Sunday, January 16, 2011

What Do UNAIDS Call a HIV Positive African? Promiscuous

To continue yesterday's theme about the difference between HIV in Western countries and HIV in high prevalence countries, most of which are in sub-Saharan Africa (SSA):

Treatment with antiretrovirals (ART) is widely touted as a type of HIV prevention because if people are responding to ART their viral load should be low and they should be far less likely to transmit the virus.

In Switzerland, in particular, HIV positive people on ART have been told that they could have unprotected sex and that the risk of transmission would be very low.

However, in SSA countries, people are not given the same advice. But also, it has been suggested that people who are on ART could experience 'disinhibition'. They could engage in higher risk sex because they think their treatment means they are less likely to transmit the virus.

Conditions in SSA are very different from those in Switzerland. For a start, perhaps a majority of people, certainly a lot of people, don't know their HIV status. When it comes to preventing sexually transmitted HIV, the more precautions people take, the better.

Even those who promote the rather unconvincing 'treatment is prevention' strategy admit that if treatment results in significant disinhibition, the modeled reductions in transmission will not occur.

So far, so good. It could be argued that conditions are so different in SSA and in Switzerland that the advice given to HIV positive people on ART should also differ.

But many articles have come out about how disinhibition doesn't occur in SSA countries. And at the same time, articles have also come out about how it does occur in Switzerland.

It would be very convenient if levels of disinhibition in SSA were not high enough to cancel out gains, but it also sounds a lot like wishful thinking. Especially if, in practice, disinhibition does occur in Switzerland.

The orthodox line about HIV, a virus that is difficult to transmit sexually, is that over 80, perhaps over 90% of it is transmitted through heterosexual sex in African countries.

In wealthy countries, the virus is usually transmitted through anal sex or through intravenous drug use. It is not much transmitted through heterosexual sex.

We are supposed to believe that, despite the difficulty of transmitting HIV through heterosexual sex, Africans do so because they have such exraordinary sex lives. But if they have these extraordinary sex lives, why is disinhibition so unlikely?

As I say, probably wishful thinking. Which is not really a good basis for a HIV treatment strategy, and even less so for a prevention strategy.

In countries where hundreds of thousands or even millions of people are infected with HIV, so many will not know their status and so many will not be on treatment even if they need it, treatment and prevention need to continue to be driven by separate initiatives.

There is little point in putting more and more people on treatment and hoping that they will adhere to the drug regime as they need to, supposing their supply of drugs even keeps up with their needs, unless efforts are also made to reduce the incidence of new infections. Drugupplies are often too unreliable to ensure that viral load will always be kept low.

But many people, also, are not being infected sexually. This means that they will not know what risks they are facing when they visit health facilities or anywhere else they may be exposed to contaminated blood or bodily fluids.

It is popular to talk about the need to test as many people as possible and to test people as often as possible. Despite this, most people have never been tested and the ones that have been, have only been tested once.

Testing on its own is not enough. It also needs to be established, for each person who becomes infected, how they are infected. The fact that they are sexually active does not mean they were infected sexually. Many people are sexually active and some of them become infected with HIV, but their partner is not positive. This means they were probably not infected sexualy.

It may take a bit of work to establish how people were infected, especially as most people will blame their own sexual behavior because they have the heterosexual theory of African HIV transmission drummed into them. But it is vital to take appropriate steps to reduce HIV transmission. Assuming that most transmission is sexual does not lead to appropriate steps.

In addition to testing and retesting, there needs to be an honest and creadible assessment of the risks people face and of all the likely routes to transmission. Those who are positive need to be assessed for treatment and those who are negative need to be made aware of all the HIV transmission risks they face, sexual and non-sexual.

HIV transmission rates are still very high in many countries. Transmission needs to be reduced. Treatment of those infected alone is not likely to reduce transmission enough. We have to keep our eye on non-sexual transmission as well as sexual transmission. Concentrating on sexual transmission alone, for example, by targeting discordant couples, is not going to protect them from non-sexual transmission.

All that remains now for HIV epidemics to be turned around is for UNAIDS and their HIV industry friends to lose their highly prejudiced views of African people and to treat Africans as they do their own employees and Westerners, who seem to be considered far more important than Africans.



Anonymous said...

I agree with the premise of your entire site regarding underdevelopment as a factor in HIV rates and transmission. Also, the idea that Africans are any more promiscuous than people in developed countries just works to reinforce racism, and the paternalistic attitudes that come with neo-colonialism. Because of Africans medical underdevelopment, would you agree that untreated and subclinical STI (NON-HIV) may be to blame for the disparity as untreated STI's create greater opportunities for HIV infection? I believe this is one of the greatest problems in dealing with HIV in SSA, that the health campaigns are not comprehensive enough dealing with co-infections, and focus on the monolithic HIV.

Simon said...

Hi, thank you for your comments. I think what you say is important and I'd like to deal with it in a future post, probably in the next few days.

In brief, I think the role of STIs in HIV epidemics has not been clearly demonstrated and there have been conflicting reports, especially where tests with treating STIs as a HIV prevention intervention have been carried out.

I think very high levels of STIs are a symptom of a poor health service that has been declining for decades. Concentration on HIV has often meant that STIs have been ignored, so this has added to the serious STI epidemics that have developed.

But because health services are so poor, taking steps to reduce STIs could have the effect of spreading HIV! If health services are quite unsafe, as I and others believe they are, people are taking a bigger risk in visiting a health facility than they are in having unprotected sex with someone who is HIV positive.

This may explain why such high percentages of sex workers were found to be HIV positive in earlier years of the HIV epidemic. They were herded into STI clinics where injecting and other equipment was contaminated with HIV. This is probably still going on, but perhaps to a lesser extent.

And I certainly agree that trying to eradicate HIV while ignoring all other health and development issues has not worked, has even been counterproductive, and will never work.