks under the orthodox criteria for risky sex. HIV prevalence patterns do not seem to relate to sexual behavior patterns.

Maybe journalists would like to look at another scenario: employed people, better educated people, wealthier people and urban dwelling people have greater access to health and cosmetic facilities, where conditions may not be very safe. UNAIDS believes that their own employees need to take care in health facilities that have not been approved by the UN. But will they ever get around to warning Africans?

[For more about non-sexual transmission of HIV through unsafe healthcare and cosmetic services, see the Don't Get Stuck With HIV site and blog.]

HIV Industry Need Non-Racist Answer to the Question 'Why Africa, Why Africans'?

After flailing around blindly, spending billions and ending up with little to show for it, the massively wealthy but spectacularly ineffective AIDS industry may finally box its way out of a wet paper bag. What it will do after that is another matter. But it's nice to see progress, however hard it is to detect.

Right at the end of a paper entitled 'Redesigning the AIDS response for long-term impact', Heidi J Larson, Stefano Bertozzi and Peter Piot make a few things clear which have, up until now, been clear to everyone but those working for the AIDS industry. But they do now accept that funding should support infection control programs relating to safe blood transfusions and injections.

Unfortunately, they deprioritize infection control in general. This would be fine if infection control was covered by health system strengthening funding (or some other way), but it's not. It would also be acceptable that AIDS money no be longer used for sexually transmitted infection (STI) programs if STI reduction received funding from elsewhere, but it doesn't.

The authors note that "The difficulty of changing sexual and drug-using behaviours was...greatly underestimated" and that "prevention tools continue to be implemented without evaluating their effectiveness in different settings." But they don't appear to question the entire vertical approach to HIV/AIDS at a time when health funding in general was totally inadequate in high HIV prevalence countries; the approach to HIV has only diverted funding further.

Instead, they seem to be suggesting that HIV funding be focused even more narrowly than before, rather than on just avoiding ineffective approaches. Do they not yet see the bigger picture of HIV epidemics thriving in countries with low and flat or declining health spending? Instead of talking about mainstreaming, integration and other nice theories, how about treating HIV as just another disease, with overlapping determinants to other diseases, such as hepatitis B and C, with similar needs, such as functional and safe health services?

Reducing HIV transmission is not just a matter of scale, as these authors must appreciate, being aware of the huge increases in funding for lucrative areas of HIV treatment and the like. But the industry, if it's to have any impact on transmission, needs to lose its obsession with sex and African sexuality, and look at disease transmission in context. This means tracing the risks HIV positive people have faced, not just tracing the sexual risks they face; non-sexual risks also need to be reduced, which involves informing people about them and how to avoid them.

Let's leave the fatuous reflexes about 'treatment being prevention' for the marketing people because treatment is not prevention. More than two and a half million infections a year show that treatment is not prevention. Saying we need to put more money into treatment will not make treatment into prevention either. Most new infections occur among people who only face low levels of sexual risk (though the industry has failed to assess non-sexual risk).

But even if treatment could possibly become a significant part of prevention, and there are serious doubts, who will be paying for this? Current programs are failing because of falling funding and an almost complete absence of infrastructure, in other words, a complete lack of health systems strengthening, among other things.

The authors conclude that there are "no short term solutions". At the rate they are going, that's all too true. But the "fundamental redesign" they call for requires a closer look at a disease that is difficult to transmit sexually, yet it spreads quickly among people whose sexual behavior is similar to that of people everywhere. The question is still 'why Africa, why Africans'? The industry needs to answer that question.

[For more about non-sexual transmission of HIV through unsafe healthcare and cosmetic services, see the Don't Get Stuck With HIV site and blog.]

Ugandan Politicians Blame Gays for Loss of Funding; Media Obediently Follows

Uganda's Daily Vision claims that the "Global Fund [to fight HIV.AIDS, TB and malaria is withholding] Shs700b for ARV Treatment Over Gay Rights". There are plenty of things to criticize the fund for, but this article is just one of many that are really about African and Western politicians trying to use the issue of homosexuality and homophobia to drive their own agenda, whatever they may be.

There are several reasons why some of the funding Uganda applied for is being withheld. The government being "harsh on sexual minorities" is only a minor reason in a minor category of reasons. The rights of minorities are not derailing the fight against HIV, as the Ugandan AIDS control manager Dr Zainabl Akol claims. Rather, their rights are being used as a pawn, along with funding for HIV, HIV positive people and various other vulnerable minorities, in a complicated game for power and wealth.

One of the main reasons the Global Fund is withholding most of the Round 10 funding is because Uganda hasn't yet spent nearly 90% of the money they received in Round 7. In fact, despite receiving larger amounts of money than some countries with more serious HIV epidemics, Uganda has only managed to get a relatively small percentage of HIV positive people on antiretroviral treatment. Despite years of media praise, Uganda has done little to understand or control its HIV epidemic.

There are several other reasons why the Global Fund and other donors might withhold funding, in addition to their apparent inability to spend much of what they receive and to account for much of what they spend. For example, an article in the Uganda Monitor reports that it is inadequacies in the country's health system that is "derailing the fight against HIV/Aids". There are chronic shortages of health personnel and health supplies. These go back a long way, pre-dating the Global Fund itself by many years.

Apparently the Ministry of Health has even blamed gay rights for the country's stagnant prevalence rates. This is ludricous. Gay rights are far more important than the political pawn that politicians see them as being, but they are not 'responsible' for Uganda's epidemic. In fact, men having sex with men accounts for a pretty small proportion of HIV transmission in African countries.

Dr Akol is right to demand that gay rights be kept separate from HIV, to the extent that lumping them together is not going to further either interests. Both issues need to be addressed, but one, HIV, is a health issue. Homosexuality is not a health issue and it is not, or should not be, a determinant of health. But nor should either be used as mere political tools.

Another reason donors are likely to reconsider funding in Uganda is corruption, financial management and low standards. These are the reasons why the Dutch government is withdrawing 14 million Euro in funding for education. The Irish and UK governments have made similar moves in East Africa in recent months. These countries may have other reasons for cutting funding that they are not revealing, of course, but the Ugandan government and others are disingenuous to suggest that any funding has been denied purely on the grounds of poor human rights, for homosexuals or any other group.

It's convenient for the Ugandan government to blame gay rights. And stupid comments like those of David Cameron about withholding aid money if Uganda and other African countries don't play ball don't help at all. But these comments really were about playing (political) ball games, not about rights. Cameron and other Western leaders don't give a damn about Africans in general, not just African gays. Heterosexual Africans should not flatter themselves so.

I contacted a media officer at the Global Fund who confirmend that there were several reasons for withholding funding, some of which were very serious. In addition to the reasons mentioned above, the Fund said that the proposal "failed to adequately address equitable access of services especially with respect to particularly vulnerable populations". This would include gay people, but does not refer to them exclusively.

Cameron, Clinton and other Western politicians are as wrong as African political leaders to use funding for HIV or anything else as a bargaining tool when human rights are at stake. But the fact that funding is being used as a bargaining tool does not mean that the Global Fund are withholding money entirely because of how Uganda deals with gay rights. Both gay rights and HIV need to be addressed, not conflated, confused or kicked around by homophobes or other kinds of bigot.

Political Smokescreens and the Corporate Barebacking of Africa

English premier David Cameron played the homosexuality card to draw attention to his current flavor of British aid to Africa, but presumably to draw attention away from the fact that the actual amount of aid is shrinking, and perhaps a few other political indiscretions. He probably wouldn't like anyone to scrutinize how much of the aid still flowing is 'ghost' aid, or just a subsidy to British industry and consultancies.

Even less would he like anyone to scrutinize how much money leaves countries like Tanzania, destined for one of those tax havens, most of which are also controlled by Britain, to swell the bulging numbered accounts of wealthy British companies. Of course, some of those companies go bust, but it's Tanzania and Tanzanians who pay the biggest price.

Now the Tanzanian premier, Mizengo Pinda, is playing the homophobia card, which could draw attention away from any number of political shenanigans. The country has "refused to accept homosexuality because the country wants to safeguard its people's moral standards". But is it 'the people's' moral standards that are in need of safeguarding? What about the moral standards of those who have soaked up millions of dollars of aid money every year for several decades?

Will the Tanzanian government ask Britain's Sun Biofuels, or David Cameron's sanctimonious government, to compensate the victims of just one of many land-grabbing operations that both governments ably (and, presumably, profitably) facilitated? Or is the moral 'threat' of homosexuality likely to cause more poverty, more starvation, more disease and more death than all the corporate thieves currently making off with the country's resources while Tanzanians starve?

Just a kilometer down the road from where I work there are cut flower production units, famous for producing cheap flowers for rich countries, with the judicious use of cheap labor, sanctioned by various nice sounding schemes, such as 'export processing zones', trade agreements, etc. A little further away there's a Tanzanite operation, famous for keeping costs low by the use of child labor.

In several regions there are gold mines and Tanzania has the third biggest gold reserves in the whole of Africa. But it's not Tanzania or Tanzanians who get the bulk of profits for these exports, it's not even Africans. There are also uranium mines, coal, natural gas and various other commodities extracted from the country with the use of favorable 'regulation', cheap labor and raw materials, but without the need to pay any more than a few percent to the Tanzanian government, no more than 3% and probably a lot less.

The smokescreen of abortion is used to hide the serious lack of health provision and appalling conditions, especially for the poorest. The smokescreen of contraception aims to hide the use of Africans as a massive market for birth control methods that are considered too dangerous to be used by non-Africans, and there's the use of illiterate and vulnerable people as cheap research fodder for drugs that are ultimately only affordable to Westerners (and sometimes to Western aid budgets).

There's even the (so-called voluntary) sterilization of African women, said to be of global benefit, because population control is the favored development paradigm for many of the best funded international NGOs. Mass male circumcision to reduce 'sexual' transmission of HIV and other diseases hides the fact that the 'global health' industry has no wish to eradicate HIV, or anything else, when it's so lucrative not to do so.

Are all those who are denying Tanzanians their rights, their wealth, their health and their lives homosexuals? Are all thieves, especially the multinational, state-sponsored ones, homosexuals? Is all the 'immorality' one finds in Tanzania so bound up with homosexuality that the issue needs to be raised in parliament and senior politicians need to 'protect' Tanzanians from these terrible threats? Politicians aside, don't Tanzanians realize who is doing the barebacking?

Zille's Rhetoric about Criminalizing Unprotected Sex is Misinformed

South African premier Helen Zille [Sorry, Premier of Western Cape!] shows a worrying level of ignorance about HIV transmission in calling for "men who have multiple sexual partners and refuse to use condoms to be charged with attempted murder." She's right that using condoms reduces the likelihood of sexual transmission of HIV, substantially. But she's wrong if she thinks that HIV is almost always transmitted sexually in South Africa and other high prevalence countries.

Leaving aside the sheer stupidity of expecting to control HIV transmission by making unprotected sex with multiple partners a crime, increased condom use, even consistent condom use, is not always associated with reduced HIV transmission. If HIV were almost always transmitted sexually, as UNAIDS and the HIV industry claim, the effect of increased condom use would be very likely to have the desired effect. But often, HIV prevalence among condom users is the same as among non-users, or even higher.

A study of data from 22 countries shows that HIV prevalence is usually higher among women than among men and higher in urban than rural areas, particularly in high prevalence African countries. Prevalence is also generally higher among the wealthier and the better educated, unlike other transmissible diseases, which tend to infect poor and less well educated people in higher numbers.

But the report is clear on the issue of condom use: use of condoms is generally associated with higher HIV prevalence, among those who use condoms at all, and even among those who use them consistently. In some cases HIV prevalence may be lower, even much lower, but in others prevalence can be much higher. This is not evidence that condoms are not effective. It could suggest that most people don't use condoms often enough. But it is also an indication that HIV may not always be transmitted sexually.

Remarkably, Zille doesn't mention male circumcision, which is another very media friendly thing to throw into a speech. But this report finds that "There appears no clear pattern of association between male circumcision and HIV prevalence - in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher." It is customary for reports to ignore those countries where HIV rates are higher among circumcised men.

Zille and any misguided followers she may have should also read an article showing that sexual risk behavior is generally higher among young people in the US than in South Africa, yet HIV prevalence is many times lower among young people in the US. In South Africa, prevalence among 18-24 year olds was over 10%, compared to less than 1% in the US. Yet, young people in the US become sexually active earlier than those in SA; number of lifetime partners is higher in the US; and use of condoms is lower in the US. There are often greater age differences between females and their partners in SA, but that could only account for a relatively small proportion of transmission.

That article concludes that effective HIV prevention demands an accurate perception of the spread of HIV. This is something Zille lacks. But she's not the only one. Among those also lacking an accurate perception of HIV transmission in African countries are UNAIDS, WHO, Johns Hopkins Medical School, the London School of Hygiene and Tropical Medicine and many others. She's in 'good' company, well-funded company. However, Zille's latest outburst will not reduce HIV transmission and will probably do a lot of damage to SA's HIV reduction efforts.

World Bank: Health Personnel Are Superfluous to Health

There has been a lot of media coverage of countries such as Tanzania (Uganda, Ghana and others) calling David Cameron's bluff on his insistance that British foreign aid should be cut to countries that have laws prohibiting homosexuality. They have told him to butt out of their business. However, if Tanzanians are so concerned about powerful interests interfering with their sovereignty, they would be better off standing up to the far more opressive and damaging strictures of the World Bank.

At around the same time as the HIV/AIDS epidemic was spreading through Tanzania, mainly unnoticed, the World Bank was busy sabotaging the country's post-independence gains in the areas of health, education, infrastructure and social services. This was the bank's policy of 'structural adjustment', which meant that desperate countries, without the ability to repay massive loans, were given massive loans on condition that they cut their public services, regardless of the rapidly growing need for them to be further expanded.

One of the consequences of this was a steady decline in the numbers of people employed in vital areas of public service, such as health. A report into human resource (HR) levels in Tanzanian health services finds that "Between 1994/95 and 2001/02, the active supply of health workers fell from 67,000 [...] to 49,900 health workers [...], an inevitable consequence of the employment freeze imposed by the Government between 1993-1999 in order to balance its budget and receive credits from the World Bank."

The report was a result of research carried out by Sikika in 2010, who have also researched and reported on dangerously low levels of medical equipment and supplies in Tanzanian hospitals. They find that on average, facilities in the area surveyed have less than half of the skilled health personnel they require; they request fewer personnel than they require every year; they receive fewer than they request; many of those deployed, more than three quarters in rural areas, do not take up their position; and attrition rates are high in some professions.

Aside from underfunding of the health sector, the authors suggest that personnel shortages may be partly related to shortages of other resources, such as medical supplies, equipment and pharmaceuticals, which would render many professionals superfluous. This effect could work in both directions, with non-human resources remaining low as long as there are too few personnel available to utilize them.

Funding is undoubtedly a serious issue and Tanzania still only spends 10-12% of its national budget on health, instead of the 15% recommended by the Abuja Declaration. But after more than two decades of neglect, and a budget that continues to be decimated by repayments to the world's biggest loan sharks, the country's health services are unlikely to catch up in the foreseeable future.

The authors make some perceptive recommendations but, without radical reform of unelected bureaucracies, such as the World Bank, IMF, UN agencies, WHO, WTO, and bureaucracies who have no democratic mandate in Tanzania, such as Western governments, the health sector will remain as stunted, malnourished, diseased and incapacitated as many Tanzanian people.

At the mercy of external commercial and political interests, efforts to reduce the spread of HIV/AIDS and to treat and care for those already infected will always be limited. At the same time, the HIV industry's obsession with sex will allow HIV transmission through non-sexual routes, such as through unsafe healthcare and cosmetic procedures, to continue unabated and uninvestigated.

Of course, severe shortages of personnel and supplies don't necessarily mean that hospital acquired HIV infection rates increase. Relatively low rates of HIV transmission in countries like Tanzania (also Kenya and Uganda) may reflect the low capacity of its health services to treat most people. We don't know that for sure; but that's because we have, as yet, no way of estimating the relative contribution of non-sexually transmitted HIV to the worst HIV epidemics.

Kristof on Poverty, Climate Change & Conflict: Birth Control is the Answer

Nicholas Kristof really knows how to pack the largest amount of conservatism into the one article. The presumptuousness of the title continues throughout the article, as well: 'The Birth Control Solution'. Kristof holds the rather naive view that underdevelopment exists because some people in some countries have too many children. The 'solution' to climate change, poverty and civil wars, and to underdevelopment in general, is birth control to limit population growth.

One result of overpopulation, according to Kristof, "is that youth bulges in rapidly growing countries like Afghanistan and Yemen makes them more prone to conflict and terrorism". All those who have spent long hours wondering why terrorism erupts in some countries should look at rapidly growing countries, with a high proportion of young people. These areas are 'prone' to conflict and terrorism, apparently.

Such populations also contribute to global poverty, we are told, and make it impossible to protect virgin forests or fend off climate change. Well that's quite a revelation to me. I always thought the biggest pressures on climate change come from rich countries. What does Kristof think virgin forests are being cut down for? To build mud huts? I am happy to let him know that the bulk of carbon emissions don't come from mud huts or from people wearing out the soles of their sandals in developing countries. There is no global shortage of food either, just a lot of people who can't afford prices that have been inflated by Western economic measures.

Kristof cites evidence that family planning works, but that is not in doubt. What's in doubt is that if you get family planning right, everything else will follow. His evidence is from India and Mexico in the 1950s and 60s. So now all Indians are rich and Mexico is peaceful? Family planning, birth control, even sexual and reproductive health, are just part of the health of a population. They need to be put into perspective.

Surprisingly, Kristof notices that the 'unmet need' for contraception is only one of many unmet needs, but he seems to think others are limited to those relating to family planning. Does he not know that there is an unmet need for access to healthcare, clean water and sanitation, education, social services and adequate infrastructure? There's nothing wrong with contraception, nor with providing more contraception, but it is just not at the top of everyone's list. It is buried inside some of those far more pressing needs.

The first thought of people planning a family (or just having a family, without any particular plans) is to have children. Then there needs to be some consideration of how to raise them. Some may wish to limit the number of children they have, but that might not come till later. What seems unlikely is that people will use contraception in order to reduce the possibility of their having an abortion. Aside from the fact that people don't think that way, abortion is illegal in many developing countries. It is just not an option. Reducing abortions is a secondary outcome of increased use of family planning methods, it is not a 'selling point'.

And those who worry about the world running out of resources tend to be those who are able to use far more of them than they need, not those who barely have access to them in the first place. Kristof seems to be thinking of his skin, and the skins of other rich Westerners. There is widespread poverty because most of the world's wealth and resources are in the hands of a few, civil wars are often fuelled by external influences (as any American journalist should know) and climate change is a result of the overconsumption of the minority world, not the sheer size of the majority world.

UK to Impose Gay Rights on Uganda While US Imposes Homophobia

Some may be disappointed by David Cameron's attempt to influence countries that make homosexuality illegal by threatening to cut off foreign aid. Uganda feels that Britain is bullying them and treating Ugandans like children, and I agree. I think homosexuals should be entitled to do whatever they do as long as it doesn't infringe on the rights of others. Nor do I think people expressing their sexuality in whatever way they choose constitutes an infringement on the rights of others.

But why should money that is supposed to be used to improve health, education, social services and infrastructure be used to threaten the government to pass legislation that suits current tastes in Britain? If aid is just a tool to get developing countries to become 'model states' in the eyes of Western countries, this is unlikely to work any better now than it has in the past.

Are Cameron and other Western leaders going to produce a list of desiderata, which can be ticked off as developing countries comply and be rewarded with another project, program, scheme or plan, and a handful of brownie points? The problem with aid in its current form is that it is not working very well. Some might say that is does work, it's just that it was never intended to work for developing countries, that the beneficiaries of foreign aid are the donor countries. That may be so, but what does that have to do with gay rights, or any rights?

Throwing money at the latest CNN moment, Aids, famines, earthquakes, hurricanes and tsunamis, is what it is, sheer posturing. But would Cameron and his fellow statespeople consider it acceptable to say to a country currently being devastated by a disaster, that aid money will be sent as soon as they improve their gender equality situation or their use of child labor (which is probably of far greater benefit to western countries than it is to developing countries)?

People here, and anywhere, can be whipped up into a frenzy about gay rights and all sorts of other things. But these are not the biggest day to day worries faced in poor countries. There's poverty, bad health, low educational standards, rotten infrastructure, inequalities of all kinds, failing governance, corruption and lots of other problems. Gay rights in Uganda are a political issue that can be milked for what it's worth or ignored, whichever political leaders and opinion makers choose at a particular time.

All Cameron is doing is adding to the frenzy. Instead of kicking someone for being gay, they can be kicked for threatening foreign aid monies. But no Ugandan politician, or politician of any country, is just going to back down and say, 'OK, we'll rewrite our legislation, sorry about that'. Bribing and threatening national administrations is not the way to change the attitudes of entire countries and it makes Cameron, and the UK, look stupid. It makes them look as if they don't really understand the concept of 'human rights'.

Cameron needs to go back to the drawing board. Threatening a country with suspension of aid, whatever kind of aid is involved, is not a way of bestowing rights on a population. Rather, it's just another way of taking away people's rights. No doubt, Cameron's tabloid reading supporters will be delighted, but he should keep his tabloid deplomacy for the UK, where he has a democratic mandate.

Interestingly, the BBC reminds us that "Some 41 nations within the 54-member Commonwealth have laws banning homosexual acts. Many of these laws are a legacy of British rule." The problem is not that former British colonies are refusing to be spoonfed, just that they now choose which of the spoonfuls to swallow and which to spit out.

What Cameron could do is go and have a word with his American puppet masters, who have done a lot to stir up the anti-gay fervor in the first place. But before that, he'll have to withdraw his idiotic remarks about withholding aid in return for 'gay rights' in Uganda. Otherwise, rights are whatever those paying the most say they are. Unfortunately, he's going to have to go through quite a transformation to follow this logic.

Injectable Depo Provera: Scientists Blame Media for their Own Indecisiveness

When scientists shout with joy, wave their hands in the air and slap each other vigorously on the back because they have decided that mass male circumcision is great, that concurrent relationships drive generalized HIV epidemics or that one of the latest offerings from the pharmaceutical industry will stop the HIV pandemic in its tracks, the mainstream media report accordingly. That's just how they are; they don't generally report critically, unless some particular flavor of the month is replaced with a new one.

So James Shelton's plea for scientists and the media to give a balanced view about the possible role of injectable hormonal contraceptives (HC) in increasing the transmission of HIV, from males to females and from females to males, seems a little pointless. The media doesn't tell scientists how to report their findings, thankfully. But scientists can't expect to be able to control how the media report theirs. The point of writing a scientific paper is to inform people about research findings. What they do with that information is up to them.

The disagreement about possible undesirable effects of Depo Provera and other injected HCs is not just a disagreement between science and the media. It is also, like a lot of disagreements, between scientists and other scientists. But the people who wrote the recent article in question, Heffron, et al, published in a peer reviewed journal, The Lancet. Although the media refuses to regulate itself and academica has no authority over the media, academia is regulated by other academics. You may not agree with the system, but there is a system.

What Shelton appears to be saying is that Heffron et al's findings don't conform to the mainstream stance that WHO, UNAIDS, USAID, CDC and various others have adopted. He doesn't like what they have reported so he tries to pick holes in the findings. I wouldn't mind if the findings were earth-shatteringly different from many earlier findings, but they are not. The only earth-shattering thing is how long various institutions have delayed issuing decisive guidelines for the use of injectable HC.

Shelton applies (some of) the criteria of Austin Bradford Hill for assessing evidence of causation and his point is clear enough; causation has not been demonstrated. But causation has not been demonstrated in the cases of mass male circumcision, concurrent relationships or the use of various highly lucrative drug programs (such as pre-exposure prophylaxis, treatment as prevention, etc). Yet these attract massive amounts of funding and publicity.

Shelton asks why the media applies so little critical thinking, but surely that's the job of academia, not the media? By the time the media get the press release, or however they are informed of what academia wishes them to know, the critical thinking should have been completed. The media have their own commercial and political interests to consider and these may or may not converge with the commercial and political interests of academia.

But one could ask Shelton and other HIV experts why it has taken so long for them to issue coherent guidance. Doubts about the safety of injectable HC have been around for a long time. Why haven't the various kinds of research Shelton mentions been carried out yet? The sheer volume of denial from academia being directed at what started with one article in the New York Times does not constitute guidance on whether to continue with this birth control method, or to switch to a different method until the safety of Depo Provera and others drugs can be assured.

The tone of those opposed to the findings of Heffron, et al, and others who have questioned the safety of injectable HC suggests that the orthodoxy is not going to change its collective mind on this issue. WHO will meet in January, but they have discussed this on and off for years without ever giving a convincing response to evidence that Depo Provera and similar products may be unsafe.

As with the possible role of unsafe healthcare and cosmetic services in HIV transmission, the HIV industry seems unwilling to scrutinize Depo Provera too closely. They say they are worried about people's sexual and reproductive health, but injectable HC is just one birth control method of many. Perhaps there is something else they are worried about?

WHO on Depo Provera: Deny, Delay, Deflect, Defer, Duh!

Around a month ago, the New York Times ran an article about research suggesting that injectable forms of popular hormonal contraceptives, such as Depo Provera, may increase the risk of HIV transmission to women, and from HIV positive women to men. Faced with the opportunity to give clear advice to women who receive these injections, WHO, UNAIDS, CDC and others have chosen to dither.

Almost all users of injectable Depo Provera and similar products are Africans in low resource countries. This means that they may also face the added risk of unsafe healthcare, reuse of injecting equipment, failure to follow (or even have) procedures to minimize risk of transmitting diseases, especially blood borne diseases such as hepatitis and HIV.

This is not even the first or most egregious instance of these institutions procrastinating over the same issue. WHO published a document in 2007, which was a response to a consultation that took place in 2005. In fact, serious concerns about the use of hormonal contraceptives in general have been raised for over thirty years, and the 2007 document says "The interaction between hormonal contraception and human immunodeficiency virus (HIV) infection has been a concern since the early days of the AIDS epidemic". So the wait until WHO's 'high-level meeting' in January seems minor in comparison to what seems like institutionalized delaying tactics.

Generally, the evidence available has not been very clear and is sometimes contradictory. However, in 2007 they noted that "The available data have been from observational studies conducted among women at high risk of HIV infection." By this, they mean sex workers and clients of STI (sexually transmitted infection) clinics. But the big question about HIV is why prevalence is so high in some African countries, even among sex workers and people with STIs, when this is not the case outside of some African countries?

In other words, being a sex worker, or even being a highly promiscuous person (and therefore at risk of infection with STIs), are not very closely associated with HIV infection among heterosexuals who don't have other risks, such as intravenous drug use, in non-African countries. Whereas, it is mainly heterosexuals with low levels of 'risky' sexual behaior in high prevalence African countries who are HIV positive. How are they becoming infected?

Unsurprisingly, in all the literature I have seen, there is no mention of the possible role of unsafe healthcare in HIV transmission. This is despite the fact that it is the injectable versions of hormonal contraceptives that are associated with higher HIV prevalence. Also, in recent discussions, there has been no mention of a paper published in 2008 which finds that women using injectable hormonal contraception are more than 10 times more likely to be infected with HIV. That's a lot more than the 2 times more likely mentioned in the New York Times article.

WHO and others are worried that people using injectable hormonal contraceptives will stop using them and may not use any alternative form of contraceptive. That is a legitimate worry. But is it preferable to tell people to continue taking these injections when such a high risk of HIV transmission has not been ruled out? What if their 'high level' meeting in January finds that it is better for people to stop using Depo Provera and similar products? Will they apologize to all the people who have been infected in the previous few months, or even years or decades?

We seem to be following the West's agenda, to promote birth control, to espouse the 'population control' theory of development and poverty reduction. But what about the risk of allowing thousands, perhaps tens of thousands of women, to continue using a dangerous product? And what about the future of reproductive health, even general health programs, if the putative beneficiaries find that we have been lying to them?