Sunday, June 5, 2011

The Myth about HIV and Sex: 30 Years in the Making

Today marks the 30th anniversary of the discovery of HIV. When the virus was discovered, it was still being transmitted rapidly in high prevalence countries, mostly in Africa. But over the ten years or so following its discovery, transmission declined, even in high prevalence countries. In Kenya, incidence peaked in the early to mid 1990s, almost a decade before the government even admitted that there was a HIV epidemic there.

Similar patterns are found in other countries. HIV incidence peaked before most people had even heard of the virus, many years before in most countries in Africa. So why did the virus decline? Because people who had spontaneously begun to have outrageous amounts of sex in the late 1970s and early 1980s, just as spontaneously ceased to have such outrageous amounts of sex in the late 1980s and early 1990s, and that trend continued up to the present?

That's what the HIV industry would have you believe, anyhow. For them, something like that story is true, although they don't ask why people would suddenly and profoundly change their sexual habits twice in the space of less than 20 years. And they don't allude to the fact that incidence, the yearly rate of new infections, peaked and declined long before mass HIV 'prevention' campaigns even started.

Thirty years ago, it was still permissble to talk about there being several ways for HIV to be transmitted, especially in a rich country context. After all, it was hardly ever transmitted through heterosexual sex in rich countries and it is even less so now. In rich countries, HIV was always transmitted mainly through men having sex with men and intravenous drug use. But talk of non-sexual transmission has declined significantly over the last 30 years.

In African countries, HIV was first noticed to reach massive levels in sex worker populations. In Kenya, prevalence is said to have reached over 80%, in Tanzania, over 70%. And this is in populations where hardly any men were infected. The fact that these ridiculous and completely unacceptable levels were found in sex workers who had been put through sexually transmitted infection (STI) programs has since been conveniently ignored. As I said, talk about such things has declined.

Fingers have been pointed, but in rich countries those fingers were pointed at men who have sex with men and intravenous drug users. Sex workers were also implicated but it's hard to see why because HIV rates were always low, except among sex workers who were also intravenous drug users.

But in African countries, fingers were pointed at men who have sex with men, commercial sex workers, truckers, soldiers, police, prisoners, internal migrants, migrant workers, internally displaced persons, fishing populations, those who engage in 'cultural practices' (such as wife inheritance, ritual cleansing, etc), teachers, 'sugar daddies', clients of commercial sex workers, partners of men who have sex with men, uncircumcised men, circumcised women, polygamists, bigamists, alcohol users, khat chewers, (non-injecting) drug users, sex tourists, Ugandans, young women and girls, older men who marry younger women, and the list goes on.

Most of these groups are still considered to be 'most at risk' populations or 'MARP'. And yet, modes of transmission surveys show that in African countries, the biggest groups of HIV positive people engage in low risk sex. Those surveys completely ignore the fact that many HIV positive people don't engage in sex at all, or hardly at all, those who take precautions are often more likely to be infected than those who do not and various other details which don't fit into the picture of the sexually animalistic African that UNAIDS has built up over the years.

UNAIDS often bandies about authoritative sounding figures, such as that 80% (sometimes even 90%) of HIV in some African countries is heterosexually transmitted. But it's interesting to see what these modes of transmission surveys are based on. There is an oft cited article that seems to have a disproportionate influence on HIV policy documents by Eleanor Gouws and others but this is based on a simplistic piece of mathematical modelling with some highly questionable figures.

If you don't believe that the mathematical model is simplistic and that the figures are questionable, you can download it and play around with it. You might be struck by the transmission probability per risky exposure act, for example. The risk for sex workers is dubious, but the risk for clients, at half the risk for sex workers, is even more so. And the risk for clients' partners is the same as that for sex workers, as is that of various other groups.

The risk for casual heterosexual sex, partners of those who engage in casual heterosexual sex and low-risk heterosexual sex is questionable enough as well. And only 10% of the population are deemed to have no risk from their sexual behavior. That's in African populations, of course! As I've said, heterosexual sex poses little or no risk to people outside of a few African countries, even in certain parts of some high prevalence African countries (such as Zanzibar and Kenya's North Eastern Province, where prevalence is lower than in a lot of US cities).

But the most laughable parts of the model relate to risks from unsafe medical injections and blood transfusions. Gouws estimated these risks to be very low, contributing less than 1% of all infections. UNAIDS ups that figure to a little over 2% when you add unsafe injections and unsafe blood transfusions together. However, this ignores any other kind of medical risk, such as from contaminated gloves, instruments and machinery of various kinds in sub-standard hospitals, wielded by poorly trained, underequipped personnel. (You can try plugging in some of the figures from here, or just make some up. UNAIDS did.)

Anyhow, the transmission probability per risky exposure act for these two items is absurd. You can try the model with a more reasonable value, even if it's just the figure for injecting drug use, and you get a far more credible estimate for the contribution of unsafe healthcare including, but not limited to, unsterile injections. And if you change the number of injections per year to something more reasonable you will also see the contribution of these non-sexual transmission modes rocketing up.

Looking at figures provided by the Kenyan Demographic and Health Survey (or the Tanzanian one, or that for many other African countries) you would be forgiven for thinking that females tend to become infected first and later infect their male partners. Far more females are infected than males, they are infected at earlier ages and rates exceed rates for males until many years of sexual activity have passed. In some population groups the number of females infected can exceed the number of males infected by 4 or 5 to one.

Does this mean that HIV is not almost always heterosexually transmitted? Certainly not. Nor does it mean that non-sexual transmission, such as through unsafe healthcare, is high, let alone higher than heterosexual transmission. It means that we don't have the faintest idea how high non-sexual HIV transmission is, relative to heterosexual transmission. And if you are puzzled at the fact that HIV prevalence is highest among young heterosexual women in a few African countries, and virtually nowhere else in the world, then you are awake (and almost certainly not working for UNAIDS or any of the HIV industry).

And yet, not only are men who have sex with men and intravenous drug users hardly ever targeted in high prevalence countries, but sex workers are not even targeted consistently in most. 'Prevention' spending represents less than 25% of HIV spending in countries like Kenya. How much less is unclear because about 80% of that is spent on unspecified prevention activities. In other words, no one has a clue what it's being spent on and they probably don't care  Even youth are not a particularly lucky group, receiving only about 5% of prevention spending. And that shows. Over 70% of infected youth in African countries are females.

And who infects them? Well, if 80% (or 90%) of transmission is heterosexual, men, of course. But which men? UNAIDS and the HIV industry can't say. Give them another thirty years of highly distorting funding and they may modify their answer. Some patterns may be consistent with HIV being sexually transmitted, but this does not mean that it always is. And some patterns are consistent with HIV being transmitted in STI clinics and other medical facilities.

But read around the data on non-sexual HIV transmission, especially unsterile injections, and you'll find that there is "Very little information on injections safety" and that it is "hard to get baselines". In fact, there is "no data about the quality of service provision". This is also a good time to look at the latest Service Provision Assessment for Kenya, which won't tell you as much about quality as it does about quantity.

The Modes of Transmission conclusion about service provision is brief, but telling: "in the future, Kenya will have to spend more time and effort analysing and assessing the quality of services provided – providing a bad service (particularly in the sensitive areas of sexual behaviour) may be worse than not providing a service at all."

What could this mean? Could it mean that the many people who do not have access to any health facilities might thereby be avoiding infection with HIV, hepatitis and various other diseases? Could it mean that people who get large numbers of injections in STI clinics every year, for STIs, hormonal contraception, etc, might face a high risk of HIV and other infection there?

HIV prevalence figures in both Kenya and Tanzania tend to be lower in areas where people have little or no access to healthcare. Unprotected sex tends to be more common in those areas. It doesn't take a genius to work out that HIV is not all about sex, but also that it could have an awful lot to do with unsafe healthcare. If even UNAIDS could inadvertently come to that conclusion, anyone can. But now it's time for UNAIDS to do what they have avoided doing for so many years: empirical research into the relative contribution of non-sexual HIV transmission in high HIV prevalence countries.



Mike Hersee said...

The serious flaws in the claims of sexual transmission are well overdue for discussion. However, you seem to have great difficulty in conceiving that the much-vaunted tests may not be as reliable as they are cracked up to be. Were you not aware that at least one '4th Generation' test (Murex) would produce 92% false positives among black people according to a researcher from the UK's Health Protection Agency? And other manufacturer's test, used for confirmation in the UK, that the manufacturer's insert said should NOT be used for confirming an HIV diagnosis, and also admitting that black people will produce a higher rate of false positives? (Immunocomb). And what about the challenges to the fundamental validity of all HIV tests, in that none of them have ever been properly validated against HIV at all? Are you not aware of just how many other factors have already been documented to trigger false positives - such as pregnancy, or having had multiple pregnancies? If you really want to help people I think it's time your research went a little deeper, which means you might need to be prepared to sacrifice some sacred cows, metaphorically speaking.

Simon said...

Hi Mike, I don't remember discussing tests, nor do I know very much about them. But I'll be on the lookout for research on the subject from now on. I'll take care only to sacrifice metaphorical cows, if any. Thank you for your comment.