Sunday, April 24, 2011

Public Money Pays the Piper, So Why Do Big Pharma Call the Tune?

Every now and again I read UNAIDS' publications. Not just for the pretty pictures and diagrams, but because I hope that some day they will play a different tune. Mainly, I want to hear that they have modified their claim that 90% of HIV is transmitted through heterosexual sex. That was the figure that appeared in a draft of their 'Getting to Zero' 2011-2015 Strategic plan. In the published version, the figure is 80%.

But that's not really a modification. They just got it wrong. The official line has for a long time been that 80% of transmission is from heterosexual sex and almost 20% is through mother to child transmission (MTCT). Men having sex with men and intravenous drug users, it appears, make a negligible contribution to high prevalence epidemics. In fact, most HIV transmission is said to result from what is essentially low risk sexual behavior. Which is strange, for a virus that is difficult to transmit through penile-vaginal sex.

UNAIDS' claim to use a 'Know your Epidemic, Know your Response' methodology is flatly contradicted by their claims about heterosexual and other modes of transmission. They don't know their epidemics and nor, we can safely conclude, do they know their response. That's why they have failed to have much impact on transmission rates.

Oddly enough, the plan doesn't mention abstinence, ABC or any of the other rubbish that has filled so much of the official literature. In fact, prevention by useless strategies appears to have been replaced with prevention by wishful thinking. Instead of admitting that hardly anything has been spent effectively on prevention since UNAIDS was established, they are implying that treating people is preventing HIV transmission.

In truth, antiretroviral treatment can reduce transmission, but on its own it is unlikely to reduce it very much. Indeed, many of the figures that 'support' various claims made by UNAIDS about heterosexual transmission are years out of date and are assumed or modeled figures, they are not drawn from empirical research. Therefore, UNAIDS also undermines its many claims that their strategic plan is 'evidence-based' or 'evidence informed'.

One area of HIV transmission that presumably fits into the 2% category is non-sexual transmission, through unsafe healthcare, unsafe cosmetic practices, etc. The WHO, in the last year or so, has admitted that an estimated 40% of injections in African countries are unsafe and the organization accepts that at least 5% of HIV infections could come from such unsafe injections. This estimate is for a region, not for any particular country. The figure for some countries is likely to be a lot higher.

Despite claiming that HIV transmission from unsafe injections is very low, UNAIDS warns its employees and those of the UN as a whole to avoid medical facilities that are not UN approved, as I mentioned yesterday (and on other occasions). If there is a risk for UN employees, there is a risk for non-UN employees. So why the discrepancy between the WHO's figures and those of UNAIDS, and why the warning for UN employees but not for ordinary people?

The whole Strategic Plan is similarly biased towards a behavioral view of HIV, whereby it is depicted as overwhelmingly a matter of individual sexual behavior. This is a dated view, it hasn't worked in the past and it is not going to work in the future. It is difficult to see how this Strategic Plan differs materially from anything UNAIDS has published in the past. Most of the references seem to be to UNAIDS publications or similar.

Finally (although there is little positive that one could say about the Plan), it states that "investment in HIV is critical for the strengthening of health systems and achievement of the MDGs." On the contrary, investment in health systems is critical for the treatment and prevention of HIV. Claiming that money spent on HIV is money spent on health systems is neither honest nor based on empirical evidence.

One only need take a cursory look at Kenya's Service Provision Assessment (or the SPA for any other high prevalence country) to see how unprepared they are to play any part in preventing HIV transmission, especially nosocomially transmitted HIV. And they are equally unprepared to treat or care for HIV positive people adequately.

UNAIDS need to pay a little less attention to what politicians, religious leaders and industrialists think they should do and pay a bit more attention to HIV, a blood-borne virus that is sometimes transmitted sexually, especially through anal sex. They have sold enough drugs for the friends in the pharmaceutical industry and it's time to address the one disease they were established to eradicate.



Matthew Black said...

Hi Simon,

Interesting post as usual. I agree that the pressure (finance) for action does not necessarily fit with the needs that are there. Strategic development in the world of HIV & AIDS is also painfully slow and inflexible. However, I am not convinced by the unsafe injection argument, or indeed the implication that heterosexual transmission is not the primary driver. I found this document quite informative

For me, mutual knowledge of status within partnerships (addressed along with the accompanying complex power dynamics) is the key for large scale gains in lowering transmission. Admittedly this does not reach certain high risk populations and here you have a point that better directed and focussed strategies are needed for MSM and IDU.

It would be good to see some more recent SPA data. I don't know how often that survey is conducted, but there should be something about.

It's an interesting debate. Keep up the good work.

Simon said...

Hi Matthew, thank you for your comments. I have replied to them in detail in today's post.