Thursday, January 27, 2011

The UNAIDS Paradox: Low Risk Sex Appears to be Risky in Africa has an article about a study carried out in Uganda which shows that there is little evidence of an increase in risky sex since the widespread rollout of antiretroviral drugs (ARV). Many people have been worried that the (relatively) easy availability of such drugs could give rise to both HIV positive and negative people disregarding principles of 'safe' sex.

It is not just in Uganda and other African countries where there are worries that such increases in risky behavior could follow ARV rollout. Wealthy countries have shown that increases in risky behavior are a reality and that this could easily wipe out some of the gains that have been made over the years. People are just not as frightened of HIV as they used to be.

But in the case of Uganda, the study gives the impression that risky sexual behavior is not such a big thing there. More surprisingly, it sounds as if it never was. After starting treatment, some people engaged in higher levels of risky behavior but later this trend reduced. In the end, they reverted to pre-treatment levels.

Well, if pre-treatment levels of risky behavior are not worrying in HIV positive people, they must be even less worrying in HIV negative people. There have been other studies like this one, also giving the impression that levels of unsafe sexual behavior are fairly low. Not that anyone has produced data showing what could count as normal and what could count as high when it comes to sexual behavior.

Not only that, even those who talk about high levels of unsafe sex don't really show that levels really are higher than elsewhere. Nor do they appear to have any reliable data to show that higl levels of unsafe sex occur more in African countries, nor in countries and regions where HIV prevalence is high.

It can be odd listening to people talking about HIV because they appear to consider the issue important, but also, in a sense, unreal. For a start, they always talk about sex, especially illicit and unsafe sex. It's as if some sex, most sex, if they are to be believed, falls into that category, while a small amount does not.

But as to what constitutes a lot of sex, no one I have asked can really say. It has been suggested that people who are HIV positive have at least one different partner a week, perhaps more, but these are just assumptions. As to why it is even assumed that some people have so many partners, and I'm not doubting that some people do, it often seems to relate to the perceived number of people who go to bars and drink alcohol.

But the Ugandan study does confirm one thing; levels of unsafe sexual behavior are not, in general, high. They probably never were. There has never been evidence of a glorious time before the HIV epidemic, when hardly anyone engaged in unsafe sex. Nor for a time when levels of unsafe sex rocketed, allowing HIV to spread rapidly. Nor for a time when all this subsided and HIV transmission rates began to decline to present levels.

Other research leads to similar conclusions. The five yearly Demographic and Health Surveys show that those who engage in risky sex are often less likely to be infected with HIV than those who don't. Trials such as the CAPRISA microbicide trial showed that the majority of people had a few sexual experiences a month and most of them only had one partner.

The Uganda study also found that use of condoms among HIV positive people increased after they started treatment. This may well be, as claimed, due to 'incraesed counselling intensity'. But condom use wasn't very high to start off with. As a minimum, you would expect people being counselled and on treatment to take some extra precautions.

However, a substantial proportion of those most likely to transmit the virus still don't wear condoms. It's hard to know if the 'intensive counselling' really has all that much effect. And when you look at sexual behavior among HIV negative people, the many years of HIV prevention interventions look even less impressive.

But the article is 100% about sex. There is never a hint that transmission may occur through any other route. Non-sexual routes to HIV infection may well have been talked about earlier on in the epidemic and, in the case of Uganda, steps may have been taken to reduce their impact. But now sex has completely taken over.

The fact that the HIV industry is attributing declines in transmission to HIV prevention programs that only started a long time after the declines suggests that they don't know why transmission declined. They don't seem to know how to reduce transmission and they don't even seem too bothered by that.

If we still don't know why HIV spread and subsequently declined, after thirty years of research, then nor do we know what to do if transmission rates begin to increase again. Don't people find that frightening? UNAIDS' claim that Uganda's epidemic is driven by low risk sex is not credible.


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