Saturday, December 31, 2011

Are UNAIDS Really Giving Good Advice to Malawians?

This could be a good time for condom manufacturers to get involved in large scale HIV prevention campaigns in African countries. After all, it must represent a huge market. But the figures for HIV prevalence among condom users are not always very encouraging. In fact, reported condom use often seems to be associated with far prevalence than those who claim not to use them.

The latest Demographic and Health Survey for Malawi is a case in point. Among women who had ever used condoms, HIV prevalence was 20.3%, whereas among those who never used them it was only 13%. Among men who had ever used them, prevalence was 11.8% but among those who never did was only 5.8%. Those are substantial differences.

Similar trends are found among men who have paid for sex in the last 12 months. Among those who ever used condoms, prevalence is 11.5% but among those who never did it was 4.1%. Even those who did not pay for sex in the last 12 months had far higher prevalence than those who did pay for sex and did not use condoms (or did not have sex in the last 12 months), at 9.3%.

Why does condom use seem to be associated with far higher HIV transmission rates in many African countries? We know they work to reduce sexual transmission of HIV and other sexually transmitted diseases, so what could be going on in Malawi? It seems surprising that condom manufacturers are not taking a careful look at these figures.

The report also finds that: "Among respondents who have never been married, the HIV prevalence [...] 2 percent for those who have never had sex. This suggests that some women and men incorrectly reported that they were not sexually active, or that there is some degree of nonsexual HIV transmission occurring (e.g., through blood transfusions or non-sterile injections)."

Granted, some people forget, lie, or misreport, in Malawi and everywhere else. But even those who have reported high levels of 'unsafe' sexual behavior are just as likely to have been infected through some non-sexual mode of transmission as those who have never had sex. After all, sexual transmission is less efficient than many non-sexual modes.

HIV rates by circumcision status also appears to be very mixed. In almost every age group, HIV prevalence is higher among circumcised men and overall prevalence stands at 10.3% for circumcised men and only 7.6% for uncircumcised. Given that a lot of Malawian men are not circumcised, let's hope the circumcision enthusiasts figure out exactly what's going on here before rushing in and carrying out an operation that doesn't decrease transmission and may increase it. There are already claims that about 250,000 Kenyan men have been circumcised to 'reduce' HIV transmission.rends

There are also the trends that you will find in other high prevalence African countries. For example, prevalence is far higher among women, roughly a 60-40 split. When you consider that most of the high risk groups that don't involve sexual transmission, intravenous drug users, men who have sex with men and prison populations, are almost all men, it makes you wonder how women can face such high risks.

Prevalence is twice as high in urban areas and varies a lot between different regions and different tribes. Prevalence also varies considerably among religions, with Anglicans having the highest prevalence, Catholics the lowest and Muslims somewhere in between.

Higher or lower levels of education are not clearly associated with HIV prevalence, with almost the same rates among those with no education and those with higher than secondary level. Employment status is a lot clearer, with rates being far higher among employed people than unemployed people.

As is often the case in high prevalence countries, wealth appears to be highly positively correlated with HIV prevalence. This is especially the case for women, where prevalence among the lowest quintile is 8.9%, rising steadily to 19.7% among the highest quintile. For men, the figures are 5.6% rising to 10.8% in the highest wealth quintile.

I'm all for promoting interventions that work and condom use is one that certainly does work to reduce sexual transmission of HIV. But there are always figures in Demographic and Health Surveys that make one wonder what proportion of HIV really is transmitted sexually and what proportion is transmitted through other routes. Many of the figures for Malawi, though, seem to suggest that a lot of HIV industry advice is really not very effective.


Wednesday, December 28, 2011

AgriSol in Tanzania: Land-Grabbing or Outright Theft?

Tanzanians and other Africans seem to be worrying a lot about reductions in foreign aid and what conditions will need to be met in order to receive whatever is available. But they don't seem to be paying much attention to the fact that land is being grabbed by foreign multinationals at a rate that involves far higher sums of money than foreign aid.

The Oakland Institute has investigated AgriSol's dirty deals in Tanzania and though they have been found wanting, they appear to be going ahead. Many Tanzanians suffer regular food shortages and poor diet but Agrisol intends to use huge tracts of land and substantial amounts of water to produce biofuels and genetically modified crops for export.

Aside from needing land and water to produce food and other things, Tanzania is not yet prepared for genetically modified organisms. Even if they have some kind of regulation, probably regulation that suits the likes of AgriSol more than it does Tanzanians, the country is unlikely to have the capacity to enforce appropriate regulation any time in the near future, which should suit the GM industry.

AgriSol and others involved in these land-grabs like to claim that the land is marginal and/or underutilized, even uninhabited, none of which are true. Biofuels and genetically modified crops, despite claims to the contrary, need water and fertile soil. So AgriSol want to bribe (or whatever the current nomenclature is) their way into 800,000 acres of fertile land which is inhabited by over 160,000 people.

Of course, AgriSol also claim they will be enriching Tanzania and the local communities who will be effectively dispossessed and displaced. AgriSol will not allow such matters to get between them and hundreds of millions of dollars profit. So they need the assistance of public relations experts, legal experts and, of course, political allies. And with that amount of money to be made, this assistance should be readily available.

The Oakland Institute have published eight myths they have identified about land-grabbing, and in particular about this current AgriSol intrigue. The first is that the land is not being used, which most land-grabbers claim. The land is inhabited by displaced Burundians, some of whom have been there for nearly 40 years, having been originally displaced by war.

AgriSol also claim they are not involved in the displacement of Burundians, which they say started independently of their efforts. This claim does not stand up to scrutiny. Their claims about cooperating fully, consultations, transparency and the like are also untrue. All the big land-grabbers claim that Africans will benefit, AgriSol being no exception, even taking steps to ensure that they can export food crops at times when there is a lack of food security in the country involved.

Indeed, AgriSol will be looking for a tax exemption and they will want to receive input subsidies that are currently destined for Tanzanians. So much for private enterprise eschewing subsidies! AgriSol go through the usual sanctimonious posturing about environmental responsibility, which simply doesn't add up for either biofuels or genetically modified organisms, which are both extremely destructive to the environment.

Very small numbers of people will be employed by AgriSol's scheme and fewer still are likely to be Tanzanians. And the amount of 'rent' they will be paying is a derisory one tenth of a dollar an acre for a 99 year lease. Good agricultural land costs in the region of millions of dollars, so it's not clear how rental revenue will even cover the costs of the paperwork.

The Oakland Institute unearths many disturbing things about AgriSol and the various well connected people involved, who seem to be more scrupulous about maximizing earnings than anything else. Sadly, there will be a few in Tanzania who will be able to pick up a nice fee for selling their friends and families. But Tanzania as a whole and ordinary Tanzanians will lose a lot more than they stand to receive in donor funds, no matter what conditions they agree to.


Thursday, December 22, 2011

Why Are Westerners So In Love With Circumcision For Africans?

Daniel J Ncayiyana, the editor of the South African Medical Journal, presents a rarely heard view in a professional medical journal: he is critical of mass male circumcision campaigns that make claims to reduce HIV transmission, by widely varying amounts. In fact, it is rare to hear someone in such a position criticizing anything to do with theory (and hence programming) relating to HIV in Africa.

Despite the often vast claims of Western proponents of voluntary (so they say, anyhow) male circumcision, Ncayiyana opposes this as a strategy, finding the evidence mixed, sometimes exaggerated and never completely convincing. Perhaps the claim that "'Male circumcision is the most powerful intervention we have at this point in time" should be interpreted as reflecting the lack of success in other areas of HIV prevention, rather than the effectiveness of circumcision?

Enthusiasts of circumcision seem to forget that if they diminish the potential effectiveness of other prevention strategies, people may get the impression that circumcision on its own is effective, which it is not. All trials of male circumcision consisted of a combination of prevention strategies, including condom use. If circumcision results in a reduction in use of other prevention strategies, sexual transmission of HIV from females to males could increase.

Of course, male to female transmission, which is far more common in African countries, will not be reduced by male circumcision; it may even be increased. This operation, which is ostensibly aimed at couples who tend not to use condoms (and other groups), sounds like it will fail to reduce transmission in the very contexts where reduction is most needed. So far, the various pronouncements about circumcision seem to have produced little but confusion.

Ncayiyana mentions the fact that prison services in South Africa report a "near-stampede" by inmates demanding circumcision (though this may be another exaggeration), who seem to think the operation will protect them against non-heterosexual, perhaps even non-sexual HIV transmission. There is simply no evidence that circumcision protects against male to male transmission, or even male to female transmission where anal sex is involved.

One of the most puzzling things about female to male sexual transmission of HIV is that it occurs so much in African countries. Counterintuitive as it may seem for a virus that is claimed to be almost entirely sexually transmitted, female to male transmission hardly ever occurs in most Western countries. The bulk of transmission is from men having sex with men and intravenous drug use. Even the percentage of female to male transmission estimated in Western countries may fail to exclude cases where people were not altogether frank about the risks they have faced, or where health professionals failed to report all the risks.

While criticizm of circumcision is not often cited, there is some published criticizm, some of which Ncayiyana alludes to. He even alludes to the lack of certainty about the relative contribution of heterosexual transmission, as opposed to other sexual and non-sexual modes of transmission. And he notes that arguments for adult male circumcision have been used as arguments for new-born babies, which is simply ridiculous.

Van Howe and Storms put it succinctly: "It is not hard to see that circumcision is either inadequate (otherwise there would be no need for the continued use of condoms) or redundant (as condoms provide nearly complete protection)." It is not hard to see, but the calls for tens of millions of men (and perhaps even more babies) to be circumcised to reduce HIV keep coming in. Even Bill Gates has forked out $50 million for circumcision.

One of Ncayiyana's main worries is that all this attention for circumcision will take attention away from HIV prevention strategies that work, at least to some extent, such as condom use. If sexual behavior needs to change, circumcision is unlikely to have much long term impact on this. If men's attitudes towards women need to change, as we are so often told they do, circumcision is not going to bring this kind of change about. And the list goes on.

I don't have as much faith as Ncayiyana seems to have in condom use, however combined with partner reduction and the like. I think they may all be useful when it comes to reducing sexual transmission or HIV, but this will not shed light on non-sexual transmission. Non-sexual transmission through unsafe healthcare, cosmetic practices, traditional medicine, tattooing, scarification and oathing may be rare, as UNAIDS claims. But UNAIDS may be wrong, they haven't checked yet. However, circumcision seems like more of an unwise leap of faith than a genuine HIV transmission prevention strategy.


Saturday, December 17, 2011

What the US Presidential Commission for the Study of Bioethical Issues Doesn't Say

The Presidential Commission for the Study of Bioethical Issues (PCSBI) has just published a report commissioned as a result of the 'discovery' of the Guatemala syphilis experiment in the 1940s, which involved infecting unsuspecting people with syphilis and other diseases for the purpose of scientific research. A lot of people were infected and many died as a result. Some of those running the Guatemalan study later took part in the Tuskegee Syphilis experiment, which continued into the 1070s.

The PCSBI wanted "assurance that the rules governing federal research today adequately guard against the abuses perpetrated by the U.S. Public Health Service" and "that current rules protect people from harm or unethical treatment, no matter where in the world U.S.-supported research occurs.". The assurance is forthcoming, in a rather limited sense, and there are many recommendations that still need to be met.

As a Public Library of Science blog notes, the report is about federally funded research, not research carried out by Big Pharma or other industries, nor even that carried out by NGOs, which probably constitute the biggest proportion of trials involving human subjects. Therefore the report is not really very reassuring at all. Outrages such as those that occurred in Guatemala and Tuskegee might occur elsewhere; they could even be occurring right now, with the knowledge of the US and other governments.

I attended part of a training course to teach rural albinos and carers of albinos about income generation schemes, planning, budgeting, etc, and becoming involved in community level savings and loans schemes. It's interesting how much effort the trainer needed to put into starting off with very basic concepts and repeating them throughout the week. Many had only a few years of primary school and had rarely used their reading or writing skills since leaving school.

So I always wonder when I hear terms like 'informed consent' and how they work in such a setting. What level of understanding do people have of complex drug regimes and other matters if they have little or no basic literacy? Many drugs come with instructions that presuppose a level of literacy that may not have been attained by all, or even most participants in some types of research. Is it enough to have a set of signatures from people involved, even if the form they are signing is written in their mother tongue?

I have blogged elsewhere about the Rebecca Project, which has published a damning report on non-consensual research in African countries, showing that such things may not happen in the circumstances described by the PCSBI report but they do still happen. David Gisselquist of the Don't Get Stuck With HIV website and blog has also written a comprehensive review of unethical and illegal research that has taken place in African countries.

It's a pity the PCSBI kept their brief so narrow because now we have no idea who, if anyone, will carry out similar research into non-federally funded research and when this might happen. The last thing we need is for the industry to fund the research itself. Given what is available to us about their ethical standards, we can be forgiven for not expecting much better from that which is unavailable.


Wednesday, December 14, 2011

Kenyan Doctors Worried About Safety in Health Facilities

A doctor working in the South West of Kenya finds conditions in health facilities very difficult and says that "Basic provisions like gloves and syringes are constantly out of stock". While this sort of thing is attested in reports such as Kenya's Service Provision Assessment and Tanzania's Sikika reports on levels of supplies and personnel, it's often unclear how health professionals cope with such shortages. Do they send patients home, reuse what is available to them or what?

Dr Lucy Ngina says that "We are always sending patients to buy their own syringes, needles and even bags for intravenous fluid." But she sometimes has to make do with gloves that are too large, for example, risking her own safety and that of her patients.

Although billions of dollars have flowed into HIV related services in African countries, spending on health in general has not increased in the last ten years and the number of healthcare personnel has remained static, although the population has increased at a rate of 2.5% per year or more in Kenya.

Apparently the Kenyan health system is "one of the most dangerous in the world, producing the worst outcomes as measured by mothers and babies who die during childbirth." It may be dangerous in other respects but more attention is paid to certain indicators than others. It is likely, for example, that TB, hepatitis B and C and other transmissable diseases are commonly transmitted in health facilities. But it is less likely that anyone is collecting much data on these phenomena.

One of the problems mentioned is the way big donors, such as the US aid agency (USAID) and the Gates Foundation, tend to concentrate on the 'big diseases', which already receive a lot of attention from other quarters. Many other diseases, often treatable and preventable, are ignored.

Another problem is 'brain drain', which can refer to health personnel qualifying in developing countries and choosing to work in wealthy countries; trained personnel being recruited into the ever-expanding private health sector; or it can refer to wealthy countries' going to developing countries to recruit the best qualified candidates they can find and persuading them to work in the West. Recent calculations may exaggerate how much this costs developing countries in monetary terms but it's probably impossible to calculate how much it costs in terms of human sickness and death.

Doctors currently on strike in Kenya are not just demanding better pay, they are also demanding better working conditions for the sake of their health and the health of their patients. Modern medicine is great when it is properly funded and safely administered. But poor and unsafe conditions can render health facilities even more dangerous than no health services at all.

In countries with serious HIV epidemics, outbreaks in hospitals could infect hundreds, even thousands of people over relatively short periods of time; partcularly when none of the various HIV institutions are actually looking out for hospital associated HIV transmissions.


Sunday, December 11, 2011

Neglected Tropical Diseases: Neglected for a Reason

It's good to hear calls for 'neglected tropical diseases' to be addressed, rather than taking the sort of vertical (single disease at a time) approach that is favored by big institutions and by countries who allocate large amounts of money to health related development. But even some of those calling for this move are still pegging vital broader health issues to the extremely narrow HIV agenda.

People living in areas with a high disease burden, poor nutrition, poor living conditions and the like, are going to be infected with many diseases during their life, HIV being just one. This is not a recent discovery, nor is it very surprising. It is also not a surprising discovery that HIV positive people are more likely to transmit HIV if they are also suffering from other, easily treatable and preventable diseases.

So, the big missed opportunity is not one for HIV prevention and treatment alone, it is for health and development in general. Picking off a few headline diseases is little better than concentrating almost all attention on HIV. But making lasting improvements to living conditions, nutrition, water and sanitation, infrastructure, health systems and education are the real missed opportunities, without which HIV prevalence will remain high for a long time to come.

I hope the American Society of Tropical Medicine and Hygiene succeed in getting more general, non-HIV related health issues some attention and funding. But addressing health more generally, avoiding the 'silo' or 'vertical' approach, is probably the best way to treat and prevent HIV, also. Doing things the other way around has not worked and never will. If you see HIV as the problem and set up a parallel health infrastructure you will fail with most or all of the other health issues and this is unlikely to have much impact on HIV either.

But Walson and others put their finger on the very difference between HIV and other diseases they now hope to deal with, ones they refer to as 'diseases of poverty'; HIV is not a disease of poverty, at least, not to the extent that intestinal and other parasites, malnutrition related conditions, waterborne diseases and acute respiratory diseases are. HIV in African countries tends to concentrate to a disproportionate extent in urban dwelling, wealthier, better educated, more mobile populations.

From a commercial point of view, there just isn't much money in 'diseases of poverty', whereas there is a huge amount of money available for HIV; that's what makes HIV an entire industry, and diseases of poverty a mere development issue. In wealthy countries enough people can afford HIV drugs, despite the fact that they are grossly overpriced.

But even in developing countries, donors, up to now anyhow, have been interested in funding HIV. They're mostly interested in funding treatment because that's a lot more lucrative than prevention. But the word on the street now is that 'treatment is prevention', so even more money may end up being spent on this single disease. Though HIV treatment is not, in any useful sense, prevention, this is unlikely to worry those whose income comes from treatment.

Waterborne diseases, respiratory diseases and the like, those that kill more people than all the headline diseases put together, do not involve lifelong treatment with expensive drugs, which need to be replaced, eventually, with even more expensive drugs as resistance builds up. Some of the most ignored drugs are ones for which the treatment is a once or twice off occurrence and the treatment is dirt cheap. What self-respecting pharmaceutical multinational corporation wants to bother producing such drugs?

There is mention of the Gates Foundation but this institution has only shown token interest in anything but wealthy institutions and industries, with pharmaceuticals and genetically modified organisms receiving massive amounts of funding. Gates himself is not shy about promoting vaccines, preferably one for each disease, but he's a lot less interested in, for example, water and sanitation, provision of which could take care of a whole spectrum of diseases. Which is not to say he spends nothing on water and sanitation, just comparatively little.

People and institutions who wish to address various health issues because they reduce the quality of life and the life expectancy of hundreds of millions of people are to be encouraged, particularly if their 'success' is not going to be judged entirely by HIV related indicators. But HIV is not just highly funded because it threatens the livelihood, health and lives of so many people; just about all diseases fit into that  category. There's long been an obsession with HIV that may not be so easy to dislodge by a few public calls for change.


Friday, December 9, 2011

Gay Footballs: Obama and Cameron Aiming to Destabilize African Development Sectors?

The COP17 climate talks are taking place at the moment in Durban, presumably to create the illusion that the climate industry sees Africa as having a part in the negotiations. Natural resources continue to be plundered from any country unlucky enough to have discovered them, and the searches are still on for oil and anything else the West can get hold of cheaply. Land is being grabbed at an unprecedented rate so that multinationals can produce food and biofuels in countries that are also recipients of poverty reduction funding, and even food aid, to be sold in rich countries.

The Global Fund (to fight AIDS, TB and malaria) has suspended operations for two years, which will affect a lot more than just HIV programming; the HIV dominated development sector will see former recipients of Global Fund monies scrambling to 'reposition' themselves as big players in health systems, reproductive health, family planning, gender based violence, LGBT and gender issues and whatever else will save their skin. Some will probably even present themselves as experts in poverty reduction, education and climate change; they gotta go where the money is.

The development sector faces huge challenges, not just from issues like the ones listed above, but because many working in the sector are not wholly convinced that their aims are being met. Recognizing that something needs to be done about human rights, poverty, health, education, infrastructure and the like in developing countries is an important first step, one that most, perhaps all working in development have made. But I have met few who have found out exactly what needs to be done; I certainly haven't.

Having said that, I work with people who are involved in projects which, ostensibly, 'make things better', in the fields of health, education, water, vulnerable populations, etc. So I expect them to be concerned about development related issues, especially the ones that threaten development funding or that risk reversing any gains they might achieve through their work. But I haven't found a colleague who knows anything about genetically modified organizms (GMO), land grabbing, biofuels or climate change, except to the extent that they involve funds. Mention certainly needs to be made of 'sustainability', 'risk', 'environment', 'inclusiveness', 'equality' and the like, but that's the responsibility of the grant proposal writer (who happens to be me).

But recently my colleagues have started to talk about development funding, and not surprisingly, because all the newspapers are running the story; a particularly wealthy individual from a wealthy country has said his government (he is the prime minister) is considering withholding development funding to countries who have punitive homosexuality laws. This is a stupid and childish thing for a prime minister to say and he has been back peddling ever since. But the damage is done; all my colleagues can talk about is gays, and how they are being 'forced' to allow gay marriages and do all sorts of things that are against 'their culture'.

Now the US government is making similar noises. I heard one of my colleagues saying that we don't need their money, neither the US's nor the UK's. There's a sense in which he is very wrong, the obvious sense. But there is an important sense in which he is right; Tanzania does not need Western countries to set their agenda in return for relatively small amounts of money that don't seem to benefit the most needy anyway. Aid money already comes with strings, so adding some more strings is not going to suddenly allow some people to benefit, for example, gay people. In fact, these moves are likely to make things a lot worse for gays. It's as if the US and UK governments are using the issue of gay rights to goad African countries into stirring up anti-gay prejudices, knowing exactly the effect their 'threats' will have.

This is only partly about African homophobia. It's also about Western homophobia, in the sense that any mention of homosexuality is highly reportable and guaranteed to polarize views (and curiously distract attention from other issues?). It is such a powerful political tool that the most experienced spin doctor couldn't invent it. But why is this tool being wielded with such force right now? Is it because foreign aid is falling anyway and Western donors need something to hide behind, to deflect the inevitable blows? I'm no pundit and I can't answer those questions, but I would bet on one thing: these moves by the UK and US are themselves homophobic, are totally inimical to gay rights, globally, and they will only make things worse for gay people in African countries.


Wednesday, December 7, 2011

Absence of HIV Does Not Equal Health

The issue of health conditions stemming from intestinal parasites, such as schistosomiasis (bilharzia), and their connection with HIV, has come up a number of times on this blog. There has been research into how these conditions may increase susceptibility to HIV in populations where they are endemic, and how they may increase the likelihood of HIV positive people transmitting the virus, sexually.

Much of what has been written on the subject is not particularly new, and even a recent review of the literature may yet receive as little attention as all the papers reviewed therein. But perhaps one day those concentrating on sexual behavior will realize that it is mostly ordinary, everyday sexual behavior, not rampant and risky sexual behavior, that is behind the bulk of transmissions in countries like Kenya, Uganda and Tanzania.

In addition to the hotly disputed (but grossly underresearched) contribution of non-sexual HIV transmission to serious epidemics, the contribution of non-risky sexual behavior also raises questions for the HIV industry. It has been apparent for a long time that the largest sexual transmission contribution to HIV epidemics comes from monogamous, heterosexual couples. Why should penile-vaginal sex result in so many infections when the probability of such transmission is quite low?

The HIV industry invented some red herrings that suited their penchant for salacious theories, all of which turned out to have little impact on HIV transmission, or to be too uncommon to explain any more than a fraction of transmissions (which is not to say that they didn't contribute anything at all). Examples are female genital mutilation, vaginal douching, multiple partnerships, concurrent partnerships, etc.

So, the review in question looks specifically at urogenital schistosomiasis, which is widespread in many African countries. Despite being common, this disease is also easily and cheaply treated. Some might wonder why prevention and treatment have not been made available decades ago, but that is another long story.

It is possible that the best chance schistosomiasis has of being eradicated now is if the HIV industry thinks it might help reduce HIV transmission easily and cheaply, given that they have spent billions on expensive and relatively ineffective interventions, and are quickly running out of money. But they may find (relatively) cheap ineffective interventions, such as mass male circumcision, that are more to their taste, and genital schistosomiasis may yet remain common, however implicated in the spread of HIV.

Much of the research into intestinal parasites and HIV show that the two are associated, but does not show causation. But why should people with these diseases have to wait for a causal connection with HIV to be proven before they receive treatment, or before attempts are made to eradicate the disease? The same question could be asked about other diseases that either make people more susceptible to HIV or more likely to transmit it.

Besides, causation has not been demonstrated for male circumcision/lack of circumcision either, yet half a million operations are claimed to have been carried out in the name of HIV prevention (many of them among the Luo of Kenya's Nyanza province, where schistosomiasis is also endemic). Some association between circumcision and lower HIV prevalence may have been shown, but a similar association may exist between female genital mutilation and lower HIV prevalence without anyone advocating for FGM as a viable HIV prevention intervention.

People have a right to health. We don't need economic arguments about cost effectiveness or proof of a causal connection between genital schistosomiasis and HIV before implementing eradication programs for all the parasitic and other neglected diseases for which preventive and curative measures have long been available.


Sunday, December 4, 2011

Global Fund: It's Not Time to Give Less, It's Time to Take Less

Paul Boateng and Aaron Oxley argue that "Now is not the time to cut funding for HIV and Aids" in the English Guardian's Global Development section, which is prominently sponsored by Bill Gates (and who isn't these days?). The authors argue that cancellation of the Global Fund will reverse gains in combating HIV (TB and malaria). But first, is the Global Fund riding on a publicity wave that taps into gains that can not all be attributed to the Fund itself? And second, does Britain really give a damn about HIV or any other social issues in developing countries?

It is true that new HIV infections have declined over the last decade. But this trend was already well established when the Global Fund got going. The Global Fund and others, such as PEPFAR and the World Bank's MAP, may have hastened the trend, but it's difficult to say by how much. In addition, aids related deaths have dropped, which can be partly (only partly because death rates peaked as a result of epidemic dynamics, often before the big funds were established) attributed to large funds like the Global Fund paying for 6 or 7 million people (depending on your source) to receive life-saving antiretroviral drugs (ART); but at what cost?

The cost of providing 6 or 7 million people with ART, and that's a fraction of the people who need or will need the drugs, is far higher than it should be. These drugs are grossly overpriced under the protectionist policies of the World Trade Organization. The real beneficiaries of big HIV funding have been pharmaceutical companies. If the Global Fund and other big funders really wanted as many people to be treated as possible, they would divert some of their attention to getting genuine competition into the generic HIV drug industry. If ART was more affordable, bug funders could spend some money on effective prevention measures (if and when they get around to finding any).

But the big question is not really about how much donor countries 'put into' HIV, but how much they extract from recipient countries. The article authors point out that 2 billion dollars are needed, from all donor countries, not just from Britain, to meet current requests up to 2014. But just one example of how much is being extracted can be found in an article that appears in the British Medical Journal. The country that benefits most from poaching skilled medical personnel from African countries is Britain, at an estimated 2.7 billion dollars, with the US a distant second, at 850 million.

The value of getting your doctors trained abroad is many times the amount donated to the Global Fund, and that's just from poaching in the health services. Britain is also one of the biggest land grabbers; they receive a large share of the continent's natural resources and leave little behind; they grow many of their luxury crops in countries that they also send food aid to, thereby extracting water, food production potential and cheap labor, not to mention damaging local markets and denying people the right to determining the use of their natural resources and food supply.

I certainly wouldn't advocate reducing spending on HIV, or on development, but I would question how all this money has been spent. Firstly, systematically stigamitizing all Africans as promiscuous, while at the same time calling for a reduction in stigma, is self-contradictory. It's time to look at non-sexual HIV transmission; we know it occurs, we just haven't yet bothered to estimate its relative contribution to the most serious epidemics. Secondly, we will never be able to afford enough drugs at the grotesque prices demanded by pharmaceutical companies; their part in bankrupting the Global Fund needs to be recognized.

So Boateng and Oxley might be better advised to campaign for less to be extracted from African countries, rather than for more token payments to be made to the rather phallic Global Fund. The amount of money extracted from these countries is many times what they have ever received, albeit in the form of highly publicized, magnanimous acts. The few million who benefit from antiretroviral drugs is nothing compared to the hundreds of millions who suffer as a result of what Western countries take, rather than what they fail to give. The authors are right, now is not the time for giving less, it's the time for taking less.

[More about the 'extractive' tendencies of Western countries who make ostentatious payments to well publicized development funds.]


Thursday, December 1, 2011

World Aids Day: How is the Orthodoxy Faring Under the Stress of Evidence?

A recently published survey shows that national HIV prevalence in South Africa has hovered at just under 30% since 2004. The authors suggest that a lot more people are living longer with HIV because they are accessing antiretroviral treatment. This may be so, but not many South Africans were accessing treatment until fairly recently. What the figures also suggest is that a few hundred thousand deaths every year are also being matched by a few hundred thousand new infections.

There's a massive variation between provinces, ranging from just over 20% in Kwa-ZuluNatal to 3% in Northern Cape. There's also a huge variation among age groups, with highest rates among 15-29 year olds, but peaking among 20-24 year olds at just over 30%. Still, the 19% prevalence figure is astonishing for 15-19 year olds and is in need of explanation.

From less than 1% in 1990, HIV prevalence has increased rapidly, exceeding 20% in 1998 and reaching 25% in 2001. Prevalence has not fallen below 25% in the last 10 years. Rates in antenatal clinics are even more astonishing, reaching over 40% among 30-34 year olds. The highest rate of all, 46.4%, was found in Uthukela, Kwa-ZuluNatal.

It's something of a conundrum that so many more women than men are infected in South Africa and other high HIV prevalence countries, all of which are in sub-Saharan Africa. It's a conundrum because hardly any women are infected in Western countries, compared to men. One of the few female risk groups in Western countries is intravenous drug users. Even sex workers are unlikely to be infected unless they are also drug users.

So why is it that the opposite is true in Africa? Western women are infected through heterosexual sex, but in very low numbers. Yet in South Africa, most of the women infected are not intravenous drug users or sex workers. According to the HIV orthodoxy, they are infected through heterosexual sex, apparently penile-vaginal sex.

And most Western men are infected through receptive anal intercourse or intravenous drug use. Some may be infected through heterosexual sex, but not many. Far more men than women are infected because far more men than women face the most serious risks.

Indeed, in African countries, it could be asked how many men are really infected by women through penile-vaginal sex. Because the lower percentage of men infected also includes those who engage in receptive anal sex and those who are infected through intravenous drug use. Few women engage in intravenous drug use, though they face the same elevated risk of infection through anal sex as men who engage in receptive anal sex.

It could make one wonder just how many men are being infected through heterosexual sex, and how so many women are being infected by what amounts to a relatively small number of HIV positive men. Of course, you can add in the HIV orthodoxy special African spice of dry sex, concurrency, rampant levels of partner change, etc. But you might still wonder...

Then there are, in the same report, the figures for syphilis. From a high of just over 11% in 1997, when HIV prevalence was just under 20%, syphilis fell steadily to a quarter or even a sixth of that rate after 2000, and stayed there. Syphilis rates do not correspond with HIV rates, not even a little bit. Kwa-Zulu Natal has the second lowest rates and Northern Cape has the highest. Also, syphilis prevalence does not vary much by age.

You might be forgiven for thinking that the virus that is difficult to transmit sexually, HIV, must also be transmitted non-sexually, perhaps to a very great extent, since the relatively easy to transmit syphilis dropped at the same time as HIV was increasing, and stayed low, while HIV stayed high. Or you might immediately dismiss that idea, since it flies in the face of so much UNAIDS propaganda.

Either way, you might wonder if the same virus, HIV, could only infect those who take the biggest risks in Western countries, yet it seems to infect more of those who take the smallest risks in African countries. Or you might be a member of the mainstream press, and not wonder at all, not once in thirty years.