Wednesday, November 30, 2011

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.]


Tuesday, November 29, 2011

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.


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].

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.]


Sunday, November 20, 2011

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.]


Thursday, November 17, 2011

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.


Monday, November 14, 2011

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?


Thursday, November 10, 2011

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.


Wednesday, November 9, 2011

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.


Monday, November 7, 2011

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.


Sunday, November 6, 2011

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.


Friday, November 4, 2011

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?


Thursday, November 3, 2011

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?