Monday, December 31, 2012

Circumcision: a Case of Retributive Healthcare?

There are many objections to mass male circumcision, but only a few of them should be required to convince someone that the vast majority of operations should never have been carried out, and that infant circumcision should not be routine anywhere. I would attach most weight to the argument that infant circumcision is a denial of the right to bodily integrity and follow that up with the consideration that it is done without consent, and can easily be postponed until the infant grows up. Where consent can truly be claimed to be informed, adult circumcision should not be so problematic. Current mass male circumcision programs in African countries are demonstrating clearly that most adult men do not choose to be circumcised; whether those who have consented are appropriately informed is open to question.

But the most important objection against mass male circumcision as a HIV transmission reduction intervention is, in my view, that not all HIV transmission is a result of sexual intercourse. Circumcision does not reduce non-sexual HIV transmission, for example, that which is a result of unsafe healthcare, cosmetic or traditional practices. The majority of circumcisions in Africa are carried out in traditional, non-sterile conditions. But even conditions in hospitals and clinics are well known to be unsafe. The UN are very clear on this point, issuing its employees with their own injecting equipment when they are in developing countries because "there is no guarantee of the proper sterilization of such materials." UN employees are also reassured that "We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment."

The US Centers for Disease Control (CDC) states that "Injection safety is part of the minimum expectation for safe care anywhere healthcare is delivered; yet, CDC has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors.  How can this completely preventable problem continue to go unchecked?  Lack of initial and continued infection control training, denial of the problem, reimbursement pressures, drug shortages, and lack of appreciation for the consequences have all been used as excuses; but in 2012 there is no acceptable excuse for an unsafe injection in the United States."

But what about safe healthcare in developing countries? The Safepoint Trust finds that each and every year due to unsafe injections there are:

  • 230,000 HIV Infections
  • 1,000,000 Hepatitis C Infections
  • 21,000,000 Hepatitis B Infections
  • The above resulting in 1,300,000 deaths each year (WHO figures)
  • Syringe re-use kills more people than Malaria a year which the WHO estimate kills 1,000,000 a year (WHO)
  • At least 50% of injections given were unsafe (WHO)

Safepoint only reports on injections. What about other healthcare procedures that may spread diseases, especially deadly ones? Many health facilities lack basic infection control capabilities and supplies, such as clean water, soap, gloves, disinfectant and much else. There are also the risks people face as a result of cosmetic procedures, such as pedicures and tattoos, and traditional procedures, such as scarification, male and female genital mutilation and traditional medicine.

Why are we even talking about something as invasive as circumcision, involving tens of millions of men and possibly hundreds of millions of infants? So many medical procedures are already carried out in unsterile conditions and can expose patients to risks of infection with HIV, hepatitis and perhaps other diseases. The circumcision operation itself is a risk for HIV and unless the risk of hospital transmitted HIV infection is acknowledged, it is not acceptable to carry out these mass male circumcision programs. It is not possible to claim that people can give their informed consent where they are unaware of the risk of infection through non-sexual routes.

A third important objection to mass male circumcision is that people in developing countries, particularly the high HIV prevalence African countries where all these mass male circumcision programs are taking place, are denied many of the most basic types of treatment. How can we propose universal infant circumcision where half of all infant deaths and a massive percentage of serious infant sickness is a result of systematic denial of basic human rights, such as access to clean water and sanitation, adequate levels of nutrition, decent living conditions, basic health services, an acceptable level of literacy and education, employment, infrastructure and a lot more?

To force 'healthcare' in the form of mass male circumcision programs on people who are lacking so many more important things is extremely patronizing, at best. But to force unsafe healthcare on people who have little access to the kind of information they need to be sure that they are protecting themselves against infection with HIV and other diseases, and against all the threats of unsafe healthcare, would be criminal behavior in western countries. Why are western countries silent about this treatment of people in developing countries? Are we punishing Africans for their poverty and lack of development, or just for their perceived sexual behavior? Mass male circumcision programs do seem very much like a form of 'retributive healthcare'.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Saturday, December 29, 2012

A Vagina is Not a Penis, But Mutilation is Always Mutilation

Those opposing female genital mutilation (FGM) often claim that male circumcision is a completely different thing, and many have no objection to it. To the extent that a vagina is not a penis, FGM and male circumcision are quite different. But they both involve mutilation. It is not the seriousness of the mutilation of a vagina that is objected to. If it was, some forms of FGM would certainly be more objectionable than male circumcision; but some forms would be a lot less objectionable.

FGM is opposed, and rightly so, because it is mutilation, and is generally carried out without consent. It also tends to be carried out in non-sterile conditions and can lead to very serious consequences in later life. But even if it were a mild operation (for example, the American Pediatric Society's 'nick') with no long term consequences whatsoever, carried out in clinical conditions by a trained surgeon, and with parental consent, most people would still object to it.

There have been calls in the UK to make 'home circumcision' (for males) illegal, following several infant deaths as a result of the operation being carried out by unqualified people in unsterile conditions. But why should serious injury or death be required before the legitimacy of male circumcision is questioned? By what reasoning is male circumcision an elective operation that parents can legally choose on behalf of their children, but female genital mutilation an outrage?

The American Academy of Pediatrics is often cited on the subject of infant male circumcision, but they do not suggest that parents should choose circumcision for their children. They say that "the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision" and that "the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs". The academy was a bit hesitant about FGM for a while but they later expressed their opposition to all forms of mutilation, even forms that do no permanent damage.

I'm not sure what kind of ethical belief could lead one to choose circumcision for an infant. But why should religious and cultural beliefs be a reason for parents being allowed to choose an unnecessary operation for their children, one that leaves permanent damage? Surely your membership of that religion doesn't depend on your being circumcised as an infant, does it? Does it depend on the operation being carried out against ones will, or can one choose it later in life?

FGM sometimes involves removal of flesh, though it need not do so to be considered mutilation. Male circumcision always involves removal of flesh. Is it really possible that the former is mutilation and the latter is an elective operation just because of the differing gender? And what about the claim that infant male circumcision is 'easier', 'causes less pain', or is in any way preferable to adult circumcision? Is there any basis for the claim, or is it only made to justify the lack of consent involved in infant male circumcision? Would anyone make the same claim about FGM (which is not generally practiced on infants)?

My view of the right to bodily integrity is that it applies equally to males and females, infants and adults, and to people of all religions and cultural groups. FGM constitutes a denial of the right to bodily integrity and ignores the principle of informed consent, but so does male circumcision (excepting cases where there is a medical need). A tolerant society would allow people their religious beliefs, but it would at the same time protect all people from injury. Nobody is being denied their "right to freedom of thought, conscience and religion" as a result of the right of all, male and female, to be protected from bodily harm.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Monday, December 24, 2012

Safe Healthcare and Bodily Integrity For All

Opposition to male circumcision need not be based on the claim that the operation is harmful, nor on the claim that it is more or less harmful than female genital mutilation (FGM), or various other processes. The facts that it is harmful, and can be more harmful than certain instances of FGM and other processes are important, but not as important as the fact that infant circumcision, like infant FGM, is a denial of the right to bodily integrity. Therefore it is no good claiming that it is cleaner, looks better, protects from diseases, etc. Those considerations, even if true, can not be used to deny the right to bodily integrity.

Many things are good for people's health and far fewer are campaigning for them, such as safe healthcare in developing countries. This is also a human right; hopefully safe healthcare rather than just any old healthcare. There is a lot of evidence that it is unsafe healthcare that causes much of the mortality and morbidity in countries with a high disease burden. We don't even need to carry out expensive research to show that safe healthcare improves health. So why the billions for circumcision, and the heavy handed campaigning, when there are more obvious and more urgent things that need to be addressed?

When it comes to the claim that circumcision reduces HIV transmission, there are several serious problems. For a start, it reinforces the view that most HIV transmission is sexual transmission, even though none of the randomized controlled trials excluded the possibility that some of the people who were infected were not infected through sex. If most HIV transmission is sexual it is unlikely circumcision will have much net benefit, especially when you consider that it is thought to increase transmission from men to women. But if most HIV transmission is not sexual, circumcision will very likely increase the risks that men face, given the conditions in healthcare facilities in high HIV prevalence countries.

Where FGM is banned, it is not permitted just as long as the conditions under which it is carried out are hygienic; it is not allowed if it is a cultural practice; the possibility that it might have some health benefits is not generally even discussed, except to deny that it has any health benefits. But mass male circumcision is aggressively promoted where many women can not even give birth in safe conditions, where people donating blood risk infection with HIV and hepatitis, where the majority of HIV infections occur in long term, monogamous relationships for which no serious sexual risks can be identified.

According to the arguments of the circumcision enthusiasts, every man in the world should be practicing male circumcision. But it's not much practiced in Ireland, or anywhere else in Europe. So why is it acceptable for rich countries to use foreign aid money to carry out mass male circumcision programs in African countries? Is it because we believe that, while HIV is mostly transmitted through male to male sex and intravenous drug use in rich countries, that it is mostly transmitted through unsafe heterosexual sex in African countries? Why do we believe that?

But if we even do a little superficial research, or read UN information leaflets, we must also know that conditions in health facilities in developing countries are unsafe, that blood and skin piercing instruments can be contaminated with HIV and other diseases; isn't it fairly telling that UN employees are issued with their own injecting equipment when going to developing countries? So how can we not believe than some HIV transmission occurs in African hospitals? And how can we believe that only about 2.5% of all HIV transmission in African countries is a result of unsafe healthcare, when the UN warns its own employees about these risks?

Even if the figure is as low as 2.5%, if health facilities are dangerous then half a million Africans could be infected from mass male circumcision programs alone. And it would be difficult to estimate how many infants and boys might be infected with HIV and other diseases through non-medical circumcision, which is what the majority receive. Are we so obsessed with 'African' sexuality that we think there are no other important HIV risks but sexual? The best way to reduce HIV transmission would be to prevent all risks, not just sexual risks. The UN has made a start in reducing the risk of infection among UN employees working in developing countries, but Africans would be wise to note the advice that is given out to non-Africans.

The problem is, of course, that health facilities have been all but ignored since the World Bank and IMF's 'structural adjustment policies' of the 1980s insisted that African countries needed fewer facilities, fewer health professionals, less money spent on training and lower salaries. There is vague talk about 'health systems strengthening' and other nice-sounding programs. But big donors still seem to favor vertical health programs, where separate, parallel health structures need to be set up for each initiative, whether it's polio, cholera, TB, lymphatic filariasis, onchocerciasis, HIV or whatever. Mass male circumcision is just another vertical program, each one destined to cost perhaps as much as real health systems, that people urgently need. And as for safe healthcare? No, that would be too much like development.

The UN is in an odd position because they claim that health facilities are safe enough for Africans as only 2.5% or less of all HIV transmission is a result of unsafe healthcare, but these facilities are not safe enough for their own employees. Even tourists going to African countries can purchase supplies of needles and syringes and they will find warnings about using health facilities in many countries in their guidebooks. It's no secret, just as long as you are from a wealthy country. Can we conclude that, not only are Africans almost uniquely susceptible to sexually transmitted HIV, even where conditions in health facilities are appalling, but also, foreigners from rich countries are uniquely susceptible to healthcare transmitted HIV? If so, then HIV is indeed anomalous.

My guess would be that the UN is telling the truth to its own employees about the dangers of health facilities in developing countries. Therefore, they must be lying when they claim that 80% of HIV transmission is a result of unsafe sex and about 18% is a result of mother to child transmission. So mass male circumcision programs will not reduce HIV transmission via sexual intercourse. On the contrary, they will probably result in increased HIV transmission through unsafe healthcare.

This is not entirely bad news. Since infant circumcision is a denial of the right to bodily integrity, will probably not result in a net reduction in HIV transmission and will cost a lot of money that could better spent on other diseases, mass male circumcision programs will clearly have to be stopped immediately. And that should free up scarce resources for more urgent issues, which should not be very difficult to identify.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Thursday, December 20, 2012

FGM and Circumcision: Rights for the Goose & Rites for the Gander

Things seemed to be looking up in Germany a few months ago when a court ruled that circumcision constituted bodily injury. But Muslims and Jews protested and the country passed a law protecting circumcision, as long as parents were informed about the risks. In the interest of protecting religious freedom, the right to bodily integrity has been denied. Perhaps male circumcision is being viewed as being no more serious an injury than ear piercing. But it is a lot more serious, which is why the question about it arose in the first place; a baby boy's genitals had been mutilated, and this is just one of the risks.

Certain forms of female genital mutilation (FGM) are undoubtedly a far more serious bodily injury. But others may be little more serious than ear piercing. None are, apparently, sanctioned by any religion. One might expect that it is not the level of injury that is involved that makes FGM an offence in countries where it is forbidden by law. Ireland has passed such a law: female genital mutilation "means any act the purpose of which, or the effect of which, is the excision, infibulation or other mutilation of the whole or any part of the labia majora, labia minora, prepuce of the clitoris, clitoris or vagina of a girl or woman". But I'm not sure about any kind of mutilation that is not permanent, such as nicking or pricking.

However, male circumcision unambiguously involves excision, permanent and irreversible damage, indeed, mutilation. If the issue ever arose in Ireland we may take the German option of hiding behind religious freedoms. But couldn't the FGM act then be challenged on the grounds of cultural freedoms? Perhaps not. But male circumcision can not generally be claimed to be "necessary for the protection of [a man or boy's] physical or mental health". Neither consent nor parental consent can be accepted as a defence for FGM, so why should they be for male circumcision? The same goes for being required or permitted for customary or ritual reasons. Even taking someone out of the country for the operation is not permitted.

In the UK, a circumcision that was carried out by a midwife using a pair of scissors on a 27 day old boy went wrong and the boy died. There is more than one offense there, but should a circumcision carried out by a qualified surgeon in a clinical setting with the consent of the parents be any more acceptable? If the operation is being carried out for religious or cultural reasons, surely it can wait until the child grows up? Maybe it is easier, cheaper or whatever is claimed by those who want it done to infants (thought I doubt if these claims are in any useful sense true), but it is a clear denial of a boy's right to bodily integrity.

Of course, many people may grow up not at all bothered whether they are circumcised or not. But if there is a right to bodily integrity, it also exists when people have no objection to what may be seen as infringements of that right. Thus, FGM is not permitted even if the person (who must be over 18) gives their consent, unless there is 'no resultant permanent bodily harm'. If a law were to protect people against infringements such as infant circumcision, it would not be an objection to the law that they may want to be circumcised, or that many people have grown up having been circumcised as an infant and are happy with that.

What bothers me is that male circumcision is not generally required or permitted for 'customary or religious reasons' in Ireland, Germany or the UK, yet none of these countries, or any other European country, appears to have any objection to mass male circumcision campaigns being aggressively promoted in African countries. These campaigns involve misinformation, political arm twisting, deceit and downright lies. But they are being carried out, supposedly in the name of HIV prevention, where they may do a lot of harm, and even in countries where HIV prevalence is higher among circumcised than uncircumcised men. Why are Ireland and other Western countries not objecting to this?

The mass male circumcision programs in African countries appear to be entirely funded by the US. But countries that would not consider such programs themselves, even for the 'public health' benefits claimed for the operation, should be questioning the right of the US to take such action. Male circumcision is itself a bodily injury, I would argue, but the risks of additional serious injury involved, on such a scale, should be enough to make people question these programs. Denial of the right to bodily integrity on such a massive scale, carried out by a wealthy and powerful country, in poor countries where inequalities are so high and healthcare is so inaccessible and unsafe, is an extremely destructive and divisive form of cultural imperialism.

It's something of a truism that male circumcision is not the same thing as FGM; but on a continuum from, say, ear piercing to FGM, male circumcision is a lot more serious than ear piercing. While ear piercing may not generally be seen to constitute an infringement of the right to bodily integrity, male circumcision, I would argue, always does. It is an infringement whether people who have been circumcised think so or not. Even if they have no objection to circumcision, they could still have been allowed them to make the decision to be circumcised for themselves.

Some countries see fit to permit infant male circumcision, but what right does the US have to aggressively promote such a practice in African countries, regardless of whether HIV prevalence is higher or lower among uncircumcised men? Ireland and other countries have taken a commendable stand against FGM, so why not infant male circumcision? Perhaps Germany has its reasons for avoiding a confrontation with Jews and Muslims. But if Jews and Muslims are not confronted about infant male circumcision, how can we justify confronting cultures where FGM is (or was) permitted? Indeed, the contradictory stances make objections to FGM sound like just another instance of cultural imperialism, which is not a conclusion we would like to come to, is it?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Monday, December 17, 2012

HIV: We May Not Know Best, But We Know Better Than You

My blog posts are a response to people I've met, things I've read, thoughts I've had and the like. The following post is partly inspired by, and wholly dedicated to, someone I met today. I hope it is the beginning of a fruitful exchange of thoughts.

If someone decides that they are not going to take medication and you want to reassure them that the drugs are safe, or that they are for the best, what do you tell them? While arguing that the fact that some drugs have turned out to be unsafe doesn't mean all drugs are unsafe sounds logical enough, would this change someone's mind? Surely the fact that some widely used drugs have serious side effects and can be prescribed to people to whom they do more harm than good would only increase their concern. And if you conclude that their concerns are legitimate, what if they also decided that they would not allow their child to have medication that had known side effects, and perhaps were not even specifically recommended for children?

I'm not opposed to the use of medicines myself; I would go to a doctor if I felt I needed to and I would bring a child to a doctor if I felt I needed to. I would also strive to take the doctor's advice. But there could be instances where I disagreed with the doctor. An example could be a urinary infection, for which the doctor recommended (male) circumcision (not that I think this would generally happy, just that it is sometimes cited as an argument for circumcision). Kids get all kinds of infections; some just disappear and others can be treated with drugs. The fact that the doctor recommended circumcision would not persuade me to have the child circumcised. If the condition was clearly caused by lack of circumcision and would be likely to persist or recur without circumcision, then I might consider it.

Mass drug administration (MDA) in countries where there is little modern healthcare is very difficult. People don't come running to the clinics just because they don't normally have access to free healthcare. Rather, MDA programs take a long time to prepare and involve a lot of work, and still often result in most people either not receiving the drug or not taking it. Rigorous programs to eradicate serious conditions such as lymphatic filiarisis (LF) do not always produce good results quickly. LF can lead to elephantiasis, causing grotesque swelling of the legs and scrotum. It is very visible. But people who do not have it, or have no symptoms, do not necessarily see the point in taking drugs.

It's quite natural to question the use of some drug or procedure, whether it is supposed to prevent or treat something. It may not work or it may have side effects, maybe even side effects that are more serious than the condition to be treated or prevented. In countries where healthcare is rare and safe healthcare is even rarer, questioning the need for or safety of the drug or procedure may be even more important. For the very reason that the threat is greater, the need for questioning is also greater. And yet, in places where healthcare is scarce and not too safe, MDA and other blanket programs tend to be paid for and implemented by outsiders, people whom those receiving the drug or procedure have no reason to trust or obey (because it is obedience that seems to be expected).

So what can we make of these figures in the Washington Times that show that 1.5 million Africans have been circumcised, or have given consent for their children to be circumcised? If it is difficult to persuade people to take drugs how could it be so easy to persuade them to be circumcised, or to allow their children to be? It is thought that adults who decide not to take drugs, such as those for LF, don't give them to their children either. That also strikes me as being quite natural. If it's not good for you why should it be good for your children? So why have 1.5 million people agreed, or agreed on behalf of someone else to be circumcised?

It may seem shocking that someone would refuse medication, and even more shocking that they would refuse medication for their children. But it seems even more shocking that some people don't have the option to refuse drugs or procedures that they believe to be either unnecessary or harmful. If the Washington Times figures are correct, how was this brought about? Were people put under pressure? Were they lied to? Were they made to think that their children would benefit from the treatment, or that their lives or their children's lives would suffer serious consequences if they did not comply (or obey)? It's shocking enough that "leading public health and anti-AIDS groups have set a goal of circumcising some 20 million men in 14 Africa countries by 2015", but why have 1.5 million people already given in and been circumcised?

Were they told they would be infected with HIV (or a host of other diseases the circumcision campaigners have added in), or that their children would be infected? Were they told that everyone is doing it, that women also like men to be circumcised, that it is hygienic, etc? It seems that many of these claims are being made, but none of them are completely true; none of them, on their own or together, constitute good or legitimate reasons for being circumcised or for having a child circumcised. Adults can quite safely decide to be circumcised or not. But why should they be persuaded to make that decision for their children? Are they told it's less painful, less difficult, safer or whatever else? Because none of these claims are true in any useful sense.

I am happy to accept that there is a virus called HIV and that it generally causes AIDS, but there are many questions about HIV transmission, such as why the most serious epidemics are in a few parts of some countries. I also do not accept that HIV is mainly sexually transmitted, nor even that sexual behavior among people in places where HIV prevalence is high is significantly different from other places, where HIV prevalence is low. Therefore, I can not accept that circumcision will reduce HIV transmission significantly; and I certainly don't think reducing HIV transmission could be a reason for deciding to have infants and children circumcised when they can easily be allowed to grow up and make this decision for themselves. As for the drugs, if I was very sick I would hope to find something to make me better, and I would hope for the same for my children.

But there is little I can say to reassure someone who refuses drugs, for HIV or any other disease, for themselves or for their children. Even if 99% of advice that our healthcare experts give us is good advice, how can we tell which is the 1% (although I'm pretty sure the figure is not as high as 99%)? Public health programs seem to require high levels of adherence (or obedience), but is adherence more important than benefit? It seems that public health programs may place a higher emphasis on everyone doing what they are told, for their sake or for the sake of someone else, or everyone else, regardless of whether they benefit, or even if they suffer undesirable consequences.

While we might wish to think we have some autonomy when it comes to public health for ourselves and our children in Western countries such as Ireland, compared to people in developing countries anyhow, maybe we don't always have as much choice as we think. Perhaps that needs to be put to the test. This is true of HIV, especially, because it's often presented to us as a matter of individual responsibility and individual behavior. If that's true, why should we make a decision about whether to take or refuse a drug or procedure, for ourselves or for our children, for the greater good of the population as a whole? I know I have a choice about certain things relating to health, but I know I don't have a choice about others; if I were to be HIV positive, or if my child were thought to be positive or at risk of being infected, decisions would not be entirely in my hands. If 'reassurance' were enough to persuade someone to avail of a drug or procedure, for themselves or their child, I'm not yet in a position to give them that reassurance.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Wednesday, December 12, 2012

It's Good to Ask Questions, Even Stupid Ones Sometimes

There's an article in the UK's Argus newspaper about a professor in Brighton University who is being criticized for denying that HIV causes AIDS. He plans to screen a film called House of Numbers, which uses typical journalistic sleight of hand to argue the its case. But why are people so worried about students being subjected to this film? The arguments in the film are so pathetic that secondary school students could easily see through them. So university students should be well able to deal with the issues, but only if they see the film. Protesting about the screening before it happens makes it sound as if they might all run the risk of being convinced that HIV does not cause AIDS just by watching it.

The problem with arguments such as those used in the film is that the HIV industry and those upholding mainstream views about the virus tend to over simplify things. If someone suggests anything they don't agree with, they brand them as a denialist. If someone questions the extent to which HIV is sexually transmitted in African countries, for example, their views are quickly dismissed. I have been called a denialist myself; it's far easier than arguing against the evidence that a substantial proportion of HIV transmission may not be sexual. However, it is perfectly consistent to dismiss denialist arguments while continuing to question the view that 80% of HIV transmission in African countries is a result of heterosexual sex.

Those making the film were easily able to find people who disagreed with various aspects of the mainstream view of HIV. But not all of those people would also deny that HIV causes AIDS. I certainly don't deny that HIV causes AIDS, but I do think HIV figures are frequently massaged by various parties for financial or other reasons. This is not something that only happens with HIV, the entire pharmaceutical industry runs on presenting dubious figures, partial findings or downright lies to maximize their profits. Views such as mine don't even sound like a denial that HIV causes AIDS. But it is useful for both sides of the argument to conflate denial with simply questioning certain aspects of the mainstream view for which there is little evidence.

I don't agree with the professor in question, but that's because I have seen the film. How can anyone claim to disagree with a film that they haven't seen? In order to disagree with something, you need to understand what it is first. The nature of HIV and its modes of transmission is not a matter of aligning yourself with a particular political view, or at least, it shouldn't be seen that way. Hearing what your opponent has to say is not something you should shy away from, not if you want to demonstrate why their view is wrong. House of Numbers is a good example of a piece of pseudo-scientific tosh put together to suit the interests of those involved in making the film. It is important for people to know that just because something is published in the mainstream media, a scientific journal or made into a film, that doesn't make it fact.

Sadly, a lot of articles published in peer reviewed scientific publications depend on assumptions that are completely unfounded, but are often unstated. House of Numbers places several arguments in a context where people can judge them for what they are. Most scientific publications are inaccessible in various ways; they are expensive to people from outside the scientific community, and also, scientific papers tend to be constructed in a way that excludes most people because it takes years to learn how to understand them. A film about how the scientific community view HIV transmission and HIV epidemics might allow far more people to raise questions about what kind of unspoken assumptions must lie behind the lofty pronouncements of people who speak in shibboleths and rarely deign to talk to those who are not also scientists.

Let everyone that wants watch House of Numbers; those with a questioning mind will refuse to accept the message that the film tries to spoonfeed us with. But let's also question other views about HIV. Mainstream views about HIV transmission also need to be scrutinized: how are we to understand it when we are told that the same virus that mostly infects men who have sex with men and intravenous drug users in Western countries mostly infects heterosexuals, in huge numbers, in certain parts of certain African countries? We are told that HIV is hardly ever transmitted through unsafe healthcare in these same African countries, yet it transmitted in this way in several non-African countries, such as China, Kazakhstan and Kyrgyzstan.

Most of us don't even need to think about whether we believe that Africans have weird sex lives, that they don't care whether they infect their partner or their children with an incurable virus; we reject the view immediately. But mainstream views of HIV transmission assume that sexual behavior is completely different in areas where HIV prevalence is high, and it is highest in a few African countries. HIV policy is based on such mainstream views and billions of dollars have been spent on implementing programs based on these policies. So if we don't think such terrible things about Africans, we need to question why policies, programs and funding are the way they are.

The good thing about House of Numbers is that it asks questions that need to be asked. The fact that the film gives implausible answers means that the whole exercise backfires on itself. If the mainstream view of HIV were to be similarly scrutinized, with questions being asked and answers being constructed to suit the interests of those answering, and transparently so, people might know a lot more about the HIV industry than they do now. They should be able to see that the mainstream view of HIV is entirely self serving. And it should be very clear how thoroughly racist it is to point the finger at the sexual behavior of African people when there is evidence that a large proportion of HIV transmission is not a result of sexual behavior; we just don't yet know how much.

[For more about non-sexual HIV transmission, see the Don't Get Stuck With HIV site.]


Mass Male Circumcision Recommended Even Where it Increases HIV Transmission

I commend The Guardian (UK) for covering the issue of circumcision from the point of view of those who are opposed to it. It's in their Science section, though it is also an important issue for development, given that it is being marketed aggressively in developing countries as a HIV intervention, and given the billions of dollars of 'aid' money that have been earmarked for these idiotic campaigns. However, the development section in The Guardian is sponsored by the Gates Foundation, which funds circumcision in high HIV prevalence countries and doesn't appreciate dissenting views. Anyhow, the fact that serious opposition to circumcision is being raised in a relatively open-minded newspaper is very heartening.

The campaigns in African countries are doing a lot of damage in the sense that hundreds of thousands of people have already agreed to be circumcised and many people seem to believe the pro-circumcision propaganda. But nowhere near the number expected are agreeing to the operation. And the majority of those being circumcised are not adults, the very people who are most at risk from sexual transmission of HIV, if the propagandists are to be believed. It's mostly teenagers that have been persuaded that the operation will be more difficult or more painful if they wait till they are adults. I'm not sure if that's what they have been told or if it is what they are allowed to believe; either way, what does it mean? Cutting off a healthy piece of flesh is the same whether you are an infant, child, teenager or adult.

Adverse events may be less frequent during infant circumcisions, but that is not a reason to make a decision that could easily be left to the person when they are an adult. After all, the majority of men will probably decide not to be circumcised, which is the best way of eliminating adverse events altogether. It may be objected that circumcision is said to give some protection against some fairly easily avoidable conditions, many of which will not be a risk till adulthood anyway. But this still doesn't make circumcision sound like something that obviously needs to be carried out universally. There doesn't seem to be anything about circumcision that makes it urgent, something that needs to be done to infants or children, or people who have not reached a stage where they can make up their own minds.

One of the most pathetic arguments is that the child should 'look like their father', which doesn't hold much sway in countries where the operation is not yet common. But I've never heard of anyone refusing to circumcise a child whose father was not circumcised just so the child can look like their father. Their father may have a tattoo or a pierced penis, but this would not be permitted on an infant just so he could resemble his father. The argument about resemblance may be more popular in Western countries anyway. But what about the claim that circumcision is 'cleaner'? Dirty finger nails are unhygienic but we don't remove finger nails. Instead, we wash our hands and use a nailbrush. Not that I'm suggesting people use a nailbrush on their penis, but if they have difficulty washing themselves, it's hard to see circumcision alone helping them much.

Of course, there is nothing that could be called debate in countries where people are simply bombarded with publicity; campaigns exhort men to 'stand proud' and that 'wise men make smart choices' (even though the main targets are teenagers; men tend to choose not to be circumcised), etc. The effectiveness of circumcision, and not just against HIV, is presented to people in Kenya and other African countries as if there is no room for doubt, as if it is just another aspect of modern healthcare, like vaccination, giving birth in health facilities and going to a hospital when you are sick. But with infant circumcision there isn't even the pretense of making a choice; the choice is made for you by a parent or by both parents.

The vast majority of males, even in high HIV prevalence countries, do not face much risk of being infected until they are well into their twenties. So there is no excuse for circumcising infants and claiming that it reduces sexual transmission of HIV and other sexually transmitted infections. Even if it can do so in theory, it will not prevent infections among those who are not sexually active. The fact that the majority of men may choose to remain uncircumcised may worry those who think public health is something that should be imposed on Africans whether they agree or not. But most of us would claim to be against imposing 'public health' measures, whether through lies, trickery, force or by any other means. We would expect informed choice to be involved, even where the intervention has been shown to be beneficial.

So much for the pretense of legitimacy. But what about the 'science'. HIV prevalence is higher among uncircumcised men in some countries (such as Kenya) and higher among circumcised men in other countries (such as Zimbabwe). If HIV is 'scientifically proven', does that mean it should only be introduced in Kenya and other countries where HIV prevalence is lower among circumcised men? And in countries like Zimbabwe, where HIV prevalence is higher among circumcised men, what would the public health experts recommend? They seem to be recommending circumcision, and hence increased HIV transmission. Imposing a public health measure for which there is weak evidence of benefit, without informed consent, is bad enough, but what about imposing a public health measure which the evidence suggests will do harm?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Thursday, December 6, 2012

WHO to Continue Dithering Over Depo Provera Risks?

Lest we forget what HIV related institutional racism looks like, there are frequent reminders. The UN's IRIN/PlusNews runs a good example this week, entitled 'Uganda: Profiles of infidelity, HIV vulnerability'. If you formulate your favorite prejudice so that it looks superficially like a hypothesis, it's not very difficult to find anecdotes that seem to supply superficial evidence. The authors interview four African women who obligingly illustrate the 'all women are victims; all men are promiscuous' prejudice.

According to the article, "Married or cohabiting couples are at a higher risk of HIV infection in Uganda than their single counterparts, with some studies finding that as many as 65 percent of new infections occur in long-term relationships." What they don't mention is that they have no idea what proportion of that 65% of infections are sexually transmitted and what proportion are non-sexually transmitted. But of course: "The prevailing culture, a hybrid of traditional mores and more modern, western values, accepts - even expects - men, and increasingly women, to have a "side dish" - a euphemism for a sexual affair." So we can just guess.

It's easy enough for us to accept the above because mainstream and specialized media sources generally say the same sort of thing, though their remarks may be couched in different terms. We are not encouraged to question the underlying views about women or Africans, nor even to suggest that you could find people in any country who would talk similarly about their experiences of sex, gender, relationships and many other matters. This is not to cast doubt on any of the anecdotes, nor of all the stories we hear about gender inequalities, gender based violence, promiscuity and the like. But these issues prevail everywhere, not just where HIV prevalence is high.

None of these stories explain why HIV prevalence is so high in some parts of Uganda. But nor do they address any of the social issues mentioned, which tend to be alluded to most when they can be associated with HIV. Gender based violence, for example, is abhorrent, occurs everywhere, and needs to be addressed whether HIV infection is involved or not. But to address HIV transmission, it needs to be clearer exactly how it is being transmitted in order to even know who is most at risk. Knowing that most of the people infected are married or are in long term relationships does not tell us how the virus is being transmitted.

I don't wish to single out IRIN/PlusNews as if they are the only biased and prejudiced news outlet. And, rather surprisingly, they also have an article this week giving some recognition to the fact that injectable hormonal contraceptives, such as Depo Provera, have been associated with a doubling of transmission from HIV positive women to men, and a doubling of transmission from HIV positive men to women. The article fails to point out that WHO simply did not warn people, but it goes further towards warning people than WHO themselves have done. Of course, it doesn't sound obviously racist to fail to warn women about these risks, until you find out that most users of injectable hormonal contraceptives are Africans and African-Americans.

Apparently WHO are going to discuss the issue this week, after making such a mess of it in May and January of this year. Even if they do make the risks clear this time, it is not at all certain that this will have any impact on the organizations that have been ruthlessly pushing these products, despite knowing the dangers. The best WHO have come up with is to warn people who are HIV positive, or who are considered to be at risk of being infected, to also use condoms. That's bad enough considering those pushing the method say injectables are a useful option where condoms are not used much, for whatever reason. But who is at risk? According to the article about infidelity in Uganda, almost everyone is at risk. Branding everyone as promiscuous renders targeting impossible.

Several people mentioned in the article said that WHO have, so far, tried to muddy the waters as much as possible and control what is said about Depo Provera and other such products. But a representative of AVAC tries to muddle out of the mess by claiming that they are "fundamentally communicating uncertainty". In fact, they are demonstrating how easy it is to lie and to deceive people whose risk of being infected with or of transmitting HIV is high (or is perceived as being high). WHO and the rest of the HIV industry are continuing to stigmatize African people for what is said to be their promiscuous sexual behavior; they want injectable contraceptive use to continue to rise so that organizations and businesses can realize their own goals, ideological, financial and whatever other form they may take.

Incidentally, AVAC calls itself a "non-profit organization that uses education, policy analysis, advocacy and a network of global collaborations to accelerate the ethical development and global delivery of AIDS vaccines, male circumcision, microbicides, PrEP and other emerging HIV prevention options as part of a comprehensive response to the pandemic". This is a long and tortuous way of saying they are a pharmaceutical industry front group; rampant institutional sexism and racism are not going to get in their way and an increase in transmission of HIV is but a small price to pay.

As part of his continued pursuit of philanthropy at all costs, Bill Gates has adopted population control (to put it mildly) as his development paradigm. His wife has argued that Depo Provera and similar products are popular in African countries without mentioning how aggressively marketed they are. The Gates Foundation has partnered up with Pfizer, who make Depo Provera, just in case anyone should doubt the place of injectable contraceptives in Gates' plans for Africa, however destructive they may be.

Assuming that HIV is almost always transmitted through heterosexual behavior in African countries (though not elsewhere) is not only highly insulting to Africans, and especially to African women; it also results in other factors that facilitate HIV transmission being ignored, such as use of Depo Provera and other injectable hormonal contraceptives, unsafe healthcare and various co-factor diseases (for example urogenital schistosomiasis, which may quadruple the risk of HIV infection for women living in certain areas). WHO need to lose their role as lackey to Big Pharma and return to thinking of health as a right, not a commodity.

[For more about non-sexual HIV transmission and injectable hormonal contraceptives like Depo Provera, see the Don't Get Stuck With HIV site.]


Tuesday, December 4, 2012

HIV and Prevention: Where There's Money, There's a Way?

The WHO (World Health Organization) finds that Pakistan has "high rates of unscreened blood transfusions and a very high demand for therapeutic injections and poor infection control practices in hospitals and clinics nationwide", which can lead to transmission of HIV and other diseases. It's a big step for the WHO to talk about non-sexually transmitted HIV in this way, and I hope their 'concern' also extends one day to sub-Saharan African countries. Because, even if infection control practices are a lot better in African countries than they are in Pakistan, and that's a very big if, the risk of healthcare transmitted HIV is still high in Africa because of the huge numbers of HIV positive people in some populations.

UNAIDS once pooled together some available figures on HIV and unsafe medical injections in a group of African countries, but they came to some fairly half-hearted conclusions about the issue. They found that "receiving multiple medical injections is significantly positively associated with being HIV-infected, for both women and men. Ever having received a blood transfusion also tends to be positively associated with being HIV-Infected". They further find that "few adults perceive the risk of HIV infection from having injections or blood transfusion". After many years and hundreds of millions of dollars of HIV education, it seems hard to believe that people are not aware of non-sexual risks, especially from contaminated blood and unsafe healthcare.

The UN itself is so acutely aware of the risks of hospital transmitted HIV that they have issued a booklet for their own employees, warning that "Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere." The problem is that UNAIDS' HIV prevention interventions do not warn Africans about these risks. Instead, Africans are told that 80% of HIV transmission is a result of unsafe sex (and about 18% is a result of mother to child transmission).

The totally misguided mass male circumcision programs (also called 'safe' male circumcision or 'voluntary' medical male circumcision) have a particularly nasty sting in the light of the above considerations. If HIV is not almost always transmitted sexually, circumcision will not prevent as many infections as enthusiasts are projecting. But also, conditions in sub-Saharan African health facilities are poor enough to warn UN employees against, so how can they provide in excess of 20 million circumcisions safely? The simple answer is that they can't, the UN can not ensure that the operations will be safe, not safe enough for their own employees, anyhow.

The oft-cited randomized controlled trials of mass male circumcision have already made it clear that it is not circumcision on its own that explains differences in transmission rates in circumcised and uncircumcised populations because HIV prevalence is as often higher among circumcised men as it is among uncircumcised men. If it protects against sexual transmission of HIV, it only does so sometimes. Apparently (Hillary) Clinton has a "blueprint for reaching an AIDS-free generation which includes throwing more drugs at the problem and circumcising men.

Making antiretroviral drugs available to everyone who has a clinical need for them is vitally important, and it has proved its worth by keeping millions alive who would otherwise have died; it has also ensured that most HIV positive women in rich countries and a majority of women in poor countries can give birth to HIV negative babies; some of them even live to raise their own children. But if we are to make drugs more widely available in order to reduce HIV transmission, we need to know which people to target. Assuming that HIV is almost sexually transmitted, as mass male circumcision programs do, will not work. But perhaps now that there is so much money tied up in reducing HIV transmission through mass antiretroviral drug administration, we will acknowledge that not all Africans are sexually promiscuous and that a substantial proportion of HIV transmission can be cut by improving conditions in health facilities.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Saturday, December 1, 2012

HIV and the Open Secret of Mass Male Circumcision

An article that begins "[The Zimbabwean] government is considering making neo-natal male circumcision compulsory as a long-term strategy for HIV prevention" may not raise an eyebrow if you have been subjected to the biased coverage in the mainstream press about mass male circumcision programs. The fact that some randomized controlled trials have shown that circumcision may reduce HIV transmission has certainly convinced a lot of people. The problem is that circumcision clearly doesn't always protect against HIV transmission and one of the countries where it does not is Zimbabwe (others are Cameroon, Malawi, Burundi, Ethiopia, Ghana, etc).

Another problem is that the randomized controlled trials did not show that circumcision protects against sexual transmission of HIV. Some people on the trial may have been infected through unsafe healthcare, or one of several other routes. This could mean that circumcision is even more effective than previously thought, of course. But it also means that we don't have a clue why or how circumcision may protect against the virus. What we do know is that the operation is unlikely to reduce transmission from HIV positive men to women, and that it probably even increases transmission. HIV positive men may already be circumcised. If they are not, they are eligible for the mass circumcision programs; so the net benefit may be negative.

But back to Zimbabwe, where HIV prevalence is higher among circumcised men. Why would circumcising anyone be beneficial? If 'the science' is behind circumcision in Kenya, Uganda and South Africa, where the randomized controlled trials suggest that the operation may be beneficial, shouldn't Zimbabwe recommend that parents do not allow their infant boys to be circumcised? Shouldn't plans to circumcise millions of Zimbabwean people, at a cost of hundreds of millions of dollars, be shelved? A spokesperson said infant circumcision was 'more sustainable' than adult circumcision. But does that mean it's cheaper? Because that is not the same things as sustainability.

The HIV industry finds Zimbabwe's HIV epidemic quite mystifying anyhow. HIV prevalence figures were estimated to be among the highest in the world in the late 90s, at almost 30%, but dropped to half that in the following 10 years. Of course, much of that drop could probably be explained by massive death rates. But it is likely that incidence, the annual rate of new infections, also dropped. The industry claims that almost all transmission is a result of 'unsafe' sexual behavior. Therefore, they are forced to believe that levels of 'unsafe' sexual behavior were reduced radically at a time when the country was experiencing political, social and economic turbulence.

There are probably several reasons why incidence declined. Radical changes in sexual behavior seem unlikely to be a result of the HIV industry's interventions because the same interventions have never been shown to have had much impact elsewhere (though the industry is loath to admit that), also because there is little evidence that Zimbabwe (or any other country) ever followed the industry's 'advice' particularly faithfully. The puzzled authors of the PLOS Medicine article above can do little but scratch their heads, but they don't even mention the possibility that health facilities may have been responsible for a significant proportion of transmission at one time in Zimbabwe and that this reduced as health facilities became less accessible.

That may be unfair to Zimbabwe health services. After all, transmission in health facilities may have reduced because conditions were improved. These are empirical questions, and ones unlikely to be answered by the HIV industry because they simply refuse to ask them, or to allow others to do so. Perhaps we'll never know. But it would seem like a smart question to ask. If HIV transmission is sometimes a result of unsafe healthcare, and it may almost never be, as UNAIDS claim, will circumcising adults make any difference? Will circumcising infants? Wouldn't it be better to reduce unnecessary operations in health facilities and concentrate on more urgent matters?

Tomorrow is World AIDS Day and one of the industry's offerings is a rather sickening song from 'Champions for an HIV-Free Generation'. It asks us what we are waiting for, tells us that circumcision is cool and clean and protects lives, that it's what the smarter generation does and advises us that if we are champions we should get circumcised. The song even mentions Zimbabwe and several other countries where HIV prevalence is higher among circumcised than uncircumcised men. This is not about whether people should or should not circumcise for religious or any other reasons, it's about the ethics of aggressively marketing circumcision for its protective benefits against HIV in countries where HIV prevalence is higher among circumcised men.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Thursday, November 29, 2012

Sex in Africa: Crime, Sin, Censure and Punishment

Disapproval of sex and measures to influence sexual behavior are nothing new. But HIV has been a godsend to those who love to disapprove, and especially those who are involved in measures to control sexual behavior. 'Use a condom so you will have fewer children' can be supplemented with 'also, you will die if you don't'. All sorts of criminal behavior, such as sexual assault and rape, commercial sex work, trafficking, organized crime and intravenous drug use, are associated with what is often just ordinary sex. The mere presence of HIV in a population is seen by the HIV industry as an indication of rampant levels of 'unsafe' sexual behavior. High levels of HIV prevalence can be used as clear evidence of behavior that can only be described as inhuman, except that we don't want to be seen to use such descriptions, thought we don't mind suggesting them.

Failure to provide women with safe sexual and reproductive health (SRH) services, even in countries where tens of millions are spent on ineffective HIV 'interventions', is a cruel and degrading form of denial. Failure to provide women with access to safe abortion is just one SRH service the denial of which can result in avoidable illness, suffering and death. In countries where SRH services are poor, inaccessible and unsafe, abortion is often a crime, punishable by law if the woman survives, even if she is seriously injured in the process. It is also a 'sin'. Yet the need for abortion can arise whether the woman has engaged in licit or illicit sex. HIV can be transmitted whether or not there is a crime or a sin being committed. Failure to provide SRH services can also result in serious injury, infection and even death. But those are neither crimes nor sins, it seems.

In countries where SRH services are considered too expensive to provide for everyone that needs them, money can often be found for contraception. Where contraception protects against HIV, this is cited as an additional benefit. But lack of contraception can not be blamed when the most urgent problem is poor, inaccessible or downright dangerous SRH services. Worse still, some forms of contraception are themselves thought to be dangerous, for example, injectable Depo Provera and similar hormonal methods. Implants and other invasive methods are aggressively promoted, like Depo Provera is, where the safety of health facilities can not be guaranteed (by the UN, for example).

Whether HIV and sex are seen as a sin or a crime or both, some countries offer women sterilization; some don't just offer it, they forcibly sterilize the woman, even telling them that it is mandated by law, apparently. In Western countries, where safe SRH services are more widely available, most HIV positive women can give birth to HIV negative babies. Advances have even been made in African countries to reduce mother to child transmission, though not as successfully as in countries where SRH services are accessible and safe. Forcible sterilizations have been carried out in South Africa, Zimbabwe, Kenya, Namibia and other countries, sometimes using funding from rich countries, where forced sterilization would not even be permitted, let alone seen as necessary.

While it may seem a lot less extreme, the aggressive lobbying and huge amounts of funding available for mass male circumcision, arguably, fits into the pattern of censure and even punishment for sexual behavior. The plan is to circumcise tens of millions of African men in countries where most are denied safe SRH services, indeed, any SRH services at all. The denial of the right to bodily integrity alone, on such a scale, should send out warning signals to those who profess a love for human rights (or even people who would see themselves as opponents of mass, multi-government sponsored oppression). But the less well publicized issue of infant circumcision, which could involve hundreds of millions of people, relates not to prudery about sex, but rather a perverse kind of prudery about the assumed sexual behavior of their parents and the future sex lives of infants, by implication (and sometimes a dangerously misinformed prudery about hygiene).

That these programs are all carried out in African countries is not purely accidental. Sex, after all, attracts censure, justified by reference to high HIV prevalence figures in African countries. The programs are even (sometimes covertly) argued for using vaguely expressed, but nevertheless neo-eugenicist grounds, the foundations of which go back to the days when population control was seen as the obvious paradigm for development (it still is by many institutions); back to the days when independence for African countries was still seen as an experiment doomed to failure (ditto); even to the days when people could openly talk about Africans as if they weren't quite people in the same sense that white people are (whatever about non-white, non-Africans).

HIV allows western institutions to continue with their interference in African countries, backed up by what is a deeply rooted racism, sexism, prudery and disapproval of people considered to be not quite like us, not quite like they 'ought' to be. It continues a long tradition of condemning people, especially women, for normal human behavior, particularly if they experience some kind of injury or are the victim of some kind of anti-social, illegal or otherwise proscribed behavior. HIV is used as just another stick to beat people over the head with, in addition to poverty, illiteracy, poor health conditions, inadequate healthcare, gender and economic inequalities, and much else. Sex is not criminal behavior, nor is illness, and health is not a result of censure, punishment or control.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Tuesday, November 27, 2012

UNAIDS: Knowledge Can Be Powerful, So Let's Keep it to Ourselves

A fairly typical UNAIDS document on modes of HIV transmission in West Africa finds that "the percentage of new infections due to unsafe medical injections is less than one percent (0.4%, range 0.1%-0.9%) and that the percentage due to contaminated blood transfusions is even lower (0.1%, range 0.0%-0.5%). The percentage due to unsafe medical injections is somewhat lower than the 1-3% found by other studies." Similar figures are extracted from UNAIDS data for high HIV prevalence sub-Saharan African countries that make unsafe medical injections sound like a very unlikely contributor to serious HIV epidemics.

UNAIDS seem intent on attributing the vast majority of HIV infections in African countries to 'behavior', mostly sexual behavior. In fact, most transmission is attributed to heterosexual behavior among people who do not appear to face particularly high risks. So how does a low risk of infection result in massive rates of infection? Only by assuming massive levels of unsafe sexual behavior, levels that are not detected by empirical investigations into sexual behavior and other risks. Using UNAIDS' methods, it is impossible to explain the kinds of prevalence figures found in some African countries without positing ridiculous levels of sexual behavior.

That's how the story goes when UNAIDS are telling Africans and non-Africans about the most serious HIV epidemics. But when they are warning UN employees who are working in African countries, in a booklet given to all UN employees called 'Living in a World with AIDS', they say quite different things. For example they say "In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections." I'm assuming that below 1% does not constitute a 'notable share'. UNAIDS go on: "Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care."

That must be a great source of relief to UN employees. As for Africans, they are told the other story, the one about 80% of HIV transmission being a result of unsafe sex. They are not told that they face non-sexual risks in health facilities. That way, it's possible to blame Africans themselves for high rates of HIV transmission. Most of the remaining 20% is said to be a result of mother to child transmission, and while we don't 'blame' mothers for causing this, poor things, they were probably forced to have unprotected sex with their evidently HIV positive and philandering husband, many women are infected in the second or third trimester, or some time after giving birth, and many of them have HIV negative husbands.

Living in a World with AIDS also says "we all have the right as UN system employees to essential prevention tools, including access to condoms, first-aid kits, new syringes and sterilized equipment for medical care, and safe blood supplies." Therefore "Because safe injection practices are not followed in all healthcare settings and it may not always be possible to purchase sterile injection devices, the WHO medical kit that is made available to all UN agencies includes disposable syringes and needles." UN employees can certainly breathe a sigh of relief because "If we receive medical care from the UN system medical services or from a UN-affiliated health-care provider, we can be confident that every effort has been made to ensure that injecting devices used to administer a shot are sterile and will not expose us to HIV." But every Service Provision Assessment carried out in an African country makes it clear that ordinary Africans do not have the same rights as UN system employees.

The forward to 'Living in a World with AIDS' notes the importance of "stamping out any stigma and discrimination associated with HIV, and speaking openly about HIV transmission", but the overall impression given is that UN employees should not be stigmatized or discriminated against. As for non-UN employees, we don't have to resort to the term 'bad AIDS' to emphasize the fact that HIV is almost definitely their own fault; except if they are an infant. But if they are a woman it's probably their own fault, as is the HIV infected infant. In fact, women are probably also responsible for tempting men, prostituting themselves or otherwise being careless or engaging in some kind of sinful or criminal behavior.

We are also reminded that "It is important to bear in mind that HIV is not easily transmitted. In the case of household employees, we assume that they will not be having sex with our family members, will not be sharing needles with them or giving them blood and will not be breastfeeding our children." That is important for everyone to bear in mind, not just UN employees. So if your partner is infected and you are not, or if your baby is infected and your partner is not, you don't need to assume that your partner has almost definitely been having sex with someone else, or that your baby has been breastfed by someone who is HIV positive, or has been sexually assaulted. But strangely, UNAIDS doesn't have much else to say about HIV positive infants whose mothers are HIV negative.

Knowledge can be powerful, as the booklet says. And there is a lot of sensible advice for UN employees. The problem is that this advice is not given to people in high HIV prevalence countries, where conditions in health facilities are appalling and ordinary people, those most at risk of being infected with HIV, do not receive free supplies of syringes and other equipment that UN employees get, and do not have the option of choosing "UN-approved medical facilities". UNAIDS are aware that "Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission." But while "We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment", what about people who are not in the 'UN system'? Shouldn't they also be warned of the risks?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Saturday, November 24, 2012

Aid and Circumcision: Just Because We Can and Because We Want To?

There is a constant stream of argument and counterargument between those who oppose and those who support mass male circumcision (MMC), the one side saying it doesn't reduce HIV transmission and the other saying it does. I am opposed to promoting MMC as a HIV prevention intervention, not because it doesn't reduce HIV, but because the evidence suggests that it only sometimes does. My objection is not that it only reduces transmission by 60%, or whatever figure is currently being bandied about. My objection is that if circumcision is associated with higher rates of transmission in some places and lower rates in others, maybe circumcision itself is not the only factor involved.

Among the mainly non-circumcising Kenyan Luo tribe, HIV prevalence is far higher than among any other tribe in the country. But there is no evidence that it is circumcision alone that results in high rates of transmission. HIV prevalence is also high among women who belong to the Luhya tribe, yet male circumcision rates are very high in this tribe. But in many other sub-Saharan African countries HIV prevalence is higher among circumcised men than it is among uncircumcised men. The problem is, all the arguments that are being used to aggressively push MMC in Kenya are also being used in countries where circumcision looks like it increases HIV transmission. That's if circumcision status on its own has any useful connection with HIV status.

A good example of this phenomenon is Malawi. HIV prevalence among circumcised men is 14%, but among uncircumcised men it is only 10%. While it is not possible to reverse a circumcision operation, pushing MMC would seem to be the most illogical action possible. Apparently the government circumcision program hopes to circumcise 2.1 million males by 2016. But why? Do they want to increase HIV transmission? Personally, I don't think the program will increase transmission very much, because I don't think circumcision status on its own has much impact on transmission, but nor will it reduce transmission.

The government is worried that only 15,000 males have been circumcised under the program, less than 1% of the target population. They feel that "something must be wrong somewhere in the process". Perhaps the electorate is smarter than the government and they can tell that 14% is indeed higher than 10% when you 'do the math'. Maybe some people have noticed the appalling conditions in health services? Or perhaps access to health services is so low that most people don't even notice this any more. Perhaps, like most sexually active men in Kenya, Malawian men just don't see the point in going through the operation. But Malawian men even have the added consideration that HIV prevalence is higher among their circumcised countrymen.

The article says that the Muslim community welcomes the project. But HIV prevalence among Muslims is higher than it is among Catholics, 11.7% compared to 9.4% (although among circumcised Catholics HIV prevalence is very high). In Malawi, as in many high HIV prevalence African countries, prevalence is far higher among urban dwellers than it is among rural dwellers. It also tends to be higher among the best educated, among the employed, compared to the unemployed, and among the wealthiest, and this tendency is particularly strong among wealthy, well-educated women.

Another article claims that Tshwane men (in South Africa) are 'queuing' for circumcision. But this doesn't mean a lot of people are agreeing to the operation, the numbers vaguely referred to seem low; nor does it mean that those doing so are actually men. In this part of South Africa, like in Malawi and Kenya, it is young boys that are coming forward to be circumcised. Apparently they are mostly between 12 and 16 years old. It's a wonder it is even legal to perform an elective operation on such young people.

It could be possible, quite cheaply, to eradicate human parasites that infect hundreds of millions of people. But it seems the aid community doesn't want to do this just because they can. However, with mass male circumcision, the aid community obviously does want to promote the operation as widely as possible, even where the evidence is against it. It is not yet clear why these aid and health professionals want to circumcise tens of millions of Africans, but the reason, according to their own data, can not be HIV reduction. It is hard not to conclude that the aid community is doing this just because they can, and because they want to. But how can this be acceptable?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Friday, November 23, 2012

Abortion: the Decision that Needs to be Made, Not Blocked

The current debates and actions for legal abortion in Ireland may have been triggered by the death of Savita Halappanavar, who died from complications following a miscarriage after being refused a clinical abortion, even though she had been told her fetus was not viable. But the issue of abortion urgently needs to be addressed in Ireland, and other countries where it is currently illegal, and not just in situations where the mother's life is at risk either.

As it is not possible to legislate against the circumstances which lead to people requiring an abortion, it is necessary to legislate about whether they should be entitled to a safe abortion. If safe abortion is available, a decision can be made about whether to have one, where a need has arisen. If safe abortion is not available, which is usually the case where abortion is illegal, people have to take other steps, which can put them in very serious danger. But making abortion illegal denies them the opportunity to make decisions that could protect them against injury, and even death. Banning abortion is refusing to make a decision about the lives of those who have a need for an abortion, and simultaneously denying them the possibility of making a decision themselves.

Holding that life begins at conception is a similar refusal to make a decision that could protect those who have need for an abortion. These are hard decisions to make, and in the case of some of the philosophical problems involved, humanity has yet to come to any solid conclusions. But we can not ask those with a need for an abortion to wait till we decide on some issues that have dogged us since civilization began. The need for access to safe abortion and for protection against unsafe abortion is too urgent to postpone making a decision on, as we in Ireland, and many other countries, have done for so long.

The issue of abortion is far more extreme in countries like Kenya and Uganda because maternal and infant morbidity and mortality rates are very high. Safe abortion is only one vital health service that people are denied. Safe healthcare of any kind is denied to most people in most developing countries. Banning abortion has resulted in women taking huge risks with their health, many having suffered terrible consequences, social as well as health-related; many have died. Far from making a moral choice about safe abortion, a choice has been made to block people from making a decision about something so vitally important.

Ireland is (or has been) very heavily influenced by the Catholic Church, which does not have a great history when it comes to the rights of human beings, Catholic or otherwise. Why Irish people still allow this institution to wield such an influence is difficult to understand. Other countries, such as Kenya and Uganda, also seem to be influenced by various Christian churches (that themselves appear to be overwhelmingly American). The reputations of powerful states such as the US, and various Christian churches, is not much better than that of the Catholic Church. So it is perplexing to be accused of breaking moral laws by institutions that preach about moral behavior, but don't always practice it.

Rather than invoking some kind of authority that goes beyond us as human beings, we need to address the issue of abortion ourselves, in terms we can understand. Political and religious leaders do not have the moral high ground they seem to assume they hold. People can not wait for decisions to be made in their name by those who are no better qualified than they are themselves. Invoking a higher authority is also a refusal to make a decision, a means of hiding behind what amounts to no more than a wish that difficult decisions didn't have to be made, a wish that things were different.


Tuesday, November 20, 2012

UNAIDS Adopts Broad Brush Approach to HIV Stigma

In my last blog post I made a statement that I feel is in need of explanation: "People who work with HIV really do distinguish between those who were infected through ways that are thought of as being within their control, and those who are infected in ways that are thought of as not being within their control. An example of the former is sexually transmitted HIV; an example of the latter is mother to child transmission."

This is highly insulting to many people who work with HIV, and that is not my intention. My objection is to the view that HIV is almost always transmitted through heterosexual sex in African countries (and hardly ever in most non-African countries; and that most of infections not transmitted through sex are transmitted from mother to child). This is sometimes referred to as the 'behavioral paradigm', and should be condemned as racist and sexist. However, I accept that many people working with HIV do not explicitly adhere to the behavioral paradigm, and that some don't even do so tacitly.

Suffice to say that I think belief in the behavioral paradigm is highly prevalent. I also think the pandemic will not end until it is acknowledged that there is a lot of evidence that a substantial proportion of transmission of HIV in African countries is not sexual. Once that is acknowledged, the issue can be addressed, and non-sexually transmitted HIV should be a lot easier to prevent than sexually transmitted. For example, a good deal of transmission may be a result of unsafe healthcare, unsafe cosmetic practices and unsafe traditional practices. Of course, such acknowledgement needs to be accompanied by taking appropriate action to address these problems. But blaming it all on people's behavior has got us nowhere.

As things stand, many HIV prevention programs, because they assume that HIV is almost always transmitted through heterosexual sex, are spread over a huge population. There is virtually no possibility of targeting because funding is limited; and if the 'target' population is, effectively, all sexually active people, often including many people who will soon be sexually active, the impact of such programs, at an individual and population level, will be very small. In addition, if the programs exclusively address sexually transmitted HIV, the virus will continue to be spread through other modes, unchecked by any warning, training or intervention.

While heterosexual transmission of HIV is not particularly efficient, male to male transmission is very efficient, especially for the receptive partner. Stigmatizing every sexually active person in high HIV prevalence countries, as the HIV industry has done, does not result in male to male sex being any less stigmatized, on the contrary. But failing to target groups who face exceptionally high risks does not protect anyone. And stigmatizing them can result in the problem not being addressed at all. Most of the billions being thrown at HIV is wasted, and very little indeed goes to those who are most in need of it.

A recent report finds that HIV incidence among men who have sex with men (MSM) in Kenya may be as high as 35%. To put that in perspective, if incidence really is that high, most men practicing receptive anal sex could be infected within three years of sexual debut. The 2009 Kenyan Modes of Transmission Survey claims that HIV prevalence among 'MSM and prison populations' prevalence is estimated at 15.2%. There is no way of guessing how much of that figure is accounted for by men having sex with men because prison populations are likely to face a lot of non-sexual risks, such as through various skin piercing procedures. But the latest figure is considerably higher. The figure for bisexual men is far lower, at 6%.

Another mode of transmission that can be very successfully targeted is mother to child transmission. Of course, it would be a lot better to establish why so many women are being infected, often in the second or third trimester, or even just after giving birth, especially when so many women have partners who are HIV negative. Telling them (or implying that) they must almost definitely have had sex with someone who is HIV positive doesn't help matters, particularly when they are sent home to tell their partner that at least one of them is HIV positive, possibly both, and possibly even one or more of their children. So, an article title goes, "Stigmatisation slows Kenya's efforts to avert mother-to-child HIV transmission". But who wants to know that they are infected with an incurable disease they are told is almost always sexually transmitted?

The article is written by someone who doesn't seem to know very much about HIV. The author writes "women end up seeking services of traditional birth attendants or deliver in poor-equipped health centers thus exposing their children to HIV". Most health facilities are badly equipped and it is in these hospitals and clinics that mothers and their babies may risk being infected with HIV. In many countries, it is women who give birth in health facilities who are most likely to be HIV positive. It would seem to be safer to give birth at home, which is quite counterintuitive when you see the living conditions for the majority of people in some African countries.

Dr William Maina, head of Kenya's National AIDS Control Program (NASCOP) bemoans the fact that "stigmatization remains a great challenge." He goes on "Some people still treat HIV as a 'special' disease. Those who are living with it are frowned upon." Excuse me Dr Maina, NASCOP exists because HIV is seen as 'special', and following the edicts of UNAIDS, WHO and other institutions ensures that belief in the behavioral paradigm is propagated. If people are afraid to use hospitals, they may have a lot to fear, but unfortunately there's no reason why they should know about hospital transmitted HIV, because the HIV industry doesn't talk about it.

Dr Maina continues with his litany of HIV industry approved statements about mothers infecting their babies, never mentioning the fact that in some countries, 15-30% of HIV infected infants have HIV negative mothers. An unknown percentage of infected mothers have uninfected partners. If mother to child transmission can be reduced from approximately 13,000 a year, that's great. But the soundest way to ensure mothers can't transmit HIV to their child is to ensure mothers don't get infected (and it's also good to ensure that babies don't get infected in health facilities). Mother to child transmission should be the exception, as it is in Western countries.

"When a pregnant woman is diagnosed with HIV, discrimination starts, particularly in the family. Her husband sees her as immoral yet many women get the disease from their spouses", according to one woman. It's not surprising that people think any woman infected has been having illicit sex, or that her partner has, since that's what people are told, incessantly, by the HIV industry. There's no point in complaining about 'stigma' and 'discrimination' when the very source of these are the industry itself. Many women do not get HIV from their spouses, but they are all branded as 'promiscuous'. Do they really believe that many pregnant women decide they will have sex with someone other than their partner, who also happens to be HIV positive? Oh yes, I forgot, they have to have sex with all and sundry because they are so poor.

"Many married women are diagnosed with HIV during antenatal clinics visit. Most of them blame their status on their husbands. The women get infected because they have little choice to make when it comes to using contraceptives or telling their men to go for HIV test" said Maina. Please, Dr Maina, UNAIDS, WHO, and all the others, try to exercise your brain a little; do you really think that most people who are infected with HIV are lying sluts? If not, have another bash at targeting HIV prevention interventions. It is a lot easier to target those most at risk when you are in a position to be frank about who those people are, and please, don't brand them as being promiscuous or dishonest or both, because that is not going to encourage them to visit your clinics. And by the way, clean up your clinics a bit, while you're at it.

I apologize to anyone who is offended by my sweeping statement about 'people who work with HIV...', but I include myself among those people. I believe that sexual transmission of HIV can be addressed in part through good education and health systems. Neither sexually transmitted nor non-sexually transmitted HIV can ever be adequately addressed in countries where health, education and various other areas of development continue to be ignored. However, denying the contribution of non-sexual transmission and continuing to disparage Africans, especially HIV positive Africans, isn't working, and it never will. Stigmatizing entire populations is not 'targeting', no matter how convenient it may be to the HIV industry.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]


Sunday, November 18, 2012

Good AIDS, Bad AIDS and African AIDS

The problem with the 'good AIDS/bad AIDS' dichotomy is that it is not just a joke. Rather, the joke was based on a real phenomenon, and it is still very much alive. People who work with HIV really do distinguish between those who were infected through ways that are thought of as being within their control, and those who are infected in ways that are thought of as not being within their control. An example of the former is sexually transmitted HIV; an example of the latter is mother to child transmission.

The HIV industry, ably (mis)led by UNAIDS and the like, urges us not to blame or stigmatize. But they also claim that the majority of infections in African countries are a result of unsafe sex, and the remainder are mostly a result of mother to child transmission. In other words, we can blame adults for their sexual behavior, and mothers for transmitting HIV to their children.

The industry is effectively saying that it is individuals' own fault, but that we must not say so. Implying that most HIV is transmitted in ways that are within the control of adults, and spending billions of dollars on intervention programs that assume most transmission is, directly or indirectly, a result of unsafe sex, reinforces the finger-pointing.

You might think that there is lots of solid evidence for the view that HIV is almost always transmitted sexually (either directly or indirectly, through mother to child transmission) in African countries. But you would be mistaken. Of course, there is a lot of evidence that HIV is sometimes transmitted sexually. But many people who may have been infected sexually may also have been infected some other way, such as through unsafe healthcare.

For example, sex workers undoubtedly face elevated levels of sexual risk. But they also face elevated levels of non-sexual risk; many visit sexually transmitted infection (STI) clinics every few months and receive a lot more injections than most other people. Men who have sex with men face elevated levels of sexual risk, especially if they are primarily receptive partners, but they too may visit STI clinics regularly. In fact, many people who face elevated levels of sexual risk may, for the reasons outlined above, also face elevated levels of non-sexual risk.

Research does tend to concentrate on sexually transmitted HIV. But there has been a fair amount of research into non-sexually transmitted HIV, even in Africa, where most funding tends to follow the western obsession with 'African' sexuality. There's a recent article in the Journal of the International AIDS Society that looks at 'non-vertical, non-sexual' HIV infection in children that cites some of the available research, though by no means all.

The authors note some appalling instances of unsafe healthcare that they and others witnessed. They list some other published accounts of infants being infected with HIV where the mode of transmission was neither from mother to child, nor was it a result of sexual abuse or even blood transfusion, and where the mother was generally not infected. In addition to poor injection safety, they note cases of surrogate breast feeding, feeding of pre-masticated food, poor hygiene and the use of unsterile healthcare equipment.

They don't make any mention of the fact that babies infected through healthcare can also transmit HIV to breastfeeding mothers, whether they are birth mothers or surrogate mothers. And some mothers and babies could be infected independently of each other. In other words, cases of infants who were not infected by their mothers may not be investigated because it is assumed they were infected by their mothers simply on the grounds that their mother is HIV positive.

But even adults who are sexually active may not have been infected sexually. One would expect infection of infants through unsafe healthcare to be rare, but the fact that it happens at all suggests that it also happens among adults and that it could far more common, because there are far more infected adults in the population. Reusing injecting equipment in a pediatric ward should be less risky than reusing injecting equipment in a ward of adults. The riskiest scenario of all could be reuse of injecting equipment in an STI clinic.

The authors even admit that there is often just not enough data collected to be certain of modes of transmission. Given the length of the paper, they also miss out on a lot of the literature, which is all the more extensive because not all research is funded by HIV industry factions. Oddly enough, though, they say that 37 children were infected in a nosocomial (hospital acquired) outbreak in Libya, whereas the actual number in the article they cite is over 400.

Other nosocomial outbreaks they mention, such as Kazakhstan and Uzbekistan, add a few hundred more. And ones they don't mention, such as those that occurred in Russia and China, bring the numbers up to the tens and hundreds of thousands. The big gap in research here, then, is research from the worst HIV epidemics in the world, which are all in sub-Saharan Africa. There have been very few documented outbreaks there and the few bits of data that have seen the light of day have remained virtually uninvestigated.

Conditions in African health facilities are often perfect for nosocomial outbreaks. Far too few facilities are run by far too few health professionals with far too little training, equipment, supplies and support. The only factor that may protect many people from hospital transmitted HIV in African countries could be the very inaccessibility of healthcare. Cotton et al also note that "Inadequate knowledge of blood-borne virus transmission risk seems prevalent among health care workers and the general population." UNAIDS are adamant that nosocomial infection rarely occurs in African countries, so most people are unaware of it. You could almost call it 'good AIDS'.

Appalling conditions in African hospitals have been widely enough reported, and blood-borne HIV risk and even transmission have occurred often enough in wealthy countries. But this has not translated into the admission that HIV may not always be transmitted sexually, even if 'Africans' do have the extraordinary sex lives attributed to them by the HIV industry. The fact that the conditions for high rates of sexual transmission were there does not mean most people were infected as a result of sexual behavior.

The main mode of HIV transmission in western countries is receptive male to male anal sex, with intravenous drug use often being the second most common mode. These are instances of 'bad AIDS', of course. We can protest as much as we like that we don't blame people for being infected with HIV, but we classify their mode of transmission as being a result of something that is within their control. We need to be very careful not to step on anyone's toes, and we certainly can not utter the words 'bad AIDS' in most western countries, but we are welcome to think what we like.

But when it comes to high prevalence countries in Africa, we don't even have to be that circumspect. Because high levels of 'unsafe' heterosexual sex need to be very high indeed to explain prevalence figures of over 20 and 30%, where the majority of people do not belong to groups known to face very high risks, simply attributing most infections to heterosexual sex is implying that it is mostly 'bad AIDS'. People infected are not just assumed to be sexually active, they are assumed to be promiscuous, and highly so. They would have to be if such high figures are really a result of heterosexual sex given known transmission probabilities.

But while we're pointing the finger, we might as well be clear that almost all AIDS could rightly be referred to as 'bad AIDS' by those bigoted enough to use such a term, implicitly or explicitly. After all, mother to child transmission is assumed to be mostly from women who were infected sexually. So let's point the finger at Africans, and let's not forget African women. We can't accept that HIV is generally a result of behavior that is within the control of adults, males and females, without at least implying that more of the blame should probably be laid at the feet of women. We may say we don't blame them, and we may adopt the 'all men are evil, all women are victims' assumption, but it's probably all 'bad AIDS' really, and far more women than men are infected.

In a way, it's a pity people no longer adopt the overtly bigoted 'good AIDS/bad AIDS' reflex, because it still lurks behind the orthodox view, that almost all HIV is transmitted through heterosexual sex in African countries. Instead, we can talk broadly about poverty, education and health, and more narrowly about gender based violence, female genital mutilation and even homophobia, without ever mentioning the institutional racism and sexism of the HIV industry, that only needs to be hidden behind a thin veil as long as no one really cares that such prejudices exist. It is because the orthodox explanation holds that almost all HIV is 'bad AIDS' that transmission rates are still out of control in sub-Saharan Africa. So let's bring back the false dichotomy and bury it properly this time, and then get on with the real work.