Tuesday, February 28, 2012

The Economist's Delusion: Money Alone Can Stop HIV

A drug [for HIV] called money, says The Economist headline. According to the article, money is the answer to reducing HIV transmission. The reason why money is the answer? Because the article assumes that most HIV is transmitted by young girls having sex with older men in return for money. There are a number of flaws in this thesis; for example, not all HIV is transmitted sexually, not all sex is transactional sex, not all poor girls are prostitutes, not all 'older' men pay younger girls to have sex, most 'older' men are not HIV positive, etc. So why would giving money to the girls be a 'drug'?

Well, a 'scientific' paper says so. The paper concludes that "Cash transfer programmes can reduce HIV and HSV-2 infections in adolescent schoolgirls in low income settings." Girls or parents in an intervention group were given varying amounts of money; some had to show that they were attending school; others didn't have to meet any conditions. But there are also a couple of flaws with this paper; it is not known how many of the girls were already HIV positive when they joined the program and, out of the girls who became infected, it is not known whether they were infected through sex or what kind of sex or whether they were infected through some other mode of infection, such as unsafe healthcare or unsafe cosmetic practices.

The paper starts off with the claim that "Lack of education and an economic dependence on men are often suggested as important risk factors for HIV infection in women." But what are these suggestions based on? I agree that many people in high HIV prevalence countries lack education and are impoverished, and often dependent; this may be particularly true of women and girls. But does much of the research data currently available, for example, the kind of socio-demographic data collected in Demographic and Health Surveys, give reason to think that poverty and low levels of education are correlated in such a way that there may be some kind of causality involved?

In fact, the contrary is often true. The relationship between economic status and educational level on the one hand, and HIV prevalence on the other, is often very unclear. And where it is clear, HIV prevalence tends to be higher in the wealthier and better educated quintiles. Fair enough, correlation is not causation; but lack of correlation does not support the sort of research that went into the above scientific paper. Only the unsupported assumption that HIV is always or almost always transmitted through heterosexual sex in African countries allows such research to be carried out, and such conclusions to be drawn from it.

Those who received money had one third of the risk of testing positive for HIV and one quarter of the risk of testing positive for herpes simplex virus, compared to those who did not receive money; there was no difference between those who had to attend school and those who did not. Among those who had already dropped out of school, there was no difference between those who received money and those who did not. Despite the small numbers infected among school-going girls, it is concluded by The Economist that money is a HIV 'drug'. What effect did the cash and/or the conditionality have on HIV transmission? We really have no idea. And if it did have any effect, it was small.

The Economist exaggerates shamefully: the researchers "conducted a randomised clinical trial of the idea that money, and money alone, can stop the spread of HIV." This allows the author to indulge in Western-style fantasies about African sexuality and money-grabbing women, sugar daddies and HIV. And it is concluded that bribery works when it comes to reducing the risk of HIV transmission. Would they also conclude that we need a sliding scale so that we bribe wealthier people with larger sums of money and poorer people with smaller sums of money? What about if people become infected with HIV, would they then be entitled to a larger bribe in return for not risking transmitting the virus to anyone else?

A good deal of Demographic and Health Survey data shows little correlation between unsafe sexual behavior and HIV prevalence. For example, those who sometimes use condoms can be more likely to be infected than those who never do. Circumcised men, despite all we may read on the subject, are often more likely to be infected than uncircumcised men. A recent paper even showed that paying for sex was inversely associated with HIV infection. There isn't even a simplistic relationship between sexual behavior and HIV, let alone between money and HIV.

The Economist may misrepresent The Lancet paper, but the latter is crying out to be misrepresented. It plays into the hands of those who hold insultingly racist and sexist views about Africans, especially those who are HIV positive and even those who live in high HIV prevalence countries. To carry out research like this you must already believe in a causal connection between HIV and transactional sex. All those involved in these exercises have demonstrated is the institutional racism and sexism that is to be found throughout the HIV industry. Of course, this is not to say that those directly involved are themselves racist or sexist; they may not be.


Sunday, February 26, 2012

Circumcision, PrEP and Vaginal Gel: HIV Prevention Show-Stoppers?

The highly unscientific but quite triumphalist term 'game-changer' appears frequently in the HIV literature. It has appeared in articles about pre-exposure prophylaxis (PrEP) after the iPrEx trial, and also in relation to three mass male circumcision trials. PrEP was said to reduce risk by 44% and circumcision by between 50 and 60%.

However, both of these figures were for relative risk. The respective figures for absolute risk were 2.3% and 1.3%. The term 'show-stopper' might be more appropriate than game-changer. The result of the trial of Tenofovir vaginal gel, also referred to as a game-changer, was said to be 51% effective; but little mention was made of the absolute risk reduction, which was about 5%. (See Joseph Sonnabend's very readable blog on relative and absolute risk.)

Why does this matter? Well, suppose the trial was between a group of people who were given a placebo, forming a control group, and a group of people who were given a herbal dose from the Old Man of Loliondo (look it up if you haven't heard), the second group being the intervention group. The difference between being given a placebo and given one out of many available herbal concoctions should be quite small. HIV incidence in both groups should be roughly the same. But suppose it was lower among those in the intervention group, and that 2 people became infected, compared to 4 in the control group. The absolute risk reduction would be so low that you might decide to spend your 24 Euro Cents for the herbal concoction on something else (though certainly not circumcision, PrEP or vaginal gel, which are at least hundreds of times more expensive).

I apologise to the Old Man and his acolytes, but he can take comfort in the fact that his concoction might easily reduce HIV infection risk as much as circumcision, PrEP or vaginal gel do. Indeed, it might even exceed their rather puny results, who knows? The relative risk reduction in the above example would be 50%. And if people were told that, they might think the Old Man is worth a visit. But they would be wrong. Even if the absolute risk reduction were a lot higher, people would be better advised to use condoms, much as they are when it comes to circumcision, PrEP and vaginal gel.

There have been numerous articles about how happy men and women are with circumcision programs, many of which have already been running for three or four years and claim to have operated on several million men to date. But there is also a recent article in a Zimbabwean paper questioning circumcision, even referring to it as a 'dangerous distraction'. In fact, the article uses the absolute risk reduction figure, so it's not surprising they question the wisdom of circumcising millions of men. It's just disappointing that more articles don't use this figure, or both figures, and question the exuberant press releases a bit more closely.

Apparently it was estimated that 750,000 HIV infections could be averted if 80% of adult males were circumcised. But this figure now seems difficult to support, especially as incidence is already dropping in some groups in Zimbabwe and in many other sub-Saharan African countries and has been for quite a few years. Gregory J. Boyle and Gregory Hill have specifically pointed out how the superficially impressive 60% relative risk reduction needs to be compared to the 1.3% absolute risk reduction. Hopefully, people will use these figures to make up their own minds before being railroaded into being circumcised or into persuading their partner or relatives to be circumcised. They also raise the rather embarassing fact that in quite a number of African countries, HIV rates are higher among circumcised people than uncircumcised people.

It's great that these questions are being asked, in an academic paper and in a newspaper. But none of the serious objections to circumcision, PrEP or vaginal gel are new to those carrying out research in these areas. There appears to be a cabal of HIV 'experts' who are doing everything they can to persuade people of the effectiveness of various public health interventions by selectively publishing favorable data and suppressing or giving far less attention to less favorable data.

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


Saturday, February 25, 2012

Condoms More Effective, Cheaper & Safer Than Male Circumcision & Depo Provera

Male circumcision as a HIV prevention intervention has often attracted the response that if you use a condom it's unnecessary and if you don't use a condom it doesn't work; so why not just use a condom? But similar remarks have been made about Depo Provera and other hormonal contraceptives; if you don't use a condom along with Depo, you risk being infected with sexually transmitted infections, such syphillis, gonorrhea, herpes and HIV. While if you just use condoms, you will be protected against those diseases and you will also avoid unplanned pregnancies; so why not just use condoms?

But there are deeper problems with both male circumcision and Depo Provera. The former almost certainly increases HIV transmission from males to females, and females are far more likely to be infected already; HIV prevalence in many groups is several times higher among females than among males. And Depo Provera may increase HIV transmission in both directions; the WHO is still out on that one and have said it could take years to give the product the all clear. So why don't they just recommend that people use condoms? Instead, they recommend that people use both Depo Provera and condoms.

One of the selling points of Depo Provera was that it would prevent conception for women who couldn't be guaranteed that their partner would use a condom. But if a condom is not used and both parties are at increased risk of being infected where Depo is used, using the hormonal contraceptive is more dangerous than not using it. There are alternatives to Depo Provera, but if they are not viable, available, accessible or whatever, it seems clear that it should not be used without condoms. Using neither condoms nor Depo Provera cannot be recommended, but using Depo Provera on its own is foolhardy. People don't weigh up the dangers and then decide that HIV is a less worrying risk than an unplanned pregnancy; they want to avoid both. Only population control hardliners believe in birth control at all costs.

There seems to be some confusion about Depo as a result of WHO's 'high level' meeting. There's an article about what may or may not have been discussed at the meeting to review the evidence about Depo Provera and it says that no conclusive decision was agreed. In a sense that's true but WHO have said that people should continue using the product, even if they are at risk of being infected with HIV or if they are already infected; however, they should always use a condom. The problem is, that's what they said before the meeting as well. In other words, the evidence they say they are going to take several years to consider has made no difference to the advice they give. Perhaps some are worried that evidence that can trigger years of research should also trigger a higher level of caution?

Articles on the subject of Depo Provera often mention that it is one of the most popular forms of modern contraception, but it has also been marketed very aggressively in African countries, at married women, at sex workers and at young, unmarried girls and women. Strangely, Depo Provera is nowhere near as popular in Western countries, except among certain ethnic populations. Hormonal contraceptive marketing is often dressed up as public health advice about family planning and birth control, which points to a dangerous conflict of interest. Marketing is not disinterested advice, quite the contrary, and it is not WHO's job to market pharmaceuticals, though people could be forgiven for thinking otherwise. But from whom do African women now get impartial advice?

Over a billion dollars, perhaps two billion, have been earmarked for an enormous and senseless mass male circumcision program; some say over 20 million men and boys will be circumcised. Many may be too young to be sexually active, too old to be sexually active, sexually inactive for other reasons, not facing any sexual risk, facing too high a sexual risk for circumcision to be of any benefit (for example, those who are engaging in anal sex with men or women), facing non-sexual risks that are far more serious, etc. Many more will probably give up using condoms in the belief they no longer need them, though some circumcision enthusiasts deny that this is a risk. Even some women already believe that circumcised men pose no HIV risk and that unprotected sex with them is safe.

Worries raised about Depo Provera are not the kind you can just ignore until several more years of research has been carried out; what if the research confirmed earlier suspicions about the product doubling risk of transmission in both directions? And with male circumcision, the evidence is slim; the 60% risk reduction is a reduction in relative risk. The reduction in absolute risk is almost negligible. Many hundreds of operations would need to be carried out to prevent one infection; but the increased risk through reduced condom use and other precautions will probably result in an overall increase in transmission.

It could be asked why international health institutions and other parties are pushing ahead with these two interventions when they both seem more likely to increase HIV transmission than reduce it. Doing nothing would seem preferable, although there are a lot of positive things that can be done. For example, prevention of mother to child transmission is successful but it needs to reach all mothers, and earlier rather than later. Reducing transmission through unsafe healthcare would also be very cost effective as it would also reduce transmission of numerous other diseases. And condoms are good for preventing sexual transmission of HIV and other diseases, as well as unplanned pregnancies. Instead, there are huge sums of money behind useless and risky circumcision programs and highly suspect Depo Provera and birth control programs; perhaps therin lies the answer.

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


Wednesday, February 22, 2012

UNAIDS' Loss May Be Kenya's Gain

It sounds like Kenya is getting more serious about non-sexually transmitted HIV, at last, particularly where the virus is being transmitted through unsafe healthcare. So far, it has been mentioned that healthcare professionals face some risk of being infected, especially where safety procedures are not strictly followed. But there is also an even higher risk to the patient. If equipment is reused without adequate sterilization, one or more patients may be infected with HIV, hepatitis and various other blood-borne diseases.

There's a relatively lengthy article in Africa's Business Daily about the training that will be given to health professionals in the new School of Phlebotomy, opening soon in Nairobi. While risks to patients are not explicitly mentioned, it is clear from a number of comments in the article that they will benefit the most if this facility is successful in its aim of training 25 people every fortnight from April onwards. Some of the sponsorship comes from Becton Dickinson, one of the world's leading producers of injecting equipment. But worth far more than the money they are contributing is the acknowledgement that there is a problem with unsafe healthcare; and equally, that there is a cheap solution to it.

This acknowledgement, which follows years of denial by international HIV institutions, should fit well with another proposed change in Kenya, mentioned in my last blog post; the idea that HIV needs to be integrated into healthcare as a whole. To this end, the government health departments and the National Aids Control Program are in agreement that there can no longer be parallel health systems, for HIV on the one hand and for everything else on the other. This is wasteful and particularly untenable at a time when HIV funding is being cut. (Unfortunately for almost every other area of health, funding was cut in the 1980s and has never recovered.)

Despite all the gloom about reduced HIV funding and the need to rethink how the disease should be approached if most other health issues are not to continue to be ignored, there are some very promising trends in public health in Kenya. Better infection control through improved training, equipment and support is a very good start. But another highly successful area in HIV prevention has been prevention of mother to child transmission (PMTCT). There are far more women in need of this form of treatment than are currently receiving it, but very wide coverage could cut transmission to the sort of low levels seen in Western countries.

There are many expensive distractions, such as male circumcision and potentially harmful hormonal contraceptives, both of which could be suspended until they have been shown to be effective in the case of male circumcision and safe in the case of Depo Provera and similar birth control methods. On the plus side, greater use of condoms would obviate the need for both of these strategies; condoms are cheap and, as circumcision and birth control enthusiasts have been forced to point out, neither of the two expensive options are of much use on their own.

There is a lot of talk about the 'dual need' to reduce unplanned pregnancy rates and at the same time, eliminate the risk of transmitting HIV and other sexually transmitted infections (STI); condoms meet this dual need. Some may view condoms with suspicion, but Depo Provera without condoms carries a far higher risk than condoms on their own, or even, arguably, nothing at all. Birth control enthusiasts seem to think the risk of unplanned pregnancy is so important that an increased risk of HIV infection is a price worth paying; but efforts to reduce MTCT seem a little self-defeating if risks to mothers are being increased.

In fact, far better than passively waiting for mothers to become infected and then attempting to intervene with PMTCT is reducing infections among women, which suspension of the use of Depo Provera could contribute to, perhaps significantly. Male circumcision is also likely to increase HIV transmission from males to females (even if it reduces infection from females to males); so again, suspending the strategy until these matters have been clarified could reduce MTCT by reducing the number of infected women. The amount of money saved by not continuing with these highly suspect programs would be small compared to the amount saved by not infecting people by continuing them; and the effect is additive!

What about the high risk groups so beloved of journalists and those who need to attract the attention of journalists? Well, they will also benefit from improvements in the safety conditions in health facilities. Those who regularly attend STI clinics, such as sex workers, their clients, men who have sex with men and perhaps intravenous drug users; people regularly receiving healthcare for STIs, who may face far higher risks of being infected with HIV non-sexually than sexually. Just think about it: many of them end up in the same clinics. They may appear to be at risk of being infected with HIV through their work or lifestyle, but there are also additional non-sexual risks.

This may be the first time in the history of HIV that countries with high prevalence get to make their own decisions about HIV (and health as a whole) and set their own priorities. It is possible that Kenya is already way ahead of the now faltering international HIV institutions, who, in the absence of the massive levels of funding they have become used to, have taken to wandering around like clapped out old druggies in search of a pusher who may never return.

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


Monday, February 20, 2012

Time To Rethink HIV and AIDS Spending

Back in March last year, in an article entitled "Aids to lose ‘special status’ in new plan", Dr Martin Sirengo of Kenya's National Aids Control Program said “HIV is no longer a big issue. It is just like any other disease because we now have the knowledge about it, we have the drugs, and nearly everybody knows about it”. Sirengo is perhaps exaggerating but more than 90% of Kenyans are not HIV positive and many suffer from diseases that could have been prevented or could be treated, if the government (and foreign donors) saw this as important enough.

Sirengo goes on to say that Kenya "is in the process of implementing a disease integration model that will eventually do away with emergency response to HIV/Aids and address it like any other chronic disease." Apparently the program was already underway then and was due to be fully implemented by 2012, resulting in the "demise of special rooms set aside for voluntary counselling and testing at health centres or even special pharmacies for HIV cases".

It's hard to know whether this 'integration' was driven by a desire to spend less money on HIV or if it was seen as a way to spread health funding beyond facilities that deal with HIV and pretty much nothing else. After all, HIV positive and HIV negative people alike suffer from and die from all sorts of conditions. But Sirengo says "These may be the first steps that could eventually lead to the dismantling of parallel, but expensive administrative structures set up to manage the pandemic."

At the time, Sirengo's comments were expected to meet with a lot of opposition from NGOs, government agencies and other parties benefiting from funding specifically for AIDS. He pointed out that specialist skills would still be needed, and that the approach was being gradually rolled out already. But sure enough, a whole group of institutions concerned with HIV and AIDS got together to protest.

It's worth looking carefully at the letter this group wrote, outlining why they see the proposed approach to HIV and AIDS as so objectionable and arguing that HIV is still an emergency. The letter is addressed to the Ministers for Public Health and Sanitation, for Medical Services and for Special Programs. It is pointed out how many people are estimated to be living with HIV, how many need treatment, how many receive treatment, numbers of new infections per year, deaths from AIDS, children born with HIV, etc.

The figures are frightening, but they don't immediately add up to an argument that the country, already starved of public sector spending on health for several decades, should spend so much money on parallel systems for one disease. The letter does not make it clear why testing people for HIV in one place and testing them for all or most other disease somewhere else is a good way of ensuring high levels of public health.

Rather, the big gap between what is required and what is available suggests a more urgent need than ever to use every shilling wisely. If a health facility can test for HIV, why should the same facility not also be able to test for other far more common diseases, including non-communicable diseases?

The letter mentions issues of stigma and discrimination, as if having parallel systems for a disease said to be between 80 and 90% heterosexually transmitted could in any way reduce these; on the contrary, separating HIV from other health issues is far more likely to fuel stigmatizing attitudes and discriminatory behavior. In fact, given that it is unlikely such a massive proportion of the disease really is spread sexually, treating HIV as different from all other diseases is a form of discrimination. People found to be HIV positive are effectively branded as being promiscuous.

However, the group is not opposed to some kind of integration. Rather than opposing the approach at all costs, they seem to interpret Dr Sirengo as using it as a smokescreen to reduce overall spending or as an excuse for continued underspending on health. They are right, sadly, in their claim that health is underfunded. But while HIV may not be overfunded, there appear to be a disproportionate number of institutions and facilities dedicated almost entirely to the virus when the majority of sick and dying people do not have HIV.

Anyhow, all this was before the Global Fund decided that it would be suspending disbursements for the next two years. And now, Dr Sirengo's comments have appeared yet again, this time in an article that says both donors and the government agree that 'downgrading' HIV's 'emergency status' is the way to go. It had been suggested that the Dr's remarks were his own and not representing those of the National Aids Control Program or the government; but even the Public Health and Sanitation Minister, Beth Mugo, is cited as being in agreement: "Integration is the way to go because it makes logistical and economic sense".

If there are about 110,000 new infections every year, and about 90,000 deaths, the costs of treatment and care will continue to rise. But one of the best ways of ensuring that the numbers of new infections go down is to identify who is at risk, what risks they face and what strategies most effectively reduce the risk. It will be painful for many groups working in the HIV and AIDS field to face up to the fact that it's not all about sex, but concentrating almost entirely on sexual transmission has failed; it's a good time to admit to being wrong.

Health facilities need to be safe places, where people don't pick up something worse than they had when they arrived, such as hepatitis or HIV. It would be inhumane to ignore the plight of those who are living with HIV; but it would be insane to continue to leave non-sexually transmitted HIV uninvestigated. And Dr Sirengo is wrong in one crucial respect; almost everyone does not know about non-sexually transmited HIV. If people don't know about non-sexually transmitted HIV, they will not recognize non-sexual risks and will no know how to avoid them.

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


Saturday, February 18, 2012

Depo Provera: English Guardian Aligns Itself With Neo-Eugenicist Policies

The English Guardian may face something of a dilemma when covering the WHO's failure to give clear advice to African women who have been persuaded to use Depo Provera and similar injectable hormonal contraceptives, which appear to be associated with a doubling of HIV transmission from females to males and from males to females; birth control is close to the heart of he who would control population, Bill Gates, whose Foundation sponsors the paper's Global Development section. Not that the article appears in the Gates sponsored section; perhaps there is no such dilemma.

But Sarah Boseley sticks pretty close to the WHO's press release and says that women who use injectables such as Depo Provera should also use condoms. As with the 'advice' from WHO, Boseley notes the use of 'dual protection' against pregnancy, on the one hand, and infection with sexually transmitted infections on the other. For Boseley and WHO, this means using condoms along with Depo Provera. But what neither seem willing to point out is that condoms on their own provide such dual protection.

So why would anyone want to use these expensive and possibly dangerous hormonal injections if condoms on their own give dual protection? Well, according to WHO and other 'experts' in reproductive health (often just a useful term for 'birth control'), condoms are not 'female controlled'; many people don't use condoms if they can help it. So rather than recommending that people who wish to avoid both pregnancy and sexually transmitted infections should use condoms, they recommend that people use Depo Provera, despite knowing that many people who opt for injectable hormonal contraceptives (and various other methods) cease to use condoms?

The oral versions of Depo Provera and similar contraceptives are said to be unsuitable because women need to take them daily and they may forget, or their husbands may object, etc. Injectable versions are said to be women controlled and only need to be taken every three months. In reality, they are to a large extent controlled by those who supply them, often NGOs and other institutions who believe strongly in the population control paradigm of development. Whatever synonyms are used, the concept of control is always detectable.

Boseley claims that women 'choose' Depo Provera and similar products but these pharmaceuticals are aggressively marketed by some of the biggest NGOs working in population control. Use of injectables has increased considerably over recent years but it's difficult to work out whether that's a matter of availability or genuine choice. Given the political and financial clout that NGOs and institutions such as the Gates Foundation have over the lives of people in developing countries, it seems unlikely that birth control is as high on the agenda of people in African countries as it is for the various non-African parties on the bandwaggon. One might even wonder if anyone gives a damn what Africans think about such matters.

It's astonishing just how uncritical Boseley is, in fact. She parrots bits about the WHO's 'expert group', but it was not concluded that hormonal contraception is safe ("Current evidence is not strong enough to prove or disprove an increased risk of HIV from hormonal contraception"). Rather, it has clearly been decided that it is safe enough for Africans and other poor people; it is not much used by white, middle-class Westerners. These products have not been shown to be safe, far from it. But the most important consideration for the WHO is that their goal of population control is not compromised by worries about safety issues, which they have been aware of for decades.

The logical conclusion to be drawn from the WHO's findings is that, if people want to avoid unplanned pregnancy and sexually transmitted infections, they should use condoms. The WHO statement is not based on a logical conclusion; it is a political declaration designed to protect the interests of Big Pharma, big NGOs and big private institutions with a population reduction agenda, and of course, the interests of the WHO itself. As for UNAIDS, they have taken a back seat; HIV prevention has never been their strong point.

Boseley finishes with a few non sequiturs and then supplies a version of the population control enthusiasts' mantra: "About 25% of the 128 million married or cohabiting women in sub-Saharan Africa aged 15 to 49 want but cannot obtain contraception." This self-serving statement doesn't tell us who was asked the questions, who was asking them, what questions were being asked and who chose those questions; a far higher percentage of women (and men and children) face numerous life-threatening issues on a day to day basis. It is likely that some of those issues would carry a higher priority, such as lack of clean water and sanitation, accessible and secure food supply, adequate living conditions, and many others.

When you know how you will get through the next few years, you can plan the next few decades. Family planning is not the panacea depicted by WHO when you are faced with low survival rates for your children and life expectancy for yourself. Population control in the form of birth control and family planning can be dressed up to look like an obvious choice for people in developing countries. But large scale population control exercises are not, neither in intention nor in practice, matters of choice for their putative beneficiaries. Population control is the prerogative of those who also control vital resources and the like, and who wish to limit access to these for people who are at the bottom of the heap.

Consider the role of eugenicist and neo-eugenicist doctrine in developing countries over a period of many decades; population has risen rapidly, regardless. Far from people being given choices over matters such as family planning, self-determination has been systematically denied. But Western maneuverings have failed to control population growth; they have only brought developing countries to their knees, creating new problems and exacerbating existing ones. When the rich and powerful talk piously about choice, it's always worth remembering that they consider their choice to be the only viable one.


Friday, February 17, 2012

WHO Refuses to Give Correct Information About Depo Provera

The WHO has issued a statement stating that the injectable and oral versions of hormonal contraceptives, such as Depo Provera, are safe for HIV positive people and those thought to be at risk of being infected with HIV. This is an odd statement to make when they have known for a long time that this form of birth control has been associated with double the risk of transmission from HIV positive women to HIV negative men and double the risk of transmission from HIV positive men to HIV negative women, where the woman is using hormonal contraceptives for birth control.

The HIV industry, and the population control obsessed development industry before them, have always placed controlling the reproductive behavior of people in developing countries above their reproductive rights and safety. Regarding Depo Provera and similar hormonal contraceptives, fatuous arguments about reducing 'unplanned' pregnancies, reducing reproductive health problems and HIV transmission have been used when the very method itself places those using it and their partners at increased risk of being infected with HIV and other sexually transmitted infections.

WHO did not make their decision on the basis of a "thorough review of evidence about links between hormonal contraceptive use and HIV acquisition"; they held their 'high-level' meeting in private and compelled all those attending to sign a confidentiality agreement, a gagging order. The thorough review would have taken, by their own admission elsewhere, several years to complete. Why the secrecy? Why the deceit? Who has an interest in putting the health and lives of millions of adults and children in Africa at risk? Is this a commercial decision, a political one, a combination or something far more sinister?

Reminiscent of the 'advice' given to African men who have been duped into being circumcised, ostensibly to reduce the probability of being infected with HIV (even though they may be far more likely to transmit the virus as a result), the WHO statement reminds people that Depo Provera and similar need to be used with condoms. However, we know condoms work; why not just use condoms, or perhaps condoms in conjunction with a method that is not harmful? If condoms don't work, why advise the use of a hormonal contraceptive that very likely increases transmission in both directions (or an operation that does little good and a lot of harm?)? We know that Depo Provera use is associated with reduce condom use, but condoms prevent conception and the transmission of sexually transmitted infections, such as HIV and many others.

What is the point of WHO now that they have shown that they do not represent the interests of ordinary women, particularly poor women; the vast majority of Depo Provera users are in sub-Saharan Africa? What about all the NGOs who have creamed off the billions of dollars of HIV money over the last thirty years to promulgate their eugenic policies? Because eugenic is what they are; if you're poor, have fewer children. People need advice, support and information, accurate, reliable information. Otherwise NGOs, WHO, UNAIDS (see UNAIDS' statement on Depo Provera) and the like are pursuing their own agenda, regardless of the interests of those they purport to serve.

Through the administrative fog generated by these grotesquely overfunded institutions, little is clear about Depo Provera except that the above institutions can not be trusted. If you want to advice, you'll have to carry out your own research, but start somewhere else; the very bodies tasked with informing people have failed, indeed, have refused to publicly discuss the information that is available to them. Judge their statements by that failure and refusal. There has never been a better time for African countries to distance themselves from those who see Africans as mere instruments in the agenda of money-making and empire building.

[There are links to some more reliable information on injectable contraception on the Don't Get Stuck With HIV website and blog. More will be made available in the coming days.]


Thursday, February 16, 2012

Much Needed Attention for Healthcare HIV Transmission, But Little for Patients

A married Kenyan couple decided to get tested for HIV after the woman became sick and it was found that she was positive but her husband was not. This is not particularly uncommon, but it is shocking that there is no mention in the article about the possibility that the woman was infected non-sexually. The husband considered leaving her, but it appears the counselor didn't tell them that HIV is not always transmitted sexually and that, whatever risks the woman faced, the husband and millions of other people also face.

Incidents like this can put the female partner especially in a lot of danger. Some have been thrown out of their home, either by their husband or other relatives, lost their children, possessions, job and much else. Some have been subjected to violence and even have died as a result. It is extraordinary that the counsellor's job appears to be merely to urge the couple to stay together, but not to recommend that the risks, both sexual and non-sexual, faced by the HIV positive person be evaluated and, if necessary, investigated.

The majority of Kenyans have probably never been tested for HIV and many more keep the results to themselves. But that's hardly surprising if people can face such threats just for revealing their status, even if they do so in order to avoid infecting others. It would be far preferable if more people knew their status and they were supported to reveal their status, at least to their sexual partner; in that way, their risks could be identified and many future infections could be prevented. But as long as UNAIDS and the rest of the HIV industry refuse to discuss the non-sexual risks people face, many people in a country like Kenya are at serious risk, regardless of their sexual behavior.

This situation tends to hit women harder than men; women are often expected to test for HIV, before, during or after pregnancy, sometimes on several occasions. It is more difficult for them to hide their status from others, although testing is ostensibly voluntary and confidential. Women are more likely, often a lot more likely, to be infected than men. And they do not generally have the authority in a marriage to insist that their partner is tested, or to receive a fair hearing if their partner is not infected.

The kind of irresponsible nonsense people hear about HIV and sex is epitomized in numerous articles, including one about "Tips for Making HIV Discordancy Work". There is no warning about non-sexually transmitted HIV or about the fact that the infected partner may not have been infected sexually. The article even recommends keeping antiretrovirals handy in the form of Pre-Exposure Prophylaxis (PEP), used when someone may have been exposed to HIV, through sexual or blood contact, for example. But those who keep PEP handy won't know when they need to use it if they have only heard of sexually transmitted HIV.

It seems unlikely that the HIV industry obsession with sex and their reluctance to talk about non-sexual exposure are going to disappear any time soon. But the Minister for Medical Services, Anyang' Nyong'o, who has touched on the subject before, has announced that Kenya will be opening up a Center for Training on Blood Safety. It sounds like the thrust of the training given will be to protect health care personnel from infection, but it may include training on unsafe use of medical equipment, which poses far higher risks to patients than it does to employees. Anyhow, the proposed Centre for Excellence in Phlebotomy and Specimen Collection, sponsored by medical equipment manufacturer Becton, Dickinson and Company, is a start.

Aside from the estimated 2.5% of HIV caused by medical equipment, which is likely to be on the low side, the article also cites 'rampant' misdiagnosis by health personnel, lack of training and poor practices. These phenomena are well attested in documents such as the Kenya Service Provision Assessment, but are rarely alluded to in the burgeoning HIV literature. Let's hope this facility proves to be a lot more than "a milestone towards the improvement of health-worker safety"; very few health workers have been infected with HIV through their work but many patients may have been exposed to HIV and other diseases through unsafe health care. Sexual transmission of HIV is only part of the story; we just don't know how big a part non-sexual transmission is.

[For more about non-sexually transmitted HIV, see the Don't Get Stuck With HIV website and blog.]


Monday, February 13, 2012

Collecting Data Only to Explain it Away

The HIV industry loves the story of massive increases in 'unsafe' sexual behavior as an explanation for rapid increases in HIV prevalence in high and medium prevalence countries. If the author can even be bothered to say why unsafe sexual behavior should have increased at some period, they vaguely point to urbanization (which started long before HIV spread from its epicenter and continues in most high prevalence countries thirty years later) or some such phenomenon. As for the decrease, it is rarely mentioned, unless it is to say that it was a result of various policies, strategies and activities, with which the HIV industry of the day was fully engaged.

The story must assume or even include subsequent and equally massive decreases in unsafe sexual behavior when prevalence rapidly drops later. The problem is, the drop in prevalence is more likely to be a result of very high death rates, which tend to occur some years after the epidemic began. As for these increases and decreases in sexual behavior alluded to, there is no evidence that either of these ever took place. It's just that if you assume HIV is almost always transmitted sexually, things have to have happened as the orthodox account says they did.

Of course, sexual behavior may have changed in various ways; unsafe behaviors may have waxed and waned, just as they have probably done elsewhere and at various times. Since sexual behavior data has been collected with a view to getting HIV transmission under control, things have certainly waxed and waned in Uganda, which is often cited as the best example of a country where HIV prevalence dropped because the country did all the right things. But unfortunately, even though HIV prevalence has bumped along at a figure that still makes Uganda a medium prevalence country, sexual behavior appears to be thoroughly waxing at the moment, and not for the first time since their heroic success of the 1980s.

There's an article in the Daily Monitor about PEPFAR funded research which shows that plenty of the behavior considered to be 'unsafe' by that bastion of sexual safety still occurs in Uganda. "20% city students in sex trade - report" screams the headline. There are also figures about the number of young people conceiving, having abortions, having sex with relatives for money or gifts, underage sex, transactional sex, rape, oral sex, anal sex, alcohol, drugs and lots more.

These are all extremely worrying phenomena; but does anything about this research show whether they relate to HIV or how they might relate to HIV? Certainly, past research tends to show that a lot of HIV transmission does not correlate very closely with sexual behavior. And if the above trends in sexual and other behaviors among young Uganda people are increasing, why is HIV not also increasing? Perhaps that will follow. But there have been articles about increasing levels of unsafe sexual behavior in uganda going back many years.

There are the usual implications that HIV transmission is being 'driven' by things like higher vulnerability among girls/women, economic dependency, transactional sex, etc, and that people need education and what not. Which is all true, the bad things mentioned are indeed bad things and people need good things, many of which are mentioned in the Universal Declaration of Human Rights. But good things have not, despite the claims of the HIV orthodoxy, been unambiguously associated with lower HIV transmission and bad things have not been unambiguously associated with higher HIV transmission.

A report from Namibia shows that good and bad things also happen there but that, in contrast to Uganda, HIV prevalence increased among a large group of people being monitored for changes between 2006/7 and 2009. Figures were higher for females, as they are in most sub-Saharan African countries, but there was very little correlation with socioeconomic factors. And while HIV knowledge was 'strongly' associated with lower prevalence, most people didn't appear to know a great deal; 75% either felt they had no risk of being infected with HIV, or they didn't know or refused to answer the question.

The paper concludes that neither prevalence nor incidence are declining and that everybody in urban areas (the research was carried out in Windhoek) is at risk. But it is hard to know what to conclude from the data collected. Only 55% of the people surveyed in 2006/7 were surveyed again in 2009, suggesting that a lot of the conclusions could be quite biased (possibilities which are discussed in the paper). It's great that the research identified geographical areas "that would require prioritized HIV campaigning"; but do we know why so many of city dwelling Namibians, a lot of whom actually face fairly low HIV risks, are being infected?

The Ugandan research may show that high rates of 'unsafe' sexual behavior do not necessarily result in high rates of HIV transmission. But the Namibian research seems to show that researchers can't quite say why sexual behavior, whether high risk or low risk, seems to result in prevalence figures that are two or more times higher than those in Uganda. Ironically, the Namibian research was carried out with a view to "improving access to affordable health care". Access to health care in Namibia is very high compared to that in Uganda. It is despite very low access to poor quality health care in Uganda that HIV prevalence is medium, unlike in Namibia, where it is high.

Sexual risk is not the only phenomenon relevant to HIV transmission, neither in Namibia or Uganda or any other country where HIV is transmitted; there are also non-sexual risks, such as unsafe health care, intravenous drug use and unsafe cosmetic practices. Both of these accounts of HIV concentrate on heterosexual risk, as do most accounts of African HIV epidemics. Data collected generally relates either to sexual risk or relates to other phenomena that are thought to or are claimed to relate to sexual risk. Instead of tying themselves in knots to explain away data that doesn't support the orthodox view, it's time to reconsider the orthodox view. Wouldn't that be more scientific?


Saturday, February 11, 2012

Circumcision: Non-Paternalistic Public Health is Possible in Africa, Isn't It?

After holding out for a while, apparently the Malawian government has now had a change of heart about male circumcision and has caved in to pressure from the international HIV industry to include the operation in its HIV 'prevention' strategy. There were good reasons for holding out: prevalence is a lot higher in the Southern part of the country, where almost everyone is already circumcised. While the headline figure is 'up to 60% less likely to be infected', there are many countries where men are more likely to be infected if they are circumcised, aside from Malawi (see table of HIV infections in circumcised and intact men).

The country claims to have circumcised 5,000 men already but they plan to circumcise another 245,000 by 2015, despite the conflicting evidence about the effectiveness of the program. It is also revealed that only 4% of the country's medical staff have been trained to carry out the procedure. That's extremely worrying in a country where there is such a shortage of medical staff, regardless of what they know about circumcision. Other research in Malawi has shown that living close to a health facility is a serious risk factor for being HIV positive. But I don't expect that to be mentioned in the evangelical literature.

The last sentence in the article is particularly badly phrased: "people still had to be reminded that male circumcision alone is not 100 percent safe". The sentence aims to express the idea that male circumcision on its own will not protect against HIV and the 'up to 60% protection' requires the use of condoms (which is why some people ask if the circumcision is even necessary). But sadly for Malawi, figures suggest that HIV prevalence is far lower among both males and females who never use condoms than among those who ever use them.

Another reason why the sentence is unfortunately phrased is that it sounds like it means the operation itself may carry risks which, ironically, is true. In addition to many unexpected HIV infections in male and female virgins, where prevalence was similar to or higher than that among non-virgins, there have also been questions raised about mass male circumcision programs, where some of those circumcised might have been infected as a result of the operation itself. In countries where health facilities are in such bad condition that they may carry as high or even higher a risk of HIV infection, mass male circumcision sounds like an extremely dangerous HIV prevention strategy, particularly in Malawi.

Meanwhile, Uganda claims to have already circumcised 600,000 men since 2009. Uganda has had quite a few probable healthcare associated HIV outbreaks, including during the Rakai circumcision trial, which is supposed to show that circumcision is a viable strategy for HIV reduction. There, the aim is to circumcise 4 million men, until HIV prevalence "reaches zero", which will be a very long time from now at the rate things are going. Notably, despite evidence for healthcare associated HIV transmission in Uganda, the ridiculous claim about 80% of transmission being through heterosexual contacts is still being made (and elsewhere it is claimed that almost 20% more is from mother to child transmission).

The article also claims that 768,000 men have been circumcised in Tanzania, against a target of 1.3 million. Strangely, it is also claimed that Kenya has only circumcised 76,000 men against a target of 860,000 men by 2011. Other claims have put the figure in the hundreds of thousands, against a far higher target, and that was just among the Luo tribe of Nyanza province, a few million people. Another country where circumcised men are more likely to be infected than uncircumcised men is Rwanda, and it is stated that they have already operated on 415,000 men, out of a target of 900,000.

Paternalism behind African 'public health' programs funded by Western countries is questionable enough, but can't these circumcision evangelists at least wait until the more dubious arguments been re-examined and until there is stable and convincing evidence for carrying out what is probably an unnecessary and clearly an unsafe operation on more than 20 million people? Jacques Pepin (in The Origins of AIDS) has shown the sort of damage that resulted from public health programs carried out in colonial days (motivated by a desire to maximize profits);  we now know far better than to carry out mass male circumcision programs, but it seems we're still going ahead with them anyway.

[For some of the less well publicized details about the three circumcision trials used to advocate for mass male circumcision, see the Don't Get Stuck With HIV website and blog.]


Wednesday, February 8, 2012

Gates to Unleash Destructive Agricultural Technology on Unsuspecting Tanzanians

An article in The Citizen opens with the statement: "Tanzania will not make significant gains in its endeavours to eradicate poverty through increased agricultural productivity if the doors to Genetically Modified Organisms (GMOs) are not opened." It seems he was quoting the minister of agriculture, who is a professor of some kind, but is also quite uncertain about the population of Tanzania.

The minister wishes for "more efficient use of resources, enhanced food production and higher farm incomes" and other nice things. He notes that three quarters of the working population are only contributing to 27% of the gross domestic product and says that low productivity is associated with poor agronomic practices and limited use of improved seed, fertilisers as well as lack of sustainable control of pests and diseases".

But Justin Sandefur of the Center for Global Development takes quite a different view. He criticizes the Bill Gates annual letter for what the man has to say about research that his Foundation is funding in Tanzania, probably the same research the above minister is welcoming, certainly a similar kind of research. Sandefur is entitled to have a view on this as he carried out some agricultural research funded by the Foundation in Tanzania. Perhaps I was wrong in suggesting that Gates doesn't have advisers who have the balls to stand up to him; perhaps he just doesn't listen to them.

Gates' optimism about innovation being enough to lift Tanzanian farmers out of poverty is contrasted with the fact that people leaving agriculture altogether has been the main source of poverty reduction. Sandefur finds that innovation is not very popular and most farmers don't use modern farming technologies. And as income levels in agriculture are much lower than those outside of agriculture, leaving agriculture is probably the best way of reducing poverty levels. This has been a trend for some time, apparently.

Sadly, Sandefur doesn't have much to say about the kind of technology Gates is particularly interested in, GMOs. These were not developed with lifting Tanzanians, or anyone else, out of poverty in mind. They were designed so those who controlled them would also control the people who grow them and the land and water where they are grown. Those who produce the GMOs also produce the agricultural technologies. That's what Gates is attracted by; I don't understand why he keeps mentioning poverty and the like but I assume it's a form of spin.

Sandefur also takes Gates up on his use of the terms 'population bomb' and 'global food supply shortages'. But Gates and his views on population are infamous; he thinks there are too many people in the world; especially poor people, whom he believes should have fewer children. But as his flunkies should be able to tell him, local food shortages are not due to a lack of food. It's just that poor people can't afford it, especially if it's being grown for export, by foreigners, for a big profit, on land that has been taken from small farmers.

I agree with Sandefur that there are limits to technological fixes but not that Gates should continue with what he is doing. GMOs are destructive to the food supply, to food security, to the economy and to the environment. Other Gates technological fixes, such as in health, can also be destructive. If more people leave agriculture, that may improve conditions for GMOs to take over, as they need very large amounts of land, a lot of technology and very few employees. But this doesn't improve the prospects of those leaving agriculture, nor does it address the problems of poverty and underdevelopment for Tanzanians as a whole. People who are poor and whose income is stagnating will only become less and less able to afford what they need to survive.

Gates doesn't have a plan for all those who stand to lose out under his proposed GMO technocracy, which is all Tanzanians, whether they work in agriculture or not. But non-GMO agriculture is in a far better position to increase food supply, ensure food sovereignty, improve nutrition, protect the environment and provide various advantages without compromising the current, very weak economy. The minister of agriculture may not wish to turn down Gates' philanthrophy but there's a good reason why Gates wants to do things in Tanzania and it has nothing to do with improving the lives of Tanzanians.

For more about GM and non-GM crops, see GMWatch.


Tuesday, February 7, 2012

Another Look At Sexual (and Non-Sexual?) HIV Risk

A recently published article finds that, out of 1834 African participants who belong to various groups thought to face high risk of being infected with HIV, incidence (the rate of new infections per year) was highest among men who had sex with men (MSM). In Western countries, MSM often have the highest rates of HIV transmission, followed by intravenous drug users (IDU). But because such a huge proportion of transmission in African countries occurs among heterosexuals who don't fall into any of the above risk groups, MSM generally account for a relatively small percentage of those infected with HIV there, as do IDUs.

It was also found that "[p]aying for sex was inversely associated with HIV infection". In Western countries, sex workers are not especially likely to be infected unless they are also IDUs. But in African countries extraordinary prevalence rates have been reported for this group, even where they are not reported to have other risks. Prevalence rates of 70 or 80% have been reported, prompting some to wonder if the women might have faced one or more non-sexual risk not examined by those doing the reporting. The alarmingly high rates reported in the 1980s and 1990s dropped rapidly, often long before the country involved made any attempts to reduce infection rates; but it's good to hear that the risks this group faces may be receding.

The study aimed to identify risk populations for HIV prevention trials. If those taking part in the trial do not face much risk it will be difficult for a trial to show an effect. But the results should also be of interest to those whose job consists of making claims such as the one about 80-90% of HIV transmission in African countries resulting from heterosexual sex. Where HIV appears to be transmitted rapidly and heterosexual sex is found to be the only significant risk, there is then a problem of explaining what is so risky about heterosexual sex between Africans, something that has eluded those working in the field so far. Some of the elusiveness may stem from the fact that heterosexual sex was assumed, rather than found to be the only risk.

One of the most surprising findings was that no HIV infections were found in over 300 women in Nairobi who identified themselves as sex workers. The authors speculate that this may be due to condom use, fewer HIV positive clients, more clients on antiretroviral drugs, etc. But hopefully the finding will prompt some reanalysis of some of the eyewatering claims made about numbers of clients per day and other speculation about unsafe sex mentioned (ad nauseum) in the past. Much of it seemed to be created to fit the rates of HIV infection found rather than to investigate if such behavior really existed or if it was common enough in high HIV prevalence areas to explain transmission rates; little effort seems to have been made to establish if sex workers faced other, non-sexual HIV risks.

The finding that pregnancy rates were higher than expected may suggest that women, even sex workers, were not using condoms particularly consistently. Extremely high rates of sexually transmitted infections in one area, and fairly high in the others, also suggest that condom use campaigns may not yet have had much impact among some high risk groups (and those thought to be high risk). If the inverse association between paying for sex and HIV prevalence among MSM is an indication that condom campaigns can work when properly targeted, that is certainly an important finding, as is the one that MSM perceive anal sex with men to be lower risk than sex with women. But some well publicized claims about female sexual behavior may have supported that perception.

One of the worrying things about this paper is that the participants are drawn from groups thought to be at high risk. However, the bulk of HIV transmission in countries where modes of transmission studies have been carried out occurs among groups of people who are not thought to be at high risk. In other words, this research excludes most of the HIV positive population in countries like Uganda and Kenya, where relatively low risk sex is said to account for over 60% of the total.

Finally, my attention has been drawn to the appendix, which I am currently unable to access, which shows that those who have received an injection in the last three months are nearly five times more likely to be infected with HIV. Those involved in clinical trials would appear to have very good reason to start looking more closely at non-sexual risks.


Sunday, February 5, 2012

Turning Off the Tap: Don't Forget, There Are Two of Them

There's an article published by Peter Piot in 1987 that has had a lot of influence on the way many others have written about HIV ever since. I'd like to say it has had influence on the way people have thought, but this article seems to have been a serious obstacle to thought. Concentrating on what it has to say about women, here's how it goes: "Among 446 sera from prostitutes in Nairobi, the prevalence of antibody to human immunodeficiency virus (HIV) rose from 4% in 1981 to 61% in 1985." Also "Among pregnant women, 2.0% were seropositive in 1985 versus none of 111 in 1981."

This article and the numerous articles like it support the 'behavioral paradigm', the view that almost all HIV transmission in African countries (but not in non-African countries) is heterosexually transmitted. Why did this become the dominant paradigm and remain so to this day, despite clear evidence that it was wrong, in addition to being deeply prejudiced and stigmatizing? Well, it was concluded from the fact that "Seropositive [ie, HIV positive] prostitutes and women with sexually transmitted diseases (STDs) tended to have more sex partners and had a higher prevalence of gonorrhoea, and in women with STDs, significantly more seropositive women practiced prostitution."

Before concluding that the last statement proves, or even supports the behavioral paradigm, consider this: if someone is found to be HIV positive, it is necessary to look carefully at both sexual and non-sexual risks before concluding that they were infected sexually. while it is indeed fairly clear that people have most probably been engaging in unsafe sex if they have one or more STD, and many commercial sex workers do engage in unsafe sex, this does not mean they never face non-sexual risks. The very same sentence that identifies the sexual risks also identifies the non-sexual risks: they were probably treated for and/or vaccinated against STDs at some time in their lives, perhaps many times in their lives.

Long before HIV was recognized, sex workers were routinely rounded up for sexual health programs. In fact, the very blood samples collected in 1981 pre-date the discovery of HIV. The blood was taken at a time when injecting equipment was often reused without sterilization to an extent that has rarely been investigated. Every one of the women participating in the program faced a whole host of non-sexual HIV risks. In all probability, sex workers all over the world continue to face serious risks of being infected with HIV and other bloodborne diseases, though the risk may no longer be so high, even in African countries.

The authors can not show that the women involved were infected sexually. They wouldn't have been able to demonstrate it then and it would still be difficult to do so now. Nor can they rule out the possibility that many, if not all, were infected through the STD programs during which the blood samples were collected. But they have good reason to suspect that they are quite wrong in their conclusion about this massive rate of heterosexual transmission. And there are many other articles like this one with these exact same flaws. There is only one way that HIV prevalence can go from 4% to 61% in the space of a few years and that is through unsafe healthcare, especially that received in STD clinics.

There's a lot more that could be said about this article but let's shoot forward to the present, where the standard of analysis set by Piot and colleagues is still being rigorously maintained. As I mentioned in my last post, PEPFAR held a consultation on what they called 'mixed' HIV epidemics, those where HIV prevalence is high among those thought to be most at risk of being infected and also high among the general population, those thought (if thought is involved) to be at low or even zero risk of being infected. Remarks about Kenya's epidemic presented during this consultation show just how persistent an obstacle to thought Piot's article is.

Despite three decades of hollering about risky sex (and keeping quiet about risky healthcare), the committee accepts that 44% of HIV in Kenya is actually transmitted through heterosexual sex among couples in long term partnerships, married or otherwise; low risk sex is, according to their figures, the most risky sex of all. After low risk sex comes slightly higher risk sex, accounting for over 20% of all transmission, that between casual partners, where there is no indication that either partner is a commercial sex worker or visits commercial sex workers.

The entire contribution assumed to come from sex workers and their clients is only 14%. Note, it is no more certain that those falling into this group were infected sexually than those found to be infected in Piot's research. Sex workers and their clients, since they may often have STDs, face significant non-sexual HIV risks. But like the general population of African countries, it is mainly African sex workers who face very high HIV risks. In other countries, sex workers are unlikely to be infected with HIV unless they are also intravenous drug users. Sexual practices in some parts of some African countries may, as claimed by the HIV industry, be risky, but so are healthcare practices.

Another 15% of Kenya's HIV epidemic is said to come from men who have sex with men and prisoners. This is very ambiguous. While there may or may not be a lot of male to male sex in prisons, and anal sex is very risks, whether homosexual or heterosexual, there are also elevated non-sexual risks in prisons. Men tattoo themselves and each other, using makeshift equipment and dyes, they may take blood oaths, engage in various traditional practices, including medicine, that involves bloodletting, even take various drugs. What proportion of HIV in prisons is non-sexually transmitted?

Having inflated the figures for sexual transmission of HIV in the 'high risk' groups and claimed that low risk sex is also high risk sex, these experts conclude that all that's left for health facility related HIV transmission is 2.52%. of course, if you start off believing that 80 or 90% of HIV is transmitted through heterosexual sex, then healthcare transmission will only account for a small amount; but that's just arguing in a circle. The approximately 95% of HIV transmission that is said to be sexual needs to be re-examined. Have those producing these figures shown that all, or even most of that 95% was sexually transmitted? or, to put it another way, can they rule out non-sexual transmission in all those groups?

They are not even asking the questions. As I say above, there is an obstacle to thought here, in the form of the behavioral paradigm. Those who hold the paradigm seem unable to go beyond it. The very questions Piot should have been asking in 1987 remain unasked by most academics publishing in the field of HIV today. Papers like this one by Piot have amply fuelled prejudices ranging from those aimed at Africans and women to those aimed at men who have sex with men, drug users, prisoners, migrants, long distance drivers, religious denominations, tribal groups, nationals of various countries and others too numerous to mention.

How do we know that most people said to have been infected with HIV through heterosexual sex were really infected through sex? We don't. How can we rule out non-sexual transmission in 95% of Kenya's HIV positive people? We can't. What is the relative contribution of non-sexually transmitted HIV, such as through unsafe healthcare? We have no idea. The HIV industry likes to use the metaphor of 'closing the tap', preventing new infections; they need to see that there are two taps and both need to be closed, regardless of which one contributes most to the pandemic.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]


Friday, February 3, 2012

PEPFAR Committee Pulls Rug Out From Under Its Own Feet

About a year ago PEPFAR carried out a technical consultation on 'mixed' HIV epidemics. These describe country epidemics where HIV prevalence is relatively high in the general population (compared to non-African countries), and high or very high among members of groups known globally to be most at risk, such as men who have sex with men and intravenous drug users. The consultation involved representatives from 12 countries but I'll just look at one right now, Ethiopia.

To make things clearer, in every country with a HIV epidemic, in every continent, HIV prevalence is found in high risk groups, such as the ones mentioned above. But it is only in some countries in sub-Saharan Africa that HIV prevalence is high or very high outside of these groups. In fact, in most countries in the world, HIV is rare outside of high-risk groups. And it is only in some countries that HIV prevalence is inordinately high among commercial sex workers, most of them in Africa.

So all countries with a serious HIV epidemic could be called 'mixed', whether HIV prevalence is high or low in the general population, that is, outside of high-risk groups. The problem of explaining why a virus that is difficult to transmit through heterosexual sex appears to be high among people who only engage in heterosexual sex is as perplexing for the highest prevalence countries, such as Swaziland, Botswana, Zimbabwe and South Africa, as it is for Ethiopia, Kenya, Uganda or Tanzania, where prevalence is a lot lower.

HIV prevalence in Ethiopia, at 2.4%, is far lower than in countries such as Kenya, Uganda or Tanzania, where it currently hovers at around 6%. But given the huge population of Ethiopia there could be almost as many people living with HIV there as in each of the other three countries. An estimated 137,000 people become newly infected with HIV every year. According to PEPFAR, 87% of these new infections are transmitted through heterosexual sex, with another 10% transmitted from mother to child.

This leaves a mere 3% for other modes of transmission, whether they be through men having sex with men, intravenous drug use or unsafe healthcare (something PEPFAR people tend not to mention). There are three women infected for every two men and, while prevalence is less than 1% in rural areas it is nearly 8% in urban areas. The vast majority of people, over 80%, live in rural areas and there a lot more males than females living in urban areas.

The consultation identified several 'risks' for HIV, including multiple, concurrent partnerships, inconsistent use of condoms, transactional or commercial sex, intergenerational sex (between older men and younger women), early initiation of sex for females, high prevalence of sexually transmitted infections, etc. At least, these are thought to be risks for sexual transmission. Injecting drug use and men having sex with men are said to be 'emerging' in Ethiopia.

But it's interesting to compare those 'risks' with the 2005 Demographic and Health Survey for Ethiopia. This survey suggests that there are some non-sexual risks that should be examined, especially among women who received "Birth and delivery care by [a] professional", where HIV prevalence is 9.9%, compared to only 1.2% for those who did not receive care by a professional and 2% for those who had not given birth in the last three years. HIV prevalence was 3.5% among those receiving ante-natal care, compared to 1% among those not receiving care and 2% among those who hadn't given birth in the last three years.

With some of the figures, it might be wondered which men are infecting women. Among women who have had 'higher risk' sex in the past year, HIV prevalence is 12.3%, but among men it is only 1.8%. And one of those figures that should be disturbing to condom manufacturers is that prevalence is 20% among women who have used condoms compared to 2% among women who have never used them. Prevalence among uncircumcised men is only 1.1%, compared to .9% among circumcised men, hardly a massive difference.

As is commonly found in such surveys, women in the wealthiest quintile and those with the highest levels of education are significantly more likely to be infected. In fact, the bulk of infections among women, which consititute the bulk of heterosexual infections, are among wealthier, better educated women. Wealthier and better educated men are also far more likely to be infected than poor and less well educated men.

As UNAIDS say, 'know your epidemic, know your response'. So should Ethiopeans reduce education and poverty reduction programs? Should fewer women attend ante-natal or post natal care? Perhaps they should avoid cities, where most health facilities are? Should health facilities be extended out to the rural areas, or would that increase the risk that women in rural areas face? One certainly wouldn't expect condoms to increase HIV risk among those engaging in heterosexual intercourse.

The data clearly show that HIV risk is not closely correlated with sexual practices. On the contrary, it is correlated with non-sexual risks, such as post and ante-natal care. Many of the vulnerabilities PEPFAR identify are not vulnerabilities to HIV; FGM (which is actually generally correlated with low HIV prevalence) is far more common in rural areas, where HIV prevalence is very low; poverty is clearly correlated with low HIV prevalence; early and intergenerational marriage is also more common in rural areas. There may be some true sexual risks, but the 87% for heterosexual transmission mentioned above can be no more than a delusion.

Before escalating their usual response, which is to assume that almost all transmission is heterosexual despite evidence to the contrary, PEPFAR should remember how closely HIV tends to cluster around main roads, close to rural centers and, crucially, close to health facilities. HIV prevalence is not evenly distributed throughout countries like Ethiopia, whereas most of the 'risk' factors listed are very general and probably quite evenly distributed; many are likely to be just as common in non-African countries.

The most at risk population in Ethiopia, as in many other high prevalence countries, is female, urban dwelling, wealthier and better educated. That does not suggest a mainly heterosexually driven epidemic and shows that many of the 'risk factors' identified by PEPFAR are red herrings. Things that are true of Ethiopia may well be true of the other 11 countries. But PEPFAR will continue to concentrate on sexual risk and ignore non-sexual risk because that is what they appear to have set out to find.

It's odd that PEPFAR should have called Ethiopia's epidemic 'mixed', only to then claim that 87% of the virus is heterosexually transmitted and another 10% is, presumably, indirectly heterosexually transmitted. But they go on to say that neither men who have sex with men nor intravenous drug use contributes much to the epidemic. While it's hard enough to explain very high levels of heterosexual transmission anywhere, the idea that the virus is almost never transmitted through unsafe healthcare or cosmetic practices in a country with deplorable living conditions and 1.2 million HIV positive people is simply untenable.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]


Thursday, February 2, 2012

How to Reduce Healthcare Transmitted HIV in African Countries?

"One consequence of the global HIV/AIDS pandemic has been the emergence of a broad awareness of the potential role of syringes in the transmission of infectious diseases", write Nicola Bulled and Merrill Singer in Aids and Behavior. Indeed, several countries experienced sudden drops in HIV incidence, the annual rate of new infections, relatively soon after the virus arrived. These drops occurred long before HIV prevention interventions became widespread, and they are likely to have resulted from the very phenomenon Bulled and Singer note. But more still needs to be done as there is a lot of evidence that bloodborne diseases may still be transmitted through unsafe healthcare.

Of course, HIV industry cant about changes in sexual behavior is legendary. But those changes, if they ever occurred, must have done so much later, particularly if they had any causal connection with the interventions claimed to have turned around some epidemics and stopped others in their tracks. While some sexual behavior change may have occurred, perhaps even as a result of these interventions, the most significant changes probably took place in hospitals and other health facilities, and would have had little to do with sex.

Therefore, the massive increase in 'unsafe' sexual behavior that is said to have given rise to the worst HIV epidemics in the world probably never occurred. which means that the equally massive decreases in sexual behavior needn't have occurred either. But while Bulled and Merrill are right in their statement, the HIV pandemic is still blamed on sexual behavior, and in countries where prevalence is highest, it's blamed on heterosexual behavior. In contrast, where HIV prevalence is not so high, it is known to be more closely related to anal sex and intravenous drug use.

Interestingly for those who believe that HIV is just one disease out of many, and nowhere near the biggest health threat that people in high prevalence countries face, is that use of unsterile injecting equipment is also linked with transmission of hepatitis B and C, Leishmaniasis, malaria and other diseases. In other words, countries where unsafe healthcare is the norm have many reasons to identify dangerous practices and improve infection control, rather than passively accepting UNAIDS' assurance that a very small percentage, perhaps one or two percent of HIV transmission, is a result of unsafe healthcare.

Far from a build-up of unsafe sexual behavior, the authors don't even mention sex, which is unusual in the literature. Instead, they describe a climate of increasing use of injecting equipment throughout the 20th century, in and out of health facilities, by professionals and non-professionals. Through unsafe injecting practices, many diseases can spread to many countries, even many continents.

The authors even mention a myth that has been propagated by numerous parties, including the US Centers for Disease Control (CDC, though they have partially retracted the myth); that HIV dies in seconds outside the human body: it doesn't. HIV and hepetitis B and C can, "given ideal conditions, survive outside the human body for several weeks". They say "HIV has been found to survive in syringes at ambient temperatures for up to 6-weeks". But unsafe healthcare practices are unlikely to require anything like six weeks: instruments could be reused straight away, and many times each.

None of the above denies that HIV can be sexually transmitted but it does put a question mark over UNAIDS' claims about epidemics being almost entirely sexually transmitted in African countries, where some of the most appalling health facility conditions can be found. And UNAIDS don't even believe their own propaganda anyway, because they give the following warning to UN employees:

"The most efficient means of HIV transmission is the introduction of HIV-infected blood into the bloodstream, particularly through transfusion of infected blood. Most blood-to-blood transmission now occurs as a result of the use of contaminated injection equipment during injecting drug use. Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. 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. 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. It is always a good idea to avoid direct exposure to another person’s blood—to avoid not only HIV but also hepatitis and other bloodborne infections."

If HIV and other bloodborne pathogens are a danger to UN employees in health facilities, this is also a danger to Africans. They need to be warned, just as they are about sexual risks. Otherwise they will be unable to identify risky practices and unable to take steps to avoid them. The authors conclude that "From a public health standpoint, identifying syringe use patterns and their role in specific syndemic events, however, is critical because syringe use presents a discrete point of potential intervention as well as a pathway for the spread of diseases outside of their historic range."

A number of harm reduction measures are recommended, along with improved supplies, education, support to clinical facilities and other steps, which the authors point out are already known. But being known to UNAIDS, WHO and others who wield a lot of power in global public health has not readily translated into action. After three decades of getting to understand HIV better, the extent of non-sexual HIV transmission, particularly in health facilities, is in serious need of investigation. There is a lot that can be done; if various international players feel unable or unwilling to do anything, perhaps African countries need to go it alone.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]


Wednesday, February 1, 2012

Lies About Sex-Trafficking: a Pre-Olympic Sport

The usual rubbish that comes out in the press before a big international sporting event is back, according to the New Internatonalist: journalists throughout the 'free' press are already salivating about the '40,000 (or some such large number) forced prostitutes' who will be compelled to work during the London Olympics. The same kind of unresearched bumf came out before the World Cup in South Africa and various other sporting events, going back years. It's not even specualtion; there is nothing to support the articles but guesswork and other, equally underresearched articles from other, equally idiotic journalists.

The worrying aspect of the articles before the South Africa World Cup is that the country has some of the worst figures for HIV prevalence in the world. Therefore, half a million or a million visitors (depending on which source you believe) faced a very real risk of being infected with HIV, hepatitis or other blood-borne diseases if they happened to go for a tattoo, dental treatment, medical treatment or any number of other procedures. UNAIDS, despite being aware that such risks exist, choose not to inform Africans, preferring just to warn their own employees. When it comes to Africans, their response is that 80-90% of transmission is from heterosexual contact. But in the run-up to the World Cup, they didn't even warn visitors to the country.

As the New Internationalist points out, the figure is purely imaginary, probably inflated by those who feel all sex work is also sex trafficking. One of the problems with this is that there is little way of telling where the real trafficking is taking place, and therefore where to concentrate efforts to reduce it. But why traffic thousands of people for a very short event, anyway? 40,000 sex workers would barely get enough business from the Olympics attendees who happen to be male, sexually active and remotely interested in having sex with someone who has been forced into the business against their will (as opposed to those who make a choice to be sex workers, for whatever reason).

There are people being trafficked, but if police concentrate all their efforts on commercial sex work, they will have difficulty identifying those who are doing it against their will. And if they think trafficked sex workers will suddenly be easy to find during the olympics, this is not going to be their 'lucky break'. But I'm sure the police know that, even if journalists don't (I'd like to say tabloid journalists but I don't think it is confined to them). Apparently there is increased police activity, with the predictable excesses that go with such measures, but let's hope they quickly realize that they have better things to do.

Luckily, unlike in South Africa, there is little risk of being infected with HIV or anything else through medical or cosmetic exposure. At least, people won't face any higher a risk than patients currently do in UK health facilities. But sudden spikes in media and political interest in such issues doesn't help anyone, the women who are mistreated by the police, women and girls who happen to be trafficked, or anyone. The various illegal practices that surround sex work, which probably arise from the fact that it hasn't yet been decriminalized, are likely to continue, unaffected by the waxing and waning of these mostly trumped-up moral crusades.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]