Sunday, February 27, 2011

Paid to Fail: the Politics of HIV Research

I recently commented on a much hyped but relatively vacuous paper by Halperin, Mugurungi, Hallett, Muchini, Campbell, Magure, Benedikt and Gregson, entitled 'A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?'

But there was one item in the paper I didn't comment on that has stuck in my mind since. They write: "Many men in focus groups and interviews reported that having less disposable income has increasingly led to reduced ability to purchase sex or maintain multiple sexual relationships".

The sentence sounds reasonable enough if you accept the overall conclusion of the paper, that changes in sexual behavior driven by fear of HIV infection resulted in massive reductions in HIV transmission. But the data used by the paper only shows minor changes in sexual behavior. In truth, correlations between sexual behavior and HIV transmission are as unconvincing as they always have been, in Zimbabwe and elsewhere.

But even thinking about this sentence from an economic point of view and the little we know about commercial sex, does having less disposable income necessarily result in a reduced likelihood of purchasing sex? I think the real worry when money becomes scarce is that those who depend on providing sexual services for money have to settle for less money or provide more and/or riskier services.

Of course, such hypotheses need to be tested and many HIV researchers are reluctant to carry out rigorous research into sexual behavior. If sex turned out to be less relevant to HIV it's likely that funding would dry up. And if HIV prevention turned out to be a matter of providing decent health care, those currently selling drugs would also quickly lose interest.

There must be a lot of money in providing safe health care but it doesn't seem to attract the donors. But then, it's important to sell HIV drugs to developing countries because that's where the bulk of the market is. The same can't be said for other health care goods and services; not yet, anyhow.

Another problem with the idea that commercial sex becomes less common when money is scarce is that you'd think the trend for wealthier people to be infected in greater numbers than poorer people would reverse. This trend has reversed in some countries, but not noticeably as a result of economic changes.

The authors of the paper in question put a lot of credence in focus group discussions and that seems unwise. But it's their analysis of those findings that seem most disingenuous. The analysis appears to be independent of the data on sexual behavior, probably because the data is the same in high prevalence countries as it is in low prevalence countries. It's almost as if they are saying "here's the data, it contradicts our conclusions but everyone knows our conclusions are true anyway".

Because this paper doesn't even give a convincing pretense of having any substance, I'm still wondering what is behind it. The authors are very well established so the only reason I can think of that they would put their names to such rubbish is that they know no one really cares how they come to their conclusion as long as they come to the approved conclusion. But it seems like an expensive and circuitous way of failing to reduce HIV transmission.


Saturday, February 26, 2011

Why Are UNAIDS So Averse To Reducing HIV Transmission?

The usual headlines and the usual claims about the number of HIV infections prevented by male circumcision, this time in Swaziland. This time it's 88,000 new infections and, as always, there will never be any way of telling how many infections were prevented. Because the majority of men in Swaziland (over 80%) are HIV negative, it will be easy enough to cite a notional figure for how many men would have been infected if the surgeons hadn't jumped in and circumcised most of the men.

The circumcision enthusiasts could look at it another way and ask how many men were infected through heterosexual sex, because that's what circumcision is supposed to reduce. But if they scrutinized the figures too closely people might start to ask if circumcising hundreds of thousands of men (there are only just over one million Swazis), this could be an embarressment to the HIV orthodoxy, with their years of manufactured 'evidence'.

Male circumcision is said to reduce HIV transmission from females to males by up to 60%, but that's the highest figure, in trial conditions. It doesn't reduce transmission from females to males and it may well increase it. But we don't talk about that. And it is said to reduce transmission during penile-vaginal sex, not anal sex. It has no positive impact on transmission through anal sex, unsafe health care or unsafe cosmetic practices, whatsoever.

Now, the assumption is that those Swazis, being Africans, have a hell of a lot of sex, especially 'unsafe' sex, regardless of what they might say about their own sex lives. So UNAIDS and their collaborators calculate HIV transmission with the assumption that it's almost all heterosexually transmitted and that unsafe health care is almost non-existant. Unsafe cosmetic practices (tattooing, manicures, etc) are rarely mentioned.

The trouble with these assumptions is that they are all flatly contradicted by the very figures that the HIV industry usually use. The five yearly Demographic and Health Surveys, for Swaziland and other high HIV prevalence African countries, clearly show that most Africans are no more sexually active than non-Africans and, crucially, that levels of sexual activity, unsafe or otherwise, show little correspondence with HIV prevalence. Similar remarks apply to other high prevalence African countries.

Swaziland has some of the highest transmission rates in the world, but the most likely people to be infected are pregnant females. And why wouldn't they be vulnerable if they are clearly having unprotected sex? But it's not even the females who are having the most children that are most likely to be infected, it's usually the wealthiest and best educated who live in cities and suburbs. Poor, uneducated, rural-dwelling females are far less likely to be infected, regardless of their higher fertility rates.

And look at the male-female ratio for HIV prevalence: for every 5 females infected, there are only three males infected. We are told (incessantly) that women are more susceptible, which may well be true. But who is infecting them? Because UNAIDS and their allies claim that almost all females are infected sexually. Is there a merry band of males, who must be doing amazing amounts of work, going out of their way to spread HIV far and wide?

Even if most women, under the heterosexual transmission theory, are being infected by men, many men are not being infected by women. It's said to be roughly twice as difficult for a man to be infected by a woman than it is for a woman to be infected by a man (1 in 1000, compared to 1 in 500). But of the three men being infected for ever five women in Swaziland, some of those men are either infected through having sex with other men (MSM) or through intravenous drug use (IDU).

The HIV industry and the media love the idea that IDUs and even MSM also have sex with women. They love to talk about 'risk groups' and 'bridging groups' (people who are at high risk transmitting HIV to people who are at low risk). Some MSM and IDUs undoubtedly do have heterosexual sex, but many probably don't. Neither the media nor the industry can cite any reliable figures anyway. But there are clearly some men who are not infected through heterosexual sex and some who are not infected through any kind of sex.

If far more women than men are infected and many of the infected men are not infecting the women anyway, how appropriate is male circumcision when it comes to reducing HIV transmission? If you assume 80 or 90% heterosexual transmission then it's easy to produce glib figures, such as the 88,000 new infections mentioned. But unless you can show that most transmission is heterosexual, or even sexual, the circumcision intervention ceases to look so effective (if you were even persuaded in the first place!).

Carrying out unnecessary operations on millions of men is dangerous enough, but the promised reductions in HIV transmission will never materialize because they are based on a false premise about the high contribution that heterosexual transmission makes in high prevalence countries. Ignoring non-sexual transmission will not make it go away; the claimed millions of HIV infections that will be averted by mass male circumcision campaigns are false. But millions of new non-sexual infections will occur while the industry sits around patting each other on the back.


Saturday, February 19, 2011

Are Most HIV Positive Infants Infected by Their Mother or by Unsafe Healthcare

HIV figures from a recent survey in Mozambique paint a fairly typical picture of prevalence patterns in underdeveloped, high prevalence African countries. People in the richest quintile are three times more likely to be infected than those in the poorest quintile.

Women with secondary or higher education are 50% more likely to be infected than women with only primary education or less. Men are a lot less likely to be infected than women. And less well educated, poorer men are less likely to be infected than well educated, wealthier men.

So, what kind of transmission scenario is responsible for these patterns? Well, it is clear that more than one scenario is needed. The one official scenario used to explain all high prevalence African epidemics at the moment is that of unsafe sex.

We are supposed to believe that huge numbers of Africans engage in unsafe sex most of the time, despite safe sex messages and education being pumped out by the hour for many years. Apparently, those urban dwellers with greater access to the media and to the benefits of education, public services and health care are at greater risk of being infected.

Which tends to suggest that the single scenario is just wrong. But the 'behavioral paradigm', the belief that almost all HIV transmission occurs via heterosexual sex, is still the official view of UNAIDS, the US Center for Disease Control and most major academic institutions working with HIV.

To take one example, are we supposed to believe that rich women with higher levels of education living in urban areas have a tendency to pay people who are at high risk of being HIV positive to have sex with them? This may happen, but is it such a common phenomenon that it drives one of the worst HIV epidemics in the world?

Who exactly is infecting these women? Are they paying rich men to have sex with them? And if their rich, male spouses are paying for extramarital sex with high risk, casual partners, who are these partners? If they are poor, uneducated, rural dwelling people, they are less likely to be infected, in which case they are also less likely to be spreading the virus.

In order to explain why those with greater wealth, education and access to public services and healthcare are more likely to be infected, one needs to posit some other mode of transmission than heterosexual sex. Men who have sex with men (MSM) are a recognised risk group, as are injecting drug users (IDU). But these groups tend to infect other MSM and IDUs a lot more than people who belong to neither of these groups.

More than a hint at what could be going on comes from the same report that the above findings are based on, the Demographic and Health Survey. An estimated 30% of HIV positive infants have HIV negative mothers (the document is in Portuguese). If their mothers did not infect them it is highly likely that they were infected nosocomially, that is, through some kind of unsafe medical procedure, such as an injection. Anyone, infant, child or adult, can be infected nosocomially.

And not only can infants be infected by their mothers during delivery or breastfeeding, but infants can also infect their mothers through breastfeeding. This can happen if a baby is infected nosocomially. Also, the number of infants infected nosocomially may be a lot higher than 30%. The fact that the mother is HIV positive does not necessarily mean that the infant was infected by their mother.

The number of pregnant women and women who have recently given birth who seroconvert late in their pregnancy, or some time in the months following delivery, is very suspicious. Most women take precautions while they are pregnant and when they have recently given birth to protect themselves and their infants.

Are we supposed to believe that many African women are not just highly promiscuous but also either stupid or careless about their health and the health of their infants?

A far more convincing scenario to explain all of the above phenomena is that people are not only infected with HIV through heterosexual sex. Many, perhaps even a majority, are infected through unsafe healthcare.

Women, especially those around childbearing age, face more invasive medical treatment than men. Richer people can afford more healthcare than poorer people, who often do without altogether. And those in urban areas have greater access to healthcare while those in rural areas often have no access whatsoever.

Some HIV transmission may occur through heterosexual sex, especially in a country where prevalence has reached such alarming levels. And those who are infected nosocomially can also transmit HIV sexually. But at present they are not considered to be 'high risk', nosocomial infection is not targeted by HIV prevention campaigns and people at risk don't even know about the risks they face from unsafe healthcare.

The single scenario, naive theory of HIV transmission through heterosexual sex raises more questions than it answers. But the dual scenario, non-sexual and sexual transmission theory answers all of the questions. None of these remarks are particularly new, nor do they apply to Mozambigue alone. So now all we have to do is convince UNAIDS, CDC and other big players in the HIV industry.


Wednesday, February 16, 2011

Researchers Seek Answers But Reject the Bits they Don't Like

The fact that very high HIV prevalence is found in some countries and not in others is usually explained in terms of differences in rates of sexual behavior, especially 'unsafe' sexual behavior. However, it has never been demonstrated that rates of sexual behavior, unsafe or otherwise, really are higher in areas where HIV prevalence is high.

A recent article on herpes simplex virus (HSV-2) is a case in point (HSV-2 Among Bar and Hotel Workers in Northern Tanzania, Kapiga, Sam, Shao et al). A group of bar and hotel workers in Moshi, Tanzania, were studied and HSV-2 prevalence was found to be 43.5%. In the US, 22% of people aged 12 years or over are infected with HSV-2. Rates of unsafe sex probably explain high HSV-2 prevalence found in both countries, but that doesn't explain low HIV rates in US, nor high rates in Tanzania.

These two HSV-2 figures may look very different until you consider that unsafe sexual behavior is thought to be more common among bar and hotel workers in African countries than it is among the general population. HSV-2 prevalence increases with age, also, so prevalence among a comparable group in the US could be expected to be a lot closer to prevalence found in the Tanzanian group.

HSV-2 is almost always transmitted sexually. HIV is sometimes transmitted sexually, though heterosexual sex is an inefficient route of transmission. HIV is far more efficiently transmitted through various non-sexual routes, such as unsafe health care, especially through contaminated injecting equipment.

The relative contribution of sexual and non-sexual transmission of HIV to high prevalence HIV epidemics, such as those found in some African countries, is not known. The assumption that HIV is almost always transmitted sexually in African countries is, therefore, without foundation. And the figures for HSV-2 prevalence in the US and Tanzania suggest that rates of unsafe sexual behavior are similar, so difference in HIV prevalence is probably due to non-sexual factors.

The problem is that high levels of unsafe sexual behavior in (some) African countries are inferred from the fact that HIV prevalence is high and low levels of unsafe sexual behavior in Western countries are inferred from the fact that HIV prevalence is low. Yet, rates for some types of unsafe sexual behavior, age at sexual debut, number of sexual partners, overlapping sexual partners, etc, are probably very similar in both African and non-African countries. Not a lot of research has focused on comparing the two.

The paper studying HSV-2 shows that condom use is low and inconsistent, so it's not surprising that rates of sexually transmitted infections are high. But, while consistent condom use may protect against sexual HIV transmission, it does not protect against non-sexual HIV transmission. Therefore HSV-2 patterns in Moshi were, in many respects, quite different from HIV patterns.

For example, women were 4 times more likely to be infected with HSV-2 than men, prevalence standing at 53.1% and 29.2%, respectively. But women were almost 10 times more likely to be HIV positive than men. HSV-2 increases the probability of transmitting HIV and of being infected with HIV, but because one is almost always sexually transmitted and the other is only sometimes sexually transmitted, infection patterns remain distinct.

In Tanzania, HIV prevalence is higher among Christians than among Muslims. The opposite is true of HSV-2, which has a 50% lower risk among Catholics (the finding was not significant among non-Catholics). Rates of unsafe sexual behavior are also found to be higher among Muslims (multiple partnerships and concurrent relationships), which could explain higher rates of HSV-2 but only explains lower rates of HIV if you accept that HIV must also be transmitted non-sexually.

The complex relationships between levels of education and HSV-2 and HIV prevalence, respectively, are also quite different. The authors of this paper interpret both diseases purely in terms of sexual transmission, which muddies the waters. But while HSV-2 rates go down with increasing education among women, HIV rates go up.

The authors speculate about possible correlations between relative levels of income/wealth and HSV-2 transmission but don't produce any relevant figures. This is a pity because unsafe sexual behavior may well be higher among females with lower incomes but HIV rates in Tanzania are often higher among wealthier women.

The age patterns for HSV-2 and HIV prevalence are also quite different, with HSV-2 rates rising with increasing age. HIV rates in women are much more closely connected with pregnancy and childbearing, which carry increased levels of non-sexual risk. HIV rates among men start to rise later in life and peak somewhat later than among women.

Also HSV-2 is rare in non-sexually active people, especially the very young. But rates of HIV can sometimes be alarmingly high among these groups. Prevalence among male and female children are quite similar, suggesting similar levels of risk. HIV rates in adult females are almost always higher than in males in high prevalence countries (and almost always far lower than in males in low prevalence countries).

The researchers were surprised to find that women who had uncircumcised sex partners had a 50% reduction in HSV-2 risk. The Tanzanian government is currently considering circumcising 2.8 million men because they have been convinced that it will reduce HIV transmission from women to men. So it might be worth doing some unbiased research before carrying out such a risky intervention.

So the article may tell us a lot about HSV-2 and sexual risk, and might even shed some light on sexually transmitted HIV. But it assumes that HIV is, like HSV-2, a sexually transmitted infection, which is certainly not accurate and may even be dangerously inaccurate.

The article gives little insight into why HIV prevalence is so high in some parts of some African countries. Yet the authors purport to find implications for HIV prevention. But such implications are unlikely to be significant or helpful unless the relative contributions of sexually and non-sexually transmitted HIV are also quantified.


Tuesday, February 15, 2011

HIV Does Not 'Die in Seconds' Outside the Body; it Can Live for Days

Sometimes a myth becomes so much repeated that it is almost impossible to persuade people even to think about it and consider if it makes any sense. One of those myths is that 'HIV only survives for seconds/milliseconds outside the body'.

Many people all around the world have been shown to have been infected by contaminated medical equipment. Millions have been infected by reused, unsterile injecting equipment. And it's not only contaminated blood that is dangerous, the virus can also be spread by anal mucus, vaginal mucus, pus and many other bodily fluids. Numerous artefacts can be contaminated this way, including latex gloves, scalpels, probes, etc.

If the virus only survived for seconds there would be no need to recall people when a medical practitioner is discovered to have been working without following procedures. Yet such recalls are commonplace, with thousands of former patients having to be tested every year. Would so much time and effort be wasted if the virus only survived for seconds?

To put it differently, how would you like to visit a dentist, surgeon or gynecologist who didn't sterilize their equipment, change their gloves or dispose of non-reusable items? Would you be willing to take a chance, if you suspected a practitioner of doing any of these things, just because you thought HIV only survived for seconds?

The myth itself is often presented very briefly and without much context. But what about the type of bodily fluid involved, concentration of the virus, the nature of the surrounding medium, temperature, moisture content, volume, whether pieces of tissue are involved, etc? What about whether the virus is cell-free or cell-associated?

Van Beuren et al investigated this in 1993 but authorities such as the US Center for Disease Control (CDC) don't seem to have noticed yet. Under the right conditions, HIV can survive for several days, perhaps even a week. Sure, it may become less viable over time, but billions of injections and other invasive medical procedures are given every year.

Kramer et al go into the matter in further detail in a more recent paper. Their literature review finds that blood borne viruses such as HV and hepatitis B virus (HBV) "have been shown to persist from only a few hours up to 7 days". That's hours, not seconds or milliseconds. Other pathogens can survive weeks or even months.

CDC is not very clear on the matter and they do not mention seconds, they mention hours, which is quite another matter. They say that the virus "doesn't survive well" and warn against interpreting tests carried out in laboratory conditions which use artificially high concentrations of HIV.

They may be right in saying that such concentrations are not found in nature, but a reused syringe or other medical equipment is not nature. "Contact with an environmental surface" may not be a threat, but you don't want a contaminated "environmental surface" getting under your skin.

Some people express the worry that HIV positive people can be stigmatized if others believe certain things about HIV. At one time, people believed they could be infected by shaking hands with a HIV positive person, sharing cutlery, etc. These, and many other things, are not risks. But invasive medical procedures are quite different; unsterile equipment can transmit HIV and other diseases.

It is also easy to neglect other potential risks, for example hairdressing and various cosmetic practices, tattooing and shaving. Care should be taken if equipment is shared. Equipment needs to be properly sterilized, no matter how long it is since it was last used. Even if HIV contamination is unlikely, there are lots of other diseases that can be spread the same way.

I don't expect to be able to wipe out the myth just by saying it is not true. But there is plenty of reading people can do to help figure out if it even makes much sense. My intention is not to increase stigma, rather to decrease it by loosening the connection between HIV transmission and unsafe sex in high prevalence African countries. Your skin protects you from HIV, but some processes are designed to go below the skin and others do so inadvertently.


Monday, February 14, 2011

Sexually Transmitted Infections Can Also Be Spread By Unsafe Healthcare

When patients are found to have been exposed to HIV or other viruses as a result of the care they received, so called 'nosocomial' infections, they are usually recalled for testing and treatment, as required. This certainly happens in many rich countries, but not always, it seems.

A doctor operating in Philadelphia illegally aborted fetuses in their third trimester and then killed them by severing their spinal cords with scissors. Many women have been seriously injured as a result of this doctor's treatment and some have died.

The doctor has been convicted of murder and the fact that so many people were affected over such a long period of time has been put down to a 'complete regulatory collapse'. The case is so horrifying that it is probably difficult for those reading about it to concentrate on anything but what should happen to the perpetrators and how this sort of thing can be prevented from happening again.

But what about all the women who have been treated in the appalling conditions described in the article? They have been exposed to all sorts of things, some of which will make them very sick, some of which will eventually kill them. They need to be screened and treated, if it's not already too late.

The issue is not just how authorities should have done their job in the first place, that's the concern of relevant institutions and regulatory bodies. But for the women concerned, their immediate need is for proper health care, albeit belated. Lives may be saved, illness averted and even mental trauma may be relieved.

Other articles I have seen involving unsafe healthcare mentioned the actions that were taken to limit the damage to those who were still alive. But I have yet to find out if all previous patients have been traced in this instance. Is this because no effort has yet been made to trace them, or is it that the sheer horror of the case has distracted attention from the victims?

A number of other employees in the same clinic were also indicted with various crimes and the clinic, which appears to have concentrated on late term abortions, was operating for 16 years. There is no telling what risks the patients faced over the years.

The circumstances surrounding the case are almost beyond belief and my question is not about the fact that so many warning signs were ignored for so long; rather, I'd like to know if it is true that most of the clientele attending this clinic were poor and/or non-white.

The chances of non-white, especially black, Americans becoming infected with HIV are far higher than the chances of white people becoming infected. Similar remarks apply to sexually transmitted infections (STI). But high prevalence of STIs doesn't merely indicate high levels of unsafe sexual behaivor. It could also indicate low levels of health care provision, especially sexual and reproductive health care.

The jury in the case of the clinic doctor, Dr. Kermit Gosnell, concluded: "Bureaucratic inertia is not exactly news. We understand that. But we think this was something more. We think the reason no one acted is because the women in question were poor and of color, because the victims were infants without identities, and because the subject was the political subject of abortion." And apparently white clients were treated quite differently.

Many women who attended this clinic were infected nosocomially with sexually transmitted infections. Being sexually active, poor and non-white, it would probably have been assumed that they were infected sexually. Nosocomial infection appears to be of interest in other cases of unsafe healthcare, but not in this one. Not so far, anyhow.


Saturday, February 12, 2011

Unsafe Health Care: the Most Efficient Means of Spreading HIV

I have often suggested on this blog that non-sexual HIV transmission could be as common as, or perhaps more common than, sexual HIV transmission. Not only do I not know the exact extent of either modes of transmission, but nor does anyone else. And I don't know of very many people who are trying to find out. Certainly none of the HIV orthodoxy.

The issue of HIV transmission in health facilities is particularly maligned by the HIV industry, who say little about it except to deny that it occurs to any great extent, even in developing countries with atrocious health facility conditions. This denial is based on anecdote, supposition and profound anti-African prejudice.

But nosocomial transmission of various diseases occurs in every country. The only difference between rich countries and poor countries is that when it occurs in a rich country, there is usually (not always, as I will argue in a future post) a thorough investigation. People who may have been exposed to diseases are recalled for testing, etc. There is no such investigation or recalling in developing countries.

Here's an example: a surgeon uses an unsterilized pair of scissors in operations, not just few times but on over 100 children. He denied operating without gloves, as well, so it may not have been just the children's health that was put at risk.

This didn't happen in a developing country, it happened in a prestigious teaching hospital in Cambridge, UK. The surgeon was sacked and the children were recalled for tests. Whether any of them were infected or received any treatment as a result of the incident (or series of incidents), is not clear. But it's good to know that someone is checking and that something happens when things go wrong.

Here's another example: a nurse thought that a machine used to check blood sugar levels automatically changed needles. It didn't, but it took two months and 55 exposed people before anyone noticed. This happened in a private radiology clinic in Australia.

A spokesperson for the facility may be right in claiming that the risk of infection is very low. In a country like Australia, there are probably not that many people visiting health facilities with undiagnosed HIV, though I'm not so sure about hepatitis B, C or other blood borne diseases. And in the UK, it's unlikely many children have HIV infections, diagnosed or undiagnosed.

But in countries where prevalence of HIV is high and prevalence of hepatitis and other diseases even higher, the risk could be tens or even hundreds of times higher. Even among children and infants in developing countries, rates can be high enough to seriously threaten the safety of those undergoing medical treatment. Undiagnosed infections could be especially common.

And just look at the numbers involved here: over 170 people at risk because of the actions of two people. Compare this with sexual HIV transmission, where most people are unlikely to infect more than one other person except under relatively ususual conditions. A handful of highly sexually active people may be able to infect a handful more and spark off a small epidemic. But only professionals can spark off the massive rates of transmission found in some sub-Saharan African countries.

A third example, and these are just ones I picked up this week: 535 attendees at a Veterans' Affairs medical facility have been recalled for testing because one dentist failed to change his gloves between patients. These failures went on for 18 years. Nor did he always sterilize all his equipment. In this instance, the person involved is still employed.

UNAIDS and the HIV industry start with the assumption (it's not a hypothesis because they refuse to modify it despite evidence that it is unwarranted) that 90% (or some such figure) of HIV in African countries is transmitted through heterosexual sex by 'promiscuous' people.

They then have to show that some people really have the amount of sex required to spread a difficult to transmit virus to the extent that it affects a large proportion of the sexually active population. And that's no small amount of sex. In fact, it's a humanly impossible amount of sex, even for commercial sex workers (and anyone else the industry finger has been pointed at, truckers, migrant workers, soldiers, teachers, etc).

For the 'reproductive number', the number of people who are subsequently infected by each infected person, to be high enough to explain the number of people infected in some countries by sexual transmission alone, people would need to be more than just promiscuous.

On the other hand, nosocomial HIV transmission is very efficient. One person can put hundreds at risk, even hundreds per year. The risk of infection for each patient who received unsafe treatment is far higher than the risk they would have faced if they had numerous unprotected penetrative sexual experiences with a HIV positive person.

Epidemiologists often talk about 'explosive' epidemics, especially in relation to HIV. But HIV as a heterosexually transmitted infection is not, by any stretch, an explosive virus. It is explosive among men who have sex with men, among injection drug users and, presumably, among women who engage in heterosexual anal sex. It is also explosive in unsafe health care contexts, highly explosive. The above figures are the tip of the iceberg because they come from rich country health facilities where something went wrong.

In poor countries, many people don't receive much health care. Those who do take their chances and many things go wrong. In African countries where health care was once available to many, HIV prevalence appears to be very high, or was once high. Zimbabwe and South Africa are two examples. In East African countries, where health care is inaccessible to most, prevalence rates are far lower, though high enough to suggest large levels of nosocomial infection.

I'm beyond calling for HIV academics to change their prejudiced attitudes, they don't see themselves as prejudiced. They don't see how ill-founded their arguments are, nor how they all stem from the 'behavioral paradigm', the belief that almost all HIV is heterosexually transmitted in African countries. They could retain these extreme racist and sexist views and still investigate levels of nosocomial HIV transmission.


Friday, February 11, 2011

UNAIDS Stigmatizes Sex Workers and Africans

John Potterat, Devon Brewer and others published a paper over 7 years ago showing that deaths from AIDS in a group of US sex workers were exclusively among those who admitted to injecting drugs or were inferred to have a history of doing so. Sex workers in the cohort faced many risks that could have lead to their death, but sexually transmitted HIV didn't seem to be one of them.

A study carried out in the late 90s in Italy, by Michele Spina, Salvatrice Mancuso and others, estimated HIV prevalence and condom use in a group of sex workers. HIV rates were higher than in the general population (though lower than in many high prevalence African countries). But the majority of the HIV positive women were injection drug users.

Condom use with paying customers was probably higher than would be found in African countries. But the fact that some of the HIV positive women were not injection drug users does not mean they were infected sexually, either. In reality, sex, even unprotected sex, has not been demonstrated to be the main risk factor in HIV transmission.

A third study, carried out 5 years ago in Uzbekistan by Catherine Todd, Mumtaz Khakimov and others looked at HIV prevalence among sex workers and the sort of risks they face. The majority of infections were among those who injected drugs. A fairly substantial number who didn't inject drugs were also infected. And treatment for a sexually transmitted infection (STI) was also found to be a risk factor. But non-sexual risks don't seem to have been taken into account.

I'm not suggesting that sex work is not hazardous, or that one of the risks sex workers face is not infection with (and transmission of) HIV. I just think that the risk of sexual transmission in sex workers in developing countries is exaggerated. I think the very fact that people are sex workers leads to the assumption that if they are HIV positive, they must have been infected sexually.

I think a similar assumption is made about HIV positive people who are not sex workers, that if they are HIV positive and they admit to being sexually active, they must have been infected sexually. This is the normal assumption in African countries. They may have been infected sexually, but couldn't a proper assessment be made of the non-sexual risks they have faced, as well as the sexual risks?

The assumption that Africans are almost always infected with HIV sexually leads to the ridiculous conclusion that even those who have never had sex, have only had sex with one, HIV negative partner or those who only ever engage in very low risk sex, if they test HIV positive, must also have been infected sexually.

The possibility that some people, perhaps a large number, have been infected non-sexually, is generally dismissed by the HIV orthodoxy. This is despite the appalling conditions in health services in African countries. It could be that people who have to attend health facilities actually face the highest risks of HIV infection.

Take sex workers, for example. They often attend clinics every few months for checkups, injectible contraceptives (the most popular form of contraceptive for sex workers and non-sex workers alike), for treatment for STIs and other invasive procedures. If any procedures in the facilities they visit are unsterile, the chances of nosocomial transmission of HIV (transmission through medical procedures) and other diseases are very high.

Take pregnant women as another example. They make visits to ante-natal clinics and undergo various invasive procedures, including injections. They may make several visits to clinics, before and after delivery. Every visit is a risk if medical practices are unsafe. And HIV rates are particularly high among pregnant women, who often seroconvert very late in their pregnancy or even after they give birth.

UNAIDS and other institutions connected with the AIDS industry usually ignore nosocomial HIV transmission, or they downplay it and claim its contribution to African epidemics is negligible. But how could it be negligible in some of the filthiest, most underfunded and understaffed facilities in the world when it is a significant risk in other countries, where conditions are far better?

While UNAIDS downplay the risks faced by Africans, they warn their own employees to avoid African health facilities because of the possible risks of nosocomial infection and unsafe healthcare in general. How could it be a risk to a rich UN employee and not to a poor African? The WHO accepts that a significant percentage of injections in African countries are contaminated. So it's time to consider non-sexual HIV risks when developing HIV prevention programs; it's time to rewrite global HIV prevention policy.


Wednesday, February 9, 2011

Researchers Have No Opinion On Nosocomial HIV Infections in Zimbabwe

Non-sexual HIV transmission, when it's even discussed by the HIV orthodoxy, is usually dismissed with little argument and no evidence. What is most extraordinary is that one could hypothesize that both sexual and non-sexual transmission contribute to most epidemics and then try to work out the relative contribution of each. But they don't tend to do that.

Halperin, Mugurungi, Hallett, Muchini, Campbell, Magure, Benedikt and Gregson toe the party line in their recent paper 'A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?' They barely even mention non-sexual transmission and completely dismiss its significance.

But they do come to a very media friendly and quotable 'conclusion', that "fear of contracting the virus [is] the primary motivation for changes in sexual behavior". Journalists have pounced on this 'finding' and will continue spreading it for some time. Perhaps these researchers have recognized the value of media friendliness and found it to be more congenial than credible, enlightening research that could turn around the HIV pandemic.

Despite constant boasts about the number of people on antiretroviral treatment and the idea that you can contain an epidemic by throwing lots of drugs at it (which happens to be the current global treatment policy), these researchers even mention the very real possibility of drug resistance making mass treatment campaigns less sustainable than they currently are. They are in good company; Bill Gates recently said more less the same thing.

But what was their quotable conclusion based on? Well, they did a bit of mathematical modelling and read a few papers written by like-minded people (actually, the bibliography overlaps considerably with the list of authors), but they also give a lot of credence to a bunch of 'stakeholders', who certainly seemed to do a fair amount of agreeing with each other. Perhaps they see this as quantitative, their credence, the stakeholders' agreement, etc.

It's odd, when people say they have never had sex, never had unprotected sex or never had sex with anyone other than their partner (who is often HVI negative), they are unlikely to be believed, especially if they are African. But if they are like-minded people holed up in a hotel, their responses are treated at face value.

"[T]he unanimous conclusion from the stakeholders meeting held to assess, triangulate, and interpret the evidence assembled in the review was that a reduction in multiple sexual partnerships was the most likely proximate cause for the recent decline in HIV risk." What a surprise.

It goes on: "In assessing the underlying factors for the national prevalence decline, high AIDS mortality appears to have been the dominant factor for stimulating behavior change." Yet, high AIDS mortality has been a phenomenon in many countries that have had very high HIV prevalence. When lots of people become infected, lots of them die, widespread treatment regimes notwithstanding.

Similar claims used to be made about Uganda, though these researchers are also keeping Uganda at arm's length. Well, it's almost certainly true that some people were devastated by what they saw around them when huge numbers of people were dying terrible deaths. That would have some impact on anyone.

But the idea that it would be almost entirely responsible for levels of behavior change that resulted in a massive drop in rates of new infections in a short space of time in Zimbabwe, but nowhere else, is not credible. Nor is it even necessary to make such a foolish claim.

The economic decline experienced in Zimbabwe in the late 90s and early 2000s, we are told, played a considerable secondary role in amplifying patterns of behavior change. No doubt it did. But economic decline could also have resulted in fewer visits to the country's deteriorating health facilities, which would have reduced the number of nosocomial infections (infections resulting from medical treatment).

And what levels of behavior change occurred? From the figures cited, age of sexual debut and condom use barely changed. And multiple partnership indicators improved a bit, but these were never common enough to explain the almost umprecedented rates of transmission once found in the country. Most of these indicators wouldn't even look out of place in rich countries.

Interestingly, the researchers mention "the Zimbabwean government's early adoption of a home-based care policy [which] may inadvertently have accelerated the process of behavior change. It has been hypothesized that, when people die at home, this direct confrontation with AIDS mortality is more likely to result in a tangible fear of death among family and friends than when patients are primarily cared for in clinical facilities, such as in Botswana"

I'd interpret the effect of this policy rather differently. It could also have taken a lot of HIV positive people out of a health system that was not able to provide people with safe healthcare.

The authors conclude that significant changes in behavior are unlikely to have resulted from increasing levels of mortality alone. They also suggest that prevention programs provided people with information about the link between risky sexual behavior and HIV transmission. And they are probably right, to an extent. But why were these programs so successful in Zimbabwe when they failed so miserably elsewhere? The authors bluster on, unconvincingly.

Indeed, they don't even seem that convinced themselves. They can't really put their finger on anything much so they talk about "cumulative exposure" to prevention messages, as if that wouldn't have happened elsewhere. Similar claims have long been made to "explain" what happened in Uganda. After all, there must be some explanation, and if it has to be about sex this one is as good as any other.

I can understand a whole group of stakeholders churning out answers that would satisfy even a UNAIDS employee about the drivers of HIV. I have met few people who wouldn't say similar things. But I don't believe the authors could look on this this paper as a publishable piece of research. If they are all happy with it, then I am disgusted. Their own research screams for investigation of non-sexual transmission levels, but they carry on regardless.


Monday, February 7, 2011

Global HIV Policy: Blame, Stigma and Finger-Wagging

With HIV/AIDS, it's always been easier to blame individuals for their reckless behavior than to examine the conditions people live in and figure out which of these conditions may explain why HIV prevalence varies from a fraction of a percent in some populations to 25% in others and even 40% in some demographic groups.

The idea that whole populations have hundreds of times less sexual experience than other groups is not credible, especially where birth rates may be very high in some countries with low HIV prevalence. India is an example of a country with high birth rates and HIV prevalence lower than 1%. There is no reason to think that Indians in general shy away from sex.

While prevalence is a lot lower than 1% in most demographic groups in India, it is 30-40% in some demographic groups in several African countries. In fact, prevalence among Indian sex workers is only 7%, which is about the same prevalence as found in Kenya, Tanzania and Uganda. Yet sex workers in India face terrible risks, far worse than most sexually active people in African countries.

That HIV prevalence is not correlated with individual sexual behavior is nothing new. But some researchers have shown that HIV prevalence is correlated with malaria prevalence, something that is clearly not just a matter of individual behavior. Whether it makes HIV positive people more likely to transmit the virus, HIV negative people more likely to be infected or both is not clear. I have only seen the abstract. But it is one more nail in the coffin for the 'individual responsibility' theory of HIV prevention.

People in high malaria prevalence areas are more than twice as likely to be HIV positive as those in low prevalence areas. Some people have been calling for research into cofactors in HIV transmission for years but such research is still relatively uncommon. But similar research was recently carried out on schistosomiasis (bilharzia) as a co-factor and it was found to be associated with higher HIV prevalence. Tuberculosis also makes people more likely to transmit and to be infected with HIV.

Further loosening the connection between HIV and individual sexual behavior, it has also been shown that "a number of biological factors are critical in determining whether an unprotected sexual exposure to HIV results in productive infection". Mentioned are "viral factors, host genetics, and the impact of co-infections and host immunology" but again, I only have access to the abstract.

These researchers even have the effrontery to claim that "HIV sexual transmission is very inefficient". That's true, but it's not something that the sex obsessed HIV industry likes to dwell on. Global HIV prevention policies are based on blame, stigma, finger-pointing and finger-wagging, not research. But these upstarts go on to mention destigmatizing the issue, leading to new and more effective strategies for prevention. Whatever next?

Another batch of researchers conclude that because new HIV infections among discordant couples (where only one partner is infected) are twice as likely to occur among those trying to have a baby, this must be a result of higher levels of 'risky' sexual behavior. Having sex with your partner is not risky, or shouldn't be. But having a baby seems to be, especially for the female partner. Perhaps the researchers would like to assess the non-sexual risks that pregnant women face, such as unsafe health care.

The researchers may well be right and their research is certainly very interesting. But any research into HIV transmission among discordant couples, especially where pregnancy is involved, is incomplete without some clarification about how the women are being infected. Sure, they must be having sex if they are trying to have children, but this does not mean that transmission is always sexual.

The 'concurrency' card is still frequently played by those in the know (about how to receive copious amounts of funding) but it is still unsupported by clear evidence that it is common or that it really does explain high rates of HIV transmission. This research from Kenya pours cold water on the concurrency theory, finding that only 3.5% of females and 4% of males were engaged in concurrent partnerships in the previous six months.

The authors claim their findings suggest that: "concurrency expands individuals' sexual networks and bridges additional networks involving partners' other sexual partners". Perhaps, but with such low rates of concurrence, it's unlikely to do so to any great extent.

We need credible explanations for high rates of HIV transmission and viable prevention interventions, not the institutional racism and sexism that we have come to expect from UNAIDS and their ilk. UNAIDS have spent long enough showing that they are not capable of acting on research, especially research that exposes their prejudice for what it is. It's time for them to stand aside and let an unbiased institution take over.


Saturday, February 5, 2011

Why is HIV Prevalence Higher Close to Health Facilities?

Caryl Feldacker, Susan Ennett and Ilene Speizer have published an article entitled "It's not just who you are but where you live: an exploration of community influences on individual HIV status in rural Malawi". Differences between urban and rural HIV rates have always been striking and have often seemed counterintuitive.

For example, people in rural areas often have less access to health facilities due to distance, cost and poor infrastructure. Yet HIV rates are almost always noticeably higher in urban areas, where infrastructure is better, there are more health facilities and people are wealthier.

This has been seen as an anomaly because poverty and accessible health services are usually associated with better health. Yet, the phenomenon is common. In Kenya, the province with least access to health, North Eastern, has by far the lowest HIV prevalence.

North Eastern also has other conditions which are sometimes associated with high HIV rates, such as low age of sexual debut, especially for females, high rates of female genital mutilation, high rates of intergenerational marriage (where the man is significantly older than the woman), low rates of condom use and high birth rates.

Several years ago, it was noted that HIV rates decline as you move from roads and urban areas in Tanzania, although the virus was becoming more common in rural areas and declining slowly in urban areas. So similar findings in Malawi are hardly a bolt from the blue.

But these researchers find that the closer you are to a health facility, the more likely you are to be infected. Those further away are less likely to be infected. In addition to highlighting the significance of non-individual possible factors in the transmission of HIV, they find that individual behavior is not nearly as significant as UNAIDS and the HIV industry insist.

Alas, what the researchers find, they try to explain away. They cite David Gisselquist and others who suggest that proximity to health facilities may increase the risk of HIV transmission because of unsafe medical practices. But the researchers speculate that a more plausible explanation is that proximity to health facilities happens to correlate with areas where risky sexual behavior is more common.

They claim this sexual behavior explanation is more 'plausible'. Well, it is if you accept that HIV transmission is almost all explained by reference to sexual behavior. These researchers show clear signs of being bitten by their own behavioral paradigm. They were not expecting to find such a clear indication that health facilities might actually be part of the problem.

So they deny it. Rather than accepting Gisselquist and co's explanation, which is compatible with their own somewhat futile specualations, they simply reject anything that threatens the paradigm. They have gone so far and no further. It's such a pity to see good research being used to prop up a crumbling theory, especially given the influence of that theory on global HIV policy.

One of the things the researchers say is particularly hard to fathom. They hypothesize "those with greater access to roads and cities, will be more likely to engage in HIV risk behaviors, and therefore, more likely to be HIV infected. Persons with greater access to health facilities will be less likely to engage in HIV risk behaviors and, therefore, less likely to be infected with HIV."

The first part of the claim has been one of the biggest failures of orthodox HIV transmission theory. There is no evidence that levels of risky sexual behavior are higher where HIV rates are higher. And there is no evidence that levels of risky sexual behavior are higher in high HIV prevalence African countries than low prevalence African and non-African countries.

And why would people with access to health facilities be less likely to engage in risky sex? Their rejection of Gisselquist and Co's theory even requires that they reject this hypothesis.

In fact, those who have greater access to roads and cities are, more or less, the same people who have greater access to health facilities. But there is nothing about health facilities themselves that results in lower levels of risky behavior (or higher levels, for that matter). There may be a bit of wishful thinking involved here, but otherwise it's a strange hypothesis.

It remains to be seen whether other researchers accept Feldaker and Co's analysis, which has the sole advantage of not threatening the mainstream. But others may begin to wonder if the possibility of non-sexual transmission, health care related transmission in particular, should be reconsidered in the light of this and other evidence. HIV prevalence may be higher close to health facilities for all sorts of reasons, but it's time to find out if health facilities are transmitting more HIV than UNAIDS has been telling us.

[Read about pre-exposure prophylaxis (PrEP) and health priorities on my other blog.]


Thursday, February 3, 2011

Increase Testing, Find Out What is Really Driving HIV Epidemic in South Africa

There is a debate in South Africa about whether schoolchildren from 13 up should be tested for HIV. Some are opposed to testing, apparently claiming that children "may not be psychologically prepared to deal with a positive result or the stigma likely to follow". But the point of pre- and post-test counselling is to psychologically prepare people for getting the test and finding out the result.

This may be more difficult in the case of younger children. But that doesn't make it any less necessary. The alternative is to wait until symptoms appear, by which time treatment will be more difficult and the risk of serious illness and even death are increased. If found to be HIV positive, people can be monitored and treated as and when treatment is required.

South African health services may not have the capacity to treat all those who are in need of treatment. But they need to test as many people as possible to assess what exactly their needs are. Even if they can't give everyone the level of treatment they require, those who are not tested won't get any treatment at all.

The fact that, as one teachers' union representative points out, even parents are afraid to be tested, is not a reason for not trying to increase the numbers of people being tested. People have been filled with notions about HIV in Africa being transmitted almost exclusively by promiscuous behavior, which means that HIV is still highly stigmatized, even after thirty years of research showing that it is not solely spread sexually and it is not primarily a matter of individual responsibility.

But teachers, teachers' unions and others should be aiming to reduce stigma, not accepting it as inevitable. They may be correct in claiming that the government is trying to make up the numbers for their exaggerated claims about how many people they were going to test in a short space of time. Certainly, testing large numbers of children, who may be seen as easy targets, is a very cynical way of achieving projected figures.

However, countries with high HIV prevalence need to test more people, especially younger people. There are three reasons, the first being that people have better health outcomes if the disease is caught early.

The second is that testing early should help to work out how people are being infected. For example, some will have been infected by their mother, some will be sexually active and some will not fall into either of these groups. People who are neither sexually active nor infected since birth will need to be investigated carefully to find out exactly how they are being infected.

Nosocomial infection is very likely to be responsible in many instances. Failing to identify such sources of new infection and failing to do anything about them will result in continuing high rates of HIV transmission in South Africa and other countries where similar failures occur.

The third reason for testing as many people as possible is that HIV prevalence among young people is a useful proxy for HIV incidence, the yearly rate of new infections. Incidence is very hard to measure but without such measurements, it is difficult to predict how the epidemic is going, whether it is increasing or reducing.

Being able to treat infected people is only one good reason to test as many as possible. Finding out what is driving the epidemic is, arguably, even more important. Far more people are at risk of becoming infected than are already infected. One of the aims of HIV policy in South Africa needs to be to prevent new HIV infections, not just to passively identify those already infected so they can be treated accordingly.

Young people, especially young girls, are those most at risk of being infected with HIV. That harsh reality is a lot better than the reality of being HIV positive. If people are still afraid to be tested then the South African Government needs to challenge global HIV policy, which denies that a significant amount of HIV transmission could be non-sexual. If South Africa, with the largest HIV positive population in the world, is not prepared to stand up to this erroneous claim, who will be?

Unfortunately, a lot of young people will be identified as HIV positive even though they have never had sex. And they will not all have been infected by their mother, who may not herself be infected. Not all HIV positive young South Africans are being infected sexually so it needs to be made clear how they are being infected. Only then can the South African epidemic be successfully tackled. The less involvement from UNAIDS and the HIV industry, the better.


Tuesday, February 1, 2011

Sexual Behavior: Myth Supports the Assumption, Evidence Does Not

IRIN has a recent article entitled "Fidelity campaigns could take years to see results". This is not news. Campaigns advocating abstinence, limiting sex to one partner and using condoms have been around for years and it is well known that they take years to show any results. It is also well known that they don't have very much effect on HIV prevalence.

Despite this, much of the money spent on HIV prevention, a very small amount compared to that spent on treatment and care, is used for fidelity campaigns of one kind or another. They usually result people in being able to trot out the right answers to questions, which keeps the market researchers happy. And, in the end, these campaigns are a good way of spending lots of money.

Various institutions that have bought into these empty campaigns are very well funded and can afford good marketing. They are hardly going to produce reports showing that their campaigns were pretty pointless. Rather, they will put a gloss on everything so that they can continue to receive funding. That's often what the funders want, too.

Institutions such as PSI, that were set up to interfere in the sexual and reproductive health of people in developing countries, can be expected to spend their enormous budgets on their traditional interests of population control (or 'eugenics', as it used to be called). But they really don't need to react with such surprise when their campaigns continue to fail to make much impression on HIV transmission rates.

Whatever the claims of PSI and similar institutions, fidelity and other behavior change approaches to HIV prevention are constantly referred to as 'evidence-based', as if that vouched for their effectiveness. But the notion that "over 90% of adult HIV infections in sub-Saharan Africa are acquired through sexual contact" is an article of faith in the HIV industry, even though the dubious claim dates back almost 20 years.

An article published in BioMed Central, by Marshall Munjoma, et al, simply assumes the truth of this 'behavioral paradigm', assumes that Africans lead incredibly active sex lives, care little about their health, the health of their children or the health of their partners, and takes things from there. And yet, the article strongly suggests that not all HIV is transmitted sexually.

These researchers start by pointing out that HIV incidence, the yearly rate of new infections, peaked in the late 1980s and declined thereafter. They don't explain the initial spread of HIV, the peak in incidence, nor its subsequent decline. And they certainly don't relate these phenomena to sexual behavior.

Yet, if the sexual behavior theory of HIV transmission is true, the major changes in behavior must have begun in the 1980s. By the end of the 1990s, most people who were infected in the 80s would have died and those infected in the 90s would have continuted to die into the 2000s. Once incidence peaked and declined, little further behavior change is required to explain what happened since the late 1990s.

Not only do the researchers fail to explain the sexual behavior changes that must have begun in the 80s and continued through the 90s but they attribute the rapid declines in prevalence in the late 1990s and early 2000s to changes in sexual behavior! The decline in prevalence is due to high death rates. High death rates continue to reduce prevalence in Zimbabwe and new infections also continue, just at far lower rates than in the 1980s.

The researchers note that new infections among women attending ante-natal clinics women are very high over a 6 year period in the 2000s. But many of these infections probably occurred during the women's third trimester or not long after giving birth. Why is it assumed that they must have been infected sexually? Some of these women were probably not having sex very much at these times. Were their partners tested?

The study also found that half those infected were 20 years or younger and nearly 100% of married women reported having sex with their spouses only. The researchers seem content to ignore the possibility of non-sexual transmission in at least some of the people they spent so long tracking. What is the point of research that ignores such vital clues as to how HIV may be transmitted?

To tie in with the IRIN article and the blind faith in behavior change interventions, the authors conclude that the decline in prevalence is due to behavior change, even though 90% of the study participants, both those who seroconverted and those who didn't, do not believe that abstinence protects against HIV. If people don't believe abstinence will protect them, why would they abstain?