Tuesday, June 26, 2012

If Anyone Can, the Vatican Can

An official at the Vatican is reported to have called for universal, free access to HIV drugs and greater investments into finding a cure. We are not told if they are going to put up some of the funding. But it's interesting that they object to the use of condoms to protect people from HIV infection, yet they think research into treatment and the like should be encouraged and the drugs should be made available to all.

Of course, the Vatican is full of surprises. You'd think unsafe healthcare would be a HIV related issue the they would embrace, given their inherent lack of understanding of sexual and even human relationships, both between heterosexuals and non-heterosexuals. Lack of access to safe healthcare and the harm that unsafe healthcare can do is known to contribute considerably to morbidity and mortality, not just in relation to HIV.

Perhaps they'd be interested to know that, of 17 billion injections given every year, 7 billion of them are unsafe? That this causes 21 million cases of hepatitis B and another 2 million cases of hepatitis C? About 5% of HIV is estimated to be transmitted through unsafe injections (though the figures is said to be 25% for India and there are no figures for individual African countries) and 0.9% of all deaths worldwide.

Apparently use of auto-disable syringes in Tanzania reduced the average time patients stayed in hospital from 7 days to 3 days. Wouldn't the Vatican wish to exert its considerable influence towards increasing use of auto-disable syringes and eradicating healthcare associated infections? This can all be done without a single condom being unwrapped. Instead of the horror of health workers demonstrating how to unwrap and don a condom, they could show people what they need to look out for when they are about to be injected, or to undergo some other kind of invasive procedure.

Another thing, even if the Vatican is opposed to homosexuality, at least among people who are not ordained priests or brothers who have taken a vow of chastity, the might care to express their opposition to persecution, bigotry, assaults and murder that are regularly carried out against people who engage in same gender sex, and even those who are suspected of doing so. I don't remember reading of any protests from the Vatican about the recent public stoning to death of a man in Nairobi, said to have been found having sex with another man, who escaped. Nor do I remember them deploring various homophobic acts in Uganda, including several murders.

The Vatican could make an impact on the fight against bigotry, rather than contributing to it. They could also help reduce HIV infection rather than allowing it to happen, only to call on others to provide those infected with drugs and possibly other healthcare services. How is it even their business to object to the use of condoms to prevent HIV infection? If they have failed to have any impact on the behavior they object to so much, the least they can do is keep quiet about other issues, instead of doing a lot more harm than good.

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


Monday, June 25, 2012

If All you Have is Condoms, Every Problem Looks...Condom Shaped

It's an oft used metaphor about development that if all you have is a hammer, every problem looks like a nail. Health and education related development are no exceptions. At different times and by different organizations, they have been dominated by the likes of birth control and related issues, water, nutrition and, of course, sex. If all you talk about is sex and all you ask about is sex, you will end up with a very rarefied view of your research area. Which is why HIV policy in African countries is mostly about sex and mostly not about any non-sexual modes of transmission.

A recently published paper by Samuel Manda, Carl Lombard and Thabang Mosala is a case in point. The title is explicit enough: "Divergent spatial patterns in the prevalence of the human immunodeficiency virus (HIV) and syphilis in South African pregnant women". A map that represents HIV prevalence in a country looks very different from a map that represents syphilis because the areas where HIV prevalence is high, in general, are places where syphilis prevalence is low, and vice versa. In fact, "HIV was more highly prevalent in deprived and populated urban areas than elsewhere, while syphilis had a high prevalence in less deprived and less populated rural areas. Spatially, the HIV prevalence was lowest in the southwestern and highest in the northeastern parts of the country". 

Though this sort of phenomenon has been demonstrated before, in research going back many years, the researchers assumed that syphilis is a "proxy for sexual behaviour and increased HIV transmission". They conclude that the "differing disease-specific spatial prevalence patterns may point to inconsistent successes in interventions between the two diseases". Syphilis prevalence may indeed be low in some areas as a result of successful eradication programs. But is there a hint that successful syphilis eradication programs may have inadvertently increased HIV prevalence? Well, I'm sure that's not one of the conclusions the authors are hinting at.

But their contention that the "discordant ecological and spatial effects between HIV and syphilis may suggest that the syphilis prevalence is not suited as a predictor of HIV prevalence" sounds spot on. Not only that, but sexual behavior is not suited as a predictor of HIV risk or HIV prevalence; and HIV status is not a reliable indicator of the sexual behavior of HIV positive and HIV negative people. HIV can be transmitted sexually, sure, but it can also be transmitted non-sexually. The question is, to what extent is the virus spread non-sexually, because prevention interventions for various modes of transmission should be very different; interventions should not be limited to hammers.

Or scalpels; because if all you have is a scalpel (or a PrePex device or some other gadget invented to perform 'bloodless' circumcision, not sure if bloodless is metaphorical) you may be tempted to circumcise a lot of men at great expense. There are better ways of spending a few billion dollars, whether it's spent on development more generally, health or even HIV, specifically. And mass male circumcision could do a lot of damage; it may give rise to an increase in unprotected sex, which would result in higher prevalence of syphilis and other STIs, not just HIV, and an increase in unplanned pregnancies. In a setting where healthcare is not safe, or where standards are not very high, HIV and other diseases might even be transmitted during the operation itself, or shortly after.

The metaphor seems to be bountiful in the HIV field; if all you have is contraception, every problem looks like an unplanned pregnancy or an unmet need for birth control. Statistics for every health issue affecting women and children seem to be used to press home the need for greater access to 'modern' methods, such as condoms, implants or, the big one in African countries with high HIV prevalence, Depo Provera and other forms of injectable hormonal contraception. The fact that Depo Provera may increase HIV transmission, from women to men and from men to women, is evidently not enough to stop this from being the number one birth control method in some countries, such as Kenya.

If you wanted to kill someone with a hammer you'd probably have to bludgeon them on the head with it or force it down their throat. And that's pretty much what UNAIDS does with its 'messages' about HIV prevention, sex and safe sex, which might be better referred to as sentences. In countries where sex is taboo, insisting that someone has a sexually transmitted infection which their partner doesn't have can be condemning them to ostracization, persecution, violence or even death. Why not tell the truth; that we don't yet know the relative contribution of non-sexual and sexual modes of HIV transmission? And then start to answer that question.

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


Friday, June 22, 2012

Zimbabwe: Healthcare Can Wait, We Need Publicity

While the English Guardian debates about the need for contraception in developing countries, which is high, but probably not quite as high as those NGOs who stand to gain most from development funding for family planning claim it is, Zimbabwe is drawing attention to mass male circumcision. According to the BBC, 10 Zimbabwean MPs have been circumcised as part of a campaign "to reduce HIV and Aids cases".

But there's a massive difference between the two programs, which will both burn through several billion dollars. Reproductive health is grossly underfunded and some of the benefits will be felt by many millions of people, directly and indirectly. On the other hand, mass male circumcision is not even guaranteed to benefit those who undergo the operation. As for reducing HIV transmission from females to males, it may even increase it. The clinical trials that are blasted from the rooftops daily in the health and mainstream press show some potential benefit from circumcision, but that is potentially outweighed by the effect mass circumcision programs may have on behavior, and actually outweighed by the effect it will have (according to one of the hyped clinical trials) on male to female transmission.

One of the weaknesses of the call for putting so much money into contraception is that poor and inaccessible health services are partly behind high morbidity and mortality among woman, infants and children. And simply limiting the number of pregnancies doesn't address the problem of poor and even dangerous healthcare. Health, even reproductive health, is a lot more than just contraception. But at least there is a chance that many urgent needs will be met. With mass male circumcision it is unlikely that there will be any great benefit to anyone, aside from those providing the circumcisions.

Politicians in Zimbabwe must be pretty hard up for attention because yesterday twenty 'parliamentarians' and 23 parliamentary staff underwent 'public' voluntary counselling and testing for HIV (another article said 60-61 planned to do so). Less well publicized was the fact that Harare Central Hospital had to tell patients to buy their own ARVs because they had forgotten to put an order in. The estimated 3,500 people a week dying from Aids may well have helped the country to reduce their very high prevalence levels, but mass male circumcision will take a lot longer to have any appreciable impact on the epidemic.

It's said that the politicians who underwent voluntary counselling and testing are not obliged to make their status known. But if one does so, it's hard to see how the others can avoid doing so too. And some of this public spirit may stem from a call Mugabe made in March for MPs to declare their status in public. I'm not sure if the president himself did so. He claims that some politicians and party officials have died of Aids. Perhaps some time he and his colleagues are not craving instant media attention they will address the country's far more acute health needs, including but not limited to sexual and reproductive health.

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


Thursday, June 21, 2012

Virus As Gun Is No Answer

The BBC has picked up on a remark made by the Northern Irish health minister, who said that the ban on blood donations should not just apply to gay people. It should also extend to people who have sex "with somebody in Africa or sex with prostitutes". According to Wikipedia, Poots is a creationist, which may mean that there's not much scope for him to think things through. But it's shocking that someone like that can hold a senior position in government.

It does sound as if Poots thinks that there is a threat from gay people, Africans and sex workers that makes it prudent to have a blanket ban on their donating blood. So how would someone end up with such a view? What has he been reading? Well, UNAIDS' publications might be enough. According to them, heterosexual sex is the dominant mode of HIV transmission in Africa.

Sometimes the institution gives a vague 80-90%, sometimes they just say the 'vast majority'. But most of those infected are either married or in a long term relationship, with the implication being that one or both partners must have been having sexual intercourse with someone other than their partner. After all, how else would there be such high rates of discordancy, which is where one partner is infected and the other is not?

UNAIDS say "paid sex is an important factor in HIV epidemics in Western, Central and East Africa. An estimated 32% of new HIV infections in Ghana, 14% in Kenya and 10% in Uganda are linked to sex work". But those figures include the sex workers, their clients and their clients' partners. And while HIV prevalence has been extraordinarily high among sex workers, especially early on in the epidemic, it's never been demonstrated that the dominant mode of transmission was heterosexual. At the time, HIV prevalence in the population as a whole was very low, so it's not clear who could have infected so many sex workers in a short space of time.

So Poots thinks that "people who engage in high-risk sexual behaviour in general should be excluded from giving blood", and going by UNAIDS' communications, Africans, women, gays and perhaps a few others fall into that group. It's shocking that such bigoted views are held by a person who has probably received some education. But perhaps it is less shocking than the fact that an institution with the sole brief of reducing HIV transmission produces publications that appear to support such bigotry.

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


Tuesday, June 19, 2012

HIV Policies and Prejudice: Divide and Rule Rules

Number 19 out of 25 'full democracies', according to the Economic Intelligence Unit's Democracy Index, is the US. A HIV positive American was recently given a 25 year prison sentence and lifetime registration as a sex offender because he had protected sex with another man. He was said to have intentionally exposed the other man to HIV infection. The sentence has been suspended and the man given supervised probation for five years, but the lifetime registration as a sex offender still stands.

A gay man is stoned to death in Kenya (number 103, hybrid regime) because he is "caught having sex" with another man (do you believe people would do something like that in a place where passers by might spot them?). One of the men escaped but was seriously injured. How the various details about the men mentioned in the article could have become available is not terribly clear. And there is more than a hint that, even if male to male sex was involved, there were probably other factors. But claiming that two men were having sex should certainly be enough to get a crowd going.

The president of Uganda (number 96, hybrid regime), Yoweri Museveni, says he is going to kill the anti-homosexuality bill that has been doing the rounds for several years now. It's not exactly comforting to hear that someone who has held power for 25 years can decide whether bills should live or die. But now that so much hatred has been stirred up, one could question the president's ability to reverse all the damage that has been done. Not that thinking he has special powers distinguishes him from many senior political and religious leaders. But apparently Museveni believes that what happens in private is private. However, he feels it "should be illegal to induce children into sexual activity" of any kind, though that hardly distinguishes him either.

Church leaders are not completely in agreement with the president on the subject of homosexuality at the moment. The Catholic church seems pretty undecided about where its work should be focused right now, even at number 19. American nuns have been taken to task for "focusing its work too much on poverty and economic injustice, while keeping ‘silent’ on abortion and same-sex marriage". The taking to task emanates from Rome, Italy (number 31, flawed democracy), issued by one Joe 'The Pope' Ratzinger, from Germany (number 14, full democracy).

So perhaps the president and the church have more in common when it comes to the subordinate role of women. An estimated 100 Ugandan women a week die giving birth. Activists are demanding that this be recognized as a violation of women's rights. But it is not just trained health personnel, adequate facilities, supplies and equipment that are lacking. There is also said to be a lack of compassion for the women and babies who die, and even for the families involved. It is pointed out that there appears to be little commitment, as there is a lot of money available for fighter jets, military hardware and other things that should not take priority over health.

So what about the efficacy of condoms or 'safe sex' in general? What about the wisdom of knowing your HIV status and behaving accordingly? What about being honest and open, or even being cautious and private where that's more appropriate? What about the individual responsibility of both parties having consensual sex, where one happens to be HIV positive? Aside from appearing a lot more compassionate than issuing pink triangles to be sewen on to jackets, how much confidence should we have in antiretroviral programs that appear to drive a wedge between those who are 'contaminated' and those who need to be 'protected'? Are HIV policies inadvertently undermining human rights, or is everything actually going to plan?

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


Friday, June 15, 2012

HIV: Still One Hump Short of a Sexually Transmitted Epidemic

When you plot a graph with UNAIDS' prevalence figures for HIV country epidemics using the figures available for 1990-2007, for most sub-Saharan African countries there is a pronounced hump where prevalence peaks, followed by a downward trend, presumably where death rates began to rise (it was far too early for declines to be much related to prevention programs). As you can see from the graph below, prevalence reached almost 30% in Zimbabwe; in Tanzania, figures never rose higher than 8%.

According to UNAIDS and the received view of HIV epidemics, the virus was spread rapidly as a result of high and increasing levels of unprotected heterosexual sex. Explanations of why levels of unprotected sex should have increased suddenly, and then declined, are not so clear. There are vague mentions of urbanization, changes in social norms, migration and all sorts of other things. However, there is little indication about why these might have changed so profoundly when they did, and none at all about why they changed back again to the way they were before (which they must have done if the received view is true).

Given all this rampant sex, you'd expect at least a slight uptick in birth rates, right? Contraceptive use was also increasing in the 70s, 80s and 90s, but not so fast; it's still not that high in many countries. Well, fertility rates have actually been declining for decades in places like Tanzania and Zimbabwe. The graphs linked to, far from showing any hump, clearly show a decline, from an average of just under 7 births per woman in 1960 to 5.5 in 2010 in Tanzania and from just over 7 in 1960 to 3.3 in 2010 in Zimbabwe.

When HIV prevalence was peaking in the 1990s, fertility continued a steep decline that began several decades before. But given the continued high rates of unprotected heterosexual sex, demonstrated by continued high birth rates in Tanzania, you might be led to expect high HIV prevalence there. Instead, the figures are substantially lower than they are in Zimbabwe, which has one of the worst HIV epidemics in the world.

Of course, these figures are rough. HIV epidemics are characterized by considerable heterogeneity; figures vary enormously between age groups, genders, tribes, religious groups, etc, and also in different areas. But there are still anomalies with the 'behavioral paradigm', the view that HIV is almost always transmitted through heterosexual sex (in African countries; the caveat needs to be in brackets, because it is generally unspoken, but HIV is most definitely not almost always transmitted through heterosexual sex in non-African countries).

For example, fertility tends to be higher in rural areas, whereas HIV prevalence tends to be higher in urban areas. HIV prevalence is generally higher among females in high prevalence African countries, but unsafe sexual behavior rates are generally higher among males. Women may face higher risks than men, but if they are almost always infected by men, rates among men shouldn't be too much lower than among women.

There was an interesting paper published a couple of years ago, entitled "Sexual behaviour does not reflect HIV-1 prevalence differences: a comparison study of Zimbabwe and Tanzania", by Munyaradzi P Mapingure, et al. And this paper found that, despite HIV rates being far higher in Zimbabwe, rates of 'unsafe' sexual behavior were far higher in Tanzania. In fact, rates of almost all sexual risk factors for HIV were higher in Tanzania than in Zimbabwe. The authors conclude that non-sexual HIV transmission may play an important role in variations in HIV prevalence.

It's interesting that the authors should make such a suggestion because there's a Wikileaks cable about HIV transmission through reused syringes in health facilities in Nigeria, written by President Obasanjo to President Bush. Obasanjo was proposing the use of autodisable syringes, which break after being used once, because the WHO estimated that nearly half of all syringes are reused in Africa and that 10% of new HIV infections are from contaminated blood, including unsafe injections.

Nigeria has the third highest number of people living with HIV in the world, behind South Africa and India. 10% represents a lot of infections through unsafe healthcare. According to UNAIDS estimates, unsafe healthcare only accounts for around 2.5% of HIV transmission. But, given Mapingure's paper, along with the distinct lack of increased birth rates at a time when massive increases in unsafe sex were said to have been causing so many appalling HIV epidemics, which are still out of control in most high prevalence countries, perhaps it's time to take another look at the relative contribution of sexual and non-sexual HIV transmission?

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


Wednesday, June 13, 2012

Re-Colonization of Africa by Canadian NGOs?

How acceptable would this be as the first sentence in a blog or article: "Girls are so devalued in parts of Canada that men routinely rape them in the belief that, by assaulting a virgin, they will be cured of HIV/AIDS"? There are so many things wrong with such a sentence it is hard to know where to start. Luckily, I don't think anyone has started an article with that sentence. However, the Canadian Globe and Mail did start an article with almost the same sentence, except it was about Kenya rather than Canada.

Supposing we had some figures for sexual assault in Canada, such as:

  • Of every 100 incidents of sexual assault, only 6 are reported to the police
  • 1 - 2% of "date rape" sexual assaults are reported to the police
  • 1 in 4 North American women will be sexually assaulted during their lifetime
  • 11% of women have physical injury resulting for sexual assault
  • Only 2 - 4% of all sexual assaults reported are false reports
  • About 50% of sex assaults occur on dates
  • 60% of sexual abuse/assault victims are under the age of 17
  • over 80% of sex crime victims are women
  • 80% of sexual assault incidents occur in the home
  • 17% of girls under 16 have experienced some form of incest
  • 83% of disabled women will be sexual assaulted during their lifetime
  • 15% of sexual assault victims are boys under 16
  • half of all sexual offenders are married or in long term relationships
  • 57% of aboriginal women have been sexually abused
  • 1/5th of all sexual assaults involve a weapon of some sort
  • 80% of assailants are friends and family of the victim
  • 63% of victims suffer physical harm
  • 9% of victims are disfigured from the attack

So, would it be acceptable for the above sentence to state that "girls are so devalued in some parts of Canada that men routinely rape them", and to go on to attribute some kind of belief or beliefs to the perpetrators that accompanies the commission of these assaults? I don't know the answer to the question but I'm guessing that if it appeared in a Kenyan newspaper, Canadians would raise some objection, if Canadians ever read Kenyan newspapers.

I don't think Kenyans would be any less horrified by figures for sexual assault and rape in Kenya than Canadians would be by those figures for Canada. As for gender inequalities, that's another story. Gender inequalities are profound at all levels of society in many countries, including Kenya. Many African countries have a long way to go, and I don't think most would deny that. But gender inequalities run deep and are unlikely to disappear in the course of a few years of setting out lines of demarcation between 'the good' and 'the bad' by concerned Canadians.

The NGO mentioned in the article may well be brilliant and their interventions may be fantastic. But what I find most disturbing is that Canadians could be arriving in Kenya believing the sort of sentence under discussion; or that donors or supporters for the organization believe such things. The matters the NGO proposes addressing are, unquestionably, horiffic and urgent. I am neither doubting the good intentions of theequalityeffect.org, nor the work that they have done and intend to do. Perhaps the organization would even distance itself from the Globe and Mail article, in particular, the first sentence? Maybe neither the executive director, cited in the article, nor anyone else working for the organization has read the article.

The fact that such a sentence can be written by a journalist, probably read by at least one editor and apparently accepted by readers suggests that Kenyan men can be depicted as not quite human; people are dehumanized by being so depicted. Their behavior is depicted as being so wrong that almost any action that could be brought to bear might well be acceptable. Perhaps there is little danger that a reputable NGO will end up treating (or even depicting) people as in some way not quite human. But there is a danger that many Kenyans will strenuously object to the actions of those who find it acceptable to depict them in this way.

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


Sunday, June 10, 2012

Some Religious Leaders Support Non-Stigmatizing HIV Strategy

It's good to read that the Christian Science Monitor is taking an interest in an initiative from the International Network of Religious Leaders living with or Affected by HIV/AIDS (INERELA+). The initiative is called SAVE, which stands for: Safe sexual and skin-piercing behavior; Access to treatment; Voluntary counseling and testing; and Empowerment. (SAVE has also been covered by this blog and by the Don't Get Stuck With HIV blog.)

The ABC strategy (Abstinence, Be faithful, use a Condom; see the AVERT site for an interesting history) was pretty clapped out when Bush and his followers took it over, claiming that it was successfully used to reduce HIV transmission in Uganda (it wasn't). But when Bush and others insisted later that it was abstinence alone that made the biggest impact and that abstinence should receive the main emphasis (and the bulk of the funding), it became obvious that the smart HIV money would be on sex and sexual transmission. Big NGOs and the rest of the HIV industry did everything they could to climb on the bandwaggon. For some, coming from various church groups and former eugenics organizations, it wasn't even a difficult climb.

Sadly, the CS Monitor article doesn't move that far away from sexual transmission. Mentioning mother to child transmission, among those who believe HIV is almost always transmitted sexually, is often used to draw attention to the 'sexual behavior' of the mother or the mother's sexual partner, or both. HIV transmission rates have probably not changed that much in the past 10 years in East African countries that receive some of the highest levels of donor funding. Indeed, new infections in the US and several Western countries have remained the same for an even longer period. But this is a good start to moving away from the behavioral paradigm, the view that most HIV transmission (in African countries) is a result of heterosexual behavior.

One of those behind SAVE, Canon Gideon Byamugisha, is quoted as saying "achieving the UN goal of zero new infections, zero discrimination, and zero AIDS-related death will require a comprehensive strategy that addresses HIV in its entirety". He goes on: "ABC's flaw...is that it takes a moral and sexual approach only – a deadly approach in African cultures where stigma, shame, denial, discrimination and inaction are all too common reactions – and doesn't teach people the multiple strategies that can prevent the spread of HIV".

Not only are people seriously misinformed in thinking that all or most HIV is transmitted sexually, which means they are unlikely to know how to avoid non-sexual HIV risks, but they are also inhibited from being tested or even discussing HIV with others. Far higher levels of HIV testing are key to treating those who are infected and protecting those who are not infected, or who may be at risk of being infected. But for wider testing to have any benefit for HIV negative people, the main routes to infection need to be established.

Once everyone is in a position to learn how to avoid infection, through whatever route, HIV positive people should be able to avail of various treatment options, rather than having to keep their status a secret or put up with the sort of prejudice that has arisen against HIV positive people, and is reinforced by the insistence that it is almost always sexually transmitted. The Christian Science Monitor and others who wish to promote the interests of SAVE need to make things much clearer than they have done so far: knowing that someone is HIV positive does not give any insight into their sexual behavior or that of their partner. People face non-sexual risks through unsafe healthcare, traditional practices and unsafe cosmetic practices.

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


Saturday, June 9, 2012

Transactional Abstinence and the Objectification of Women

Similar to the HIV scare stories before the 2010 World Cup in South Africa (and numerous other sporting events), the mainstream media is full of the same in the run up to Euro 2010 and the London Olympics. According to the Washington Post, Ukraine has a booming prostitution industry, which is going to boom even more while the football is on.

Of course, for the media this is all about sexually transmitted HIV. Much of Ukraine's epidemic is a result of intravenous drug use and even many of the sex workers who are infected may not have been infected sexually. But mainstream journalists seem shy of mentioning that blood-borne infections, such as HIV, hepatitis and others, can be transmitted through unsafe healthcare, tattoos and various other routes.

We are told that an estimated one in ten sex workers in Ukraine is HIV positive. Someone cited in the article says "If a fan is not using a condom, he has a very good chance of getting infected." But even if someone not wearing a condom has sex with a HIV positive sex worker (a one in ten chance), they don't have anything like a one in ten chance of being infected. And wearing a condom won't protect people from non-sexual infection, if anyone happens to visit a health facility or get a tattoo. What constitutes 'a very good chance'?

The article then gets bogged down with some of the horrific experiences a sex worker risks, without questioning the sort of society that allows some women to be subjected to things that would be criminal were anyone else to experience them (which is by no means something peculiar to Ukraine, or even to poorer countries). The article makes it seem inevitable that if someone works as a sex worker, they will be persecuted with impunity.

Aside from allowing the author to express a bit of righteous indignation and fill up some space (and why shouldn't journalists make a bit of money out of the sex trade, lots of other people do?), it's hard to see any point to an article like this. It doesn't promote public health and, far from promoting the interests of sex workers in Ukraine, it appears to advertise the country as the ideal destination for sex tourism and underage sex. Or perhaps that's what Washington Post readers demand?

The anthropologist Laura Agustin expertly denounces the conflation of sex trafficking with sex work, which does nothing for those who have been or are in danger of being trafficked and does a lot of harm to sex workers and those who are thought to be sex workers. There are also protests in the UK about the 'crackdown' on the sex trade, which is unlikely to amount to much more than police redoubling their usual efforts to exercise their prejudices against people who may or may not be sex workers.

In a bizarre twist of logic though, the HIV industry has decided that transactional sex is such a bad thing that they are willing to give girls in some African countries money not to have sex. Ostensibly, the money is to keep them in school, but given that one of the aims is to reduce HIV transmission, and that the industry believes almost all HIV is transmitted through heterosexual sex, it is not a big step to see this as transactional abstinence.

At one time, the message was that it is bad to exchange money for sex. Now the message is that you can make more by not being infected with HIV or a sexually transmitted infection, or by not getting pregnant. It's unlikely to result in people having less sex; nor is it even clear why staying in school for longer appears to have been accompanied by a reduction in HIV transmission.

But the strategy doesn't seem that different from transactional sex by another means. How are the recipients not being objectified? How are they not being seen as sex objects? They are being treated as if they are all potential sex workers, particularly if they are poor. The HIV industry seems to be proposing the control of people's sex lives using financial inducements. Compare this to Laura Agustin's article on the use of 'rescue and rehabilitation' approaches to sex work and their long and venerable history. Except that in the African case the girls are probably not involved in sex work. But there seems to be a danger that the cash incentive will simply underline just how lucrative transactional sex can be.

The media, the HIV industry and various religious and political interests are selling us what amounts to deeply ingrained institutional prejudices against women, sex workers, Africans and many others. If a story sounds like a journalist's wet dream, that's probably exactly what it is. But this kind of coverage can draw attention away from, rather than towards, the worst injustices that are being committed in the name of public health, crime reduction and the protection of vulnerable people.

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


Friday, June 8, 2012

Circumcision: A Few Billion to Spare for Africa

According to one source, Uganda plans to circumcise 4.2 million men by 2015 in the hope that this will reduce transmission of HIV from women to men (there is evidence that it increases transmission from men to women). At around $120 dollars per operation (probably a low estimate), that comes to 500 million dollars or so. And that's just 15-49 year olds; there's no telling how many infants and children will also face the same treatment.

Just to put those ludicrous figures in perspective, Uganda is short of surgeons by an estimated 3,300. It's said that the problem is not a shortage of trained medical personnel, but rather brain drain. But with fewer than 100 specialist surgeons for 34 million people, it might strike one as strange to add such an almighty burden to an already overstretched health service.

The cost of each circumcision will probably be about 25 times per capita spending on health by government and donors combined. The $150 million said to be spent on treating government officials abroad seems diminished beside what will be spent on a mass male circumcision program that, even according to enthusiasts, may only prevent one infection in every 100 men circumcised.

Perhaps we should not worry so much. There are plans to train people who are not surgeons, who are not even doctors, to carry out the bulk of the operations. But, rather than spending so much on what will effectively be a parallel health system, dedicated entirely to circumcising men, it might seem better to provide incentives for some of the tens of thousands of trained Ugandan health professionals currently working in the US to return to their home country for a while?

In fact, $500 million could do a lot for health in Uganda. Instead of blowing it on an operation that is more risky, more expensive and less effective in reducing HIV transmission than correct penile hygiene, many of the most common diseases that cause the highest proportion of morbidity and mortality could probably be cut to a fraction with that kind of money. So why the continued insistence on circumcision at all costs?

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


Wednesday, June 6, 2012

Compulsory HIV Testing Will Lead to Adversarial 'Public Health'

It may be tempting to believe that if everyone were to undergo a HIV test, this would make it easier to control the disease. And it could be a good start, there is a lot to be said for universal testing. But as Alvar Mwakyusa writes in Tanzania's Daily News, there are some important matters to be discussed first. The idea that people should be compelled to be tested for certain diseases is highly questionable. Should patient autonomy be suspended? Or would it only be for HIV, or for other designated diseases, and which ones? And would this only be in countries where HIV prevalence is high, or everywhere?

Apparently, some would go further than compulsory HIV testing and insist that people also be compelled to disclose their status. To everyone? Just their HIV status? Perhaps they would also be compelled to disclose how they were infected, whether it was sexual or non-sexual, by a casual partner or a monogamous partner, by a tattoo artist or by a medical doctor, etc. I'm not arguing that there is a slippery slope from disclosing status to disclosing a lot of other highly sensitive personal information about yourself and probably others; I'm suggesting that, in the current climate, revealing your HIV status could be construed as implying a lot about your lifestyle, morals, associates and more.

After all, most HIV infections in Western countries are said to occur as a result of either male to male sex or intravenous drug use. The former is frowned upon in many countries (and in many more families, communities, social groups, etc) and the latter is illegal in most countries, perhaps in every country. In many developing countries and most African countries, the received view is that HIV is almost always transmitted heterosexually, with the added implication that some kind of illicit sexual behavior was involved, such as extra-marital sex or transactional sex. Declaring that you are HIV positive is never just revealing a discrete piece of information about yourself. And what will be implied about you and those associated with you can often only be guessed at.

Why should we believe that HIV testing would even be voluntary? Some believe it should be universal but that people should not be compelled. Mass male circumcision programs are supposed to be voluntary, but some have claimed that there is a lot more than 'awareness raising' when it comes to recruiting people to undergo the operation. Most seem to be very badly informed, perhaps even deliberately misinformed, or at least only given partial information. Some men and women believe they are 'protected' from HIV and don't need to use a condom.

What protection do people have against the prejudice that they will almost certainly be subjected to once they have declared their status? Will they even be eligible for treatment? Many HIV positive people, even some who have reached an advanced stage of the disease, do not receive the drugs they need to keep them alive. Others receive them intermittently. And many on treatment are finding that they need a lot more than just drugs, but are unlikely to receive anything else. Even if the status of everyone was known, would that guarantee that their lives would be improved, that they would thereby gain access to things that have been denied them up to now?

Already, people who may face the highest risks from prejudice and discrimination because of their HIV status, or their perceived HIV status, are often more likely to be tested without being given much option about whether to test or not; their confidentiality may not be guaranteed either. These groups include pregnant women, sex workers and others. It seems to be assumed sometimes that the person who tested positive first infected others, but this may not be so. Just because a pregnant woman tests positive does not mean she infected her partner. And if her partner turns out not to be infected, which seems to happen a lot, this does not mean she has had other sexual partners.

The problem is that HIV is not always heterosexually transmitted, despite assurances that it almost always is in Africa (but nowhere else). When I talk about the 'current climate' above, this is what I am referring to. It is often assumed that HIV positive people in African countries are either promiscuous or in some other way involved in illicit sex. It's not enough to educate people about testing, it is also necessary for UNAIDS, WHO, CDC and other institutions to come clean about the relative contributions of sexually and non-sexually transmitted HIV.

The discussion about testing in Tanzania makes several references to the HIV and AIDS Prevention and Control Act of 2008, according to which intentional transmission of HIV is an imprisonable offence, carrying a sentence of between five and ten years. But if counselling and testing often can't establish how someone became infected, who may have infected them, who they may have infected, etc, how can such a law even be tenable?

James Krellenstein and Sean Strub have written an article entitled 'The ethical implications of “treatment as prevention” in the United States' that looks at the situation in a wealthy country, where many of the above considerations may be of less relevance. But the article shows that there are a lot of issues still to be discussed, that the matter is by no means clear.

Someone in the Tanzanian article asks if the country even has the resources to test everyone, whatever about the other issues. But something not raised is how often people would have to be tested. Would it be every year, more, less? People's status can change in the space of a few months, especially in places where transmission rates are high. It seems unlikely that Tanzania would have the resources to test all 40 million people once, or even all adults, let alone do so regularly. Will any of the outstanding issues be adequately discussed? The list above is by no means exhaustive. Or will zealous donors turn up with the money and get going before the main issues have been addressed, as they have done with mass male circumcision and other programs?

Since the 1980s, fingers have been pointed at various groups, certain practices have been said to be more likely to transmit HIV, old prejudices have been stoked up and new ones formed. But in several countries it has become clear that a sizable proportion of people becoming infected with HIV could not be considered to be at high risk of being infected. And some who do face high risk of sexual transmission also face non-sexual risks. For example, sex workers, who are unlikely to be infected sexually in Western countries, clearly face obviously sexual risks in African countries. But they also face non-sexual risks, which are also obvious if you are open to the possibility of non-sexual transmission.

The proposal to test everyone for HIV, and even the proposal to put all HIV positive people on antiretrovirals, are not the first instances of ethical standards being lowered. Aggressively 'marketing' birth control that may not be safe and circumcision programs that are neither safe, necessary nor effective are just a couple of earlier examples. Refusing to countenance the idea that a large proportion of HIV transmission is non-sexual may not be unethical but failing to use data that raises questions about the received view, on which most HIV policy is based, surely is.

If expanded HIV testing was being used as an opportunity to trace infections to find out where they are coming from and to prevent more infections, the more people tested, the better. This would not justify compelling people to be tested, but if they could do so without fear of repercussions, it would be a big step forward in reducing HIV transmission. But treating HIV differently from all other health issues is one of the reasons why people who are HIV positive are subjected to so much prejudice. The principles of medical ethics can not be compromised on the grounds that HIV is an emergency. On the contrary, it is because of the urgency that those principles remain vital.

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


Tuesday, June 5, 2012

Sexual Distraction: Healthcare Associated HIV Transmission

Kiangiosekazi wa Nyoka gives a robust response to the claim of the Parliamentary Standing Committee on HIV/AIDS that "excessive overcrowding of remand prisoners at Segerea has culminated in unimaginable free sex in that prison". They sound almost envious. But as Kiangiosekazi wa Nyoka points out, high levels of HIV transmission does not demonstrate high levels of sexual intercourse.

This is not to deny that conditions in prisons are appalling, nor that male to male sex occurs in prisons of course, nor even that these can increase the risk of HIV transmission. But emphasizing sex, especially male to male sex, may distract attention from inhuman conditions in prisons, including conditions that also increase the risk of non-sexual HIV transmission.

The author acknowledges sexual risks that prisoners face but also reminds us about "injecting drug use (IDU), tattooing, piercing, sharing of razors, hair clippers and unsafe medical or dental care". He could also add traditional practices, including saro, blood oaths and perhaps a few other items. The author goes on to note that it is generally not possible to establish if prisoners were infected with HIV before or after spending time in prison. There is also a long list of factors that may further contribute to the above risks, resulting in the very high rates of HIV prevalence found among prisoners in many African countries.

The author rightly condemns the sloppy research used in this instance. But even careful research tends to be biased towards sexual modes of HIV transmission, especially where the sexual behavior can be painted as somehow illicit: male to male sex, extra-marital sex, sex work, etc. Just as this bias deflects much needed attention to the plight of prisoners and people on remand, the same bias deflects attention to the plight of all HIV positive people and those felt to be at risk of being infected.

On the one hand, public health programs claiming to address HIV transmission end up depicting all sexual behavior as illicit, because the majority of people being newly infected with HIV in mature epidemics do not engage in 'unsafe' sex; most of the people infected have one sexual partner, who is HIV negative; if this is really how so many people are infected by a virus that is difficult to transmit sexually, it's high time to say what it is that is so different about Africans that explain very high transmission rates. On the other hand, non-sexual transmission, such as through unsafe healthcare and various other routes, remain almost entirely uninvestigated, however strenuously the extent of their contribution is denied.

By all means address matters that are of great importance, but not at the expense of others that may be of equal importance. If people need condoms, birth control, counselling, HIV testing and all sorts of other things, they should have access to them. But these kinds of programs have been scaled up in many countries where HIV prevalence hasn't declined for years, such as Uganda, Kenya, Tanzania and others. Hundreds of thousands of new infections continue to occur every year in East Africa alone. We need to test new hypotheses about why incidence is still so high.

Huge antiretroviral (ARV) treatment programs are a testament to what can be done for those already infected. But, despite claims that 'treatment is prevention', it seems that it is not. Otherwise HIV prevalence would be increasing in countries, as more and more HIV positive people are living for longer, rather than remaining more or less the same.

Even if it were true that high levels of 'unsafe' sex is responsible for a large proportion of HIV transmission in African countries, and this has never been unambiguously demonstrated, this does not mean that all healthcare is safe; it does not mean that people do not face any risks where contaminated medical instruments have been reused and may have infected people receiving treatment. Healthcare facility conditions are terrible in East African countries, numerous reports have shown that. Therefore, it can not be guaranteed that people are not at risk of being infected with HIV and other diseases nosocomially.

I would hesitate to use even the city hospitals in East Africa and UNAIDS, rightly, warn UN employees not to use them, as they have alternatives. But Africans are not warned of the risks they may face when receiving healthcare. And the majority of people don't attend city hospitals; they attend smaller facilities, where the most senior person is a 'clincal officer', clinics where they are lucky to find anyone with proper medical training, unofficial clinics, pharmacies, unlicenced shacks that offer injections, tooth pulling and the like, all sorts of places where the possibility of HIV transmission can not be ruled out.

Kiangiosekazi wa Nyoka draws attention to a vital area of public health: non-sexually transmitted HIV. Prisoners may face such risks daily, but so would members of the general public. In Western countries we know well how risky health facilities can be when there is an outbreak of something unexpected, but there are procedures for investigating, dealing with the problems, recalling and testing those who have been exposed and treating those who have been infected. These procedures are generally not available in hospitals in East Africa; they are not even universal in the bigger hospitals. We don't have to stop talking about sex, but we also need to talk about health facility associated HIV transmission.

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