HIV Rorschach Test: It's All About Sex, Say Researchers

Several commentators who were working in African health facilities in the 1980s, when HIV started to be diagnosed, have said that their earliest clients tended to be male, employed, mobile, relatively well off and relatively well educated. While it may at first have been suspected that these were the very people who were most likely to have access to health facilities, which may have made it appear that the above characteristics were significant factors in HIV transmission, population based surveys carried out later confirmed that there often was a marked correlation between HIV status with education and wealth, among women as well as among men.

Concentrating on education for the moment, Hargreaves, Slaymaker, Fearon and Howe have this to say: "HIV prevalence trends in Tanzania differ between socioeconomic groups. While HIV prevalence was initially higher among those with higher levels of educational attainment, it has fallen fastest among these groups. Among those with lower levels of education HIV prevalence has been stable. The behavioural dynamics underlying this phenomenon remain unclear...".

While the data doesn't say that more education means less HIV, it may say something about education. Perhaps the researchers are hinting that those who had access to education were able to modify their sexual behavior, at least to some extent, in response to safe sex campaigns; HIV prevalence declined in some population sectors. Whereas, those who had less access to education, or none at all, didn't modify their sexual behavior, or did so more slowly; and HIV prevalence stagnated. But the authors list many limitations to their study and recommend further research.

To demonstrate how this hinted at mechanism may work, the researchers go on to suggest a theory that might contribute to providing "a framework to aid interpretation of emerging data". This theory is called the 'inverse equity hypothesis', which "suggests that the introduction of health interventions will tend to benefit those of the highest socioeconomic position first, only later benefiting those in lower socioeconomic groups", except that the health interventions in this instance were health education interventions, specifically.

Then comes the breathtaking sleight of hand, the fallacious move from HIV prevalence rates to rates of 'unsafe' sexual behavior: "Although little data on sexual behaviour are available from earlier in the epidemic, in the 1980s to 1990s prevailing sexual risk patterns must have been higher in higher socioeconomic groups because these groups had the highest levels of HIV prevalence in early studies." The fallacy has a long history; it's called 'affirming the consequent'. If A then B; B, therefore A (where A is 'high sexual risk' and B is 'high HIV prevalence').

Don't get me wrong; some proportion of HIV is accounted for by sexual behavior. But what proportion, and what kind of sexual behavior, exactly? And some proportion of HIV must be accounted for by certain non-sexual modes of transmission, probably involving unsafe healthcare, cosmetic and traditional practices. In the syllogism above, we must be able to explain B without begging the question about A; A must be shown to have caused B, not assumed to have done so without evidence.

So let me finish by saying why I also think the inverse equity hypothesis may have a role to play in accounting for the HIV epidemic in Tanzania and in other African countries. Men who are employed, mobile, well educated and relatively well off, what the authors refer to as "those of the highest socioeconomic position", may benefit from health interventions, that's true. But if health facilities are unsafe places, where common skin-piercing procedures such as injections may carry a high risk of transmitting HIV, hepatitis, bacterial infections and the like, men may also be among the first to be infected with whatever is going around in the blood-borne infection department.

Think of it this way, for example: factors such as mobility and wealth may facilitate unsafe sexual behavior. But unsafe sexual behavior can result in sexually transmitted infections (STI). Wealthier and better educated people with jobs are far more likely to have access to health facilities, not just at home, but away from home, where STI clinics would be more anonymous.

If Tanzanian businessmen travelled to Uganda or the Democratic Republic of Congo in the early 80s, where HIV prevalence was already higher than at home, a visit to a sex worker would have involved the risk of infection with HIV or some STI or other. But a visit to an STI clinic would almost certainly have included the risk of transmission of some blood-borne infection; especially before HIV was even recognized, but even after, when health facility transmission may not yet have been idenfitied. Why not investigate non-sexual transmission, and even look for data, rather than plugging an empirical gap with a logical fallacy?

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

Is Anyone Really Convinced by Arguments for Male Circumcision?

Two recent publications discuss medical male circumcision. The first is a technical report from the 'Task Force on Circumcision' of the American Academy of Pediatrics (AAP). The second is an article entitled 'Costs and Effectiveness of Neonatal Male Circumcision', published by the Archives of Pediatrics and Adolescent Medicine (APAM). The first concludes that "the health benefits of newborn male circumcision outweigh the risks". The second concludes that, based on a mathematical model, "[c]ontinued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women".

Firstly, the AAP report is about circumcision for infants, whereas the randomised controlled trials (RCT), so often referred to in defence of circumcision, are about adult circumcision. Research has not shown that the same results are equally applicable to adults and infants. Also, the RCTs were carried out in African countries, for the specific reason that HIV prevalence in some areas is very high. It is not credible that the same results for African countries are equally applicable to the US; the majority of infections in the US are a result of men having sex with men, followed by intravenous drug use, whereas the majority in African countries are not.

In the APAM article, most of the cost savings from increasing levels of male circumcision assume the ability to avert increases in transmission of various diseases. But if the results from the RTCs are not applicable in the US, the model could end up showing very little indeed. But how applicable are the African RCTs in Africa? They did not investigate how people were infected, whether sexually or otherwise; it was just assumed that all transmissions were a result of heterosexual sex. Had some of the transmissions not been a result of heterosexual sex, this could have enhanced their findings considerably. However, there may be other reasons for discounting the relative contribution of non-sexual transmission; it might be difficult to attract volunteers to be circumcised, for a start.

One of the RCTs found that appropriate penile hygiene gave far better protection than circumcision, but this finding is not widely reported. Clearly, penile hygiene is important for the circumcised and the uncircumcised, the sexually active and those who are not, etc. Some research has even shown that circumcision may increase transmission from males to females, which makes up the greater proportion of transmission in African countries (though not in the US or in Western countries).

On the other hand, the reported 'low risks' involved in circumcision would appear to be more applicable to the US. The AAP report says: "Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management". None of these are guaranteed in high prevalence African countries. In fact, some studies suggest extremely high rates of adverse events where the operation is carried out in clinical settings, and far higher rates when the operation is carried out in a non-clinical setting; the majority of circumcisions are currently carried out in non-clinical settings in African countries (the article is by Robert Bailey, a pro-circumcision fundamentalist).

So, highly suspect data from three places in Africa are being used to sell the idea of circumcision; OK, ostensibly it's being sold to Americans, but the mass male circumcision programs in African countries are being pushed by American institutions, using American money. The claimed low risks involved apply to the US, if they apply anywhere. But the evidence for any protective effects from mass male circumcision in African countries is still too slight to support a program that proposes to circumcise tens of millions of men and perhaps tens of millions of infants. And conditions in health facilities are not adequate for such a program to be carried out safely.

It all seems so reasonable: the more we circumcise, the better; and the costs of doing this will far outweigh the levels of disease and sickness that would result if we don't do it. But we seem to have been here before: the claimed benefits bestowed on us by Big Pharma may be outweighed by costly adverse drug reactions. Using carefully selected bits of data from RCTs is bad enough, but using them to support circumcision in the US, while using data pertinent to the US to argue for the operation in African countries, is surely an insult to the intelligence.

If individuals wish to be circumcised, fine, although I'm at a loss to know what to say to people in the US who wish their infants to be circumcised. But neither infant nor adult mass male circumcision should be foisted on African countries where it will do little good, nay, is likely to do a lot of damage.

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

Big Pharma Innovation: New Packaging for Old Drugs

Donald W Light and Joel R Lexchin's paper in the British Medical Journal, 'Pharmaceutical research and development: what do we get for all that money?' make it clear that 'we' don't get very much at all; but pharmaceutical companies get handsome profits. Despite all the references we see to an 'innovation crisis' in the industry, this is just one of many ploys to maintain and even increase levels of protection against competition from generic equivalents.

Light and Lexchin point out that, despite the many new drugs that appear every year, very few represent any real therapeutic advance. And while there have been some benefits, there has also been "an epidemic of serious adverse reactions that have added to national healthcare costs". The bulk of the claimed costs of research carried out by Big Pharma is paid for by taxpayers, more than four fifths. Only 1.3% of revenues is spent by Big Pharma itself. And even the 1.3 billion dollars the industry claims to spend can be whittled down to something less than 60 million dollars once you adjust for the more imaginative accounting measures.

This might explain some recent moves to expand significantly the number of uses of antiretroviral drugs, even to people who are not infected with HIV, which could increase the market by several hundred percent in a few years. At present, say around 8 million people are receiving the drugs (depending on which figures you use); the number requiring the drugs to keep them alive is probably double this figure, or more. But the aim is not really to provide drugs for all those who need them, it's more to provide drugs to those who don't yet need them, to those who only need them for a while and to those who don't now, and may never, need them.

The first group fit into two categories, treatment as prevention, whereby anyone found to be HIV positive will receive the drugs because it is said to reduce onward transmission; and early treatment, whereby HIV positive people are put on treatment at a clinical stage far earlier than that used in the recent past. The second group includes mothers on prevention of mother to child transmission (PMTCT), who currently receive the drugs for a matter of months; the plan is to put them on treatment for life. And the third is pre-exposure prophylaxis (PrEP), whereby HIV negative people felt to be 'at risk' of being infected take antiretroviral drugs to reduce the probability of being infected if exposed.

While research often concentrates on how certain results could benefit Big Pharma, generally because they fund the research, less attention tends to be paid to any adverse effects on those taking the drugs, or even instances where there is no net benefit. That may sound like a good reason to question this sort of strategy to most people. But the main question for Big Pharma is about where the money will come from. Whether the eventual number of people on drugs is double the current figure, treble, or something much higher, is anyone's guess. As for any damage done, it's unlikely anyone is checking.

So it becomes clearer why Big Pharma constantly whinge about how much they spend on 'innovation'; the 1.3% of revenue (or whatever fraction that's really involved) is small beer. It's the 25% of revenue spent on 'marketing' "that an independent analysis estimates is spent on promotion, and gives a ratio of basic research to marketing of 1:19". Lobbying for public money and for legislation to support the industry, and for various forms of protection, are worth far more than a little research. Given that what Big Pharma churn out at grotesquely inflated prices can be produced at an affordable cost by makers of generic equivalents, the bulk of the industry's hundreds of billions in revenue comes from various forms of market protection, nothing more nothing less.

It's estimated that about 80% of ARVs currently used in developing countries are generics from India. If only about a third of those who need them are receiving them, how many would still receive them if the proposed EU-Free Trade agreement, which would prevent India from producing these generics, was signed? This agreement is not designed to cut off antiretrovirals from Europe or other rich countries, who tend not to depend on them so much. It is to cut off the supply of (relatively) affordable drugs to countries with the worst HIV epidemics, those who can least afford to subsidize Big Pharma.

The EU trade commissioner, Karel De Gucht, denies that the agreement will have any negative impact on supplies of affordable drugs to developing countries. But it doesn't take a genius to work out that the EU would have little interest in drawing up an agreement that would benefit poor nations. Or to put it another way, the EU has a strong interest in protecting Western manufacturers of drugs and other products; that's precisely what the union is for. so I don't know whether de Gucht thinks the public is a bunch of idiots or if he is just another glove puppet; perhaps the two are compatible.

Interestingly, UNAIDS doesn't accept de Gucht's bullshit. But unfortunately, they do accept the bullshit research that is used to support calls for early treatment, treatment as prevention, lifelong PMTCT and PrEP. UNAIDS is to the HIV industry what the EU is to protectionism more generally. The fact that they are putting their oar in suggests that they are just not happy with whatever is in it for them.

The form of protectionism that makes healthcare virtually unaffordable to those who need it most is patents. These patents do not, as is claimed, allow those doing the 'innovating' to claw back their costs and make a reasonable profit. Rather, the 'innovations' are just new ways of looking at existing medicines. The costs are orders of magnitude smaller than claimed and are mostly paid for by public funds. But Big Pharma profits dwarf almost everything, the exception being the massive amounts of disease, disability and loss of life that results from this cosy relationship between a bunch of ruthless bastards and the people and institutions that are supposed to protect us from such excesses.

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

Circumcision - Medical Intervention, Money Spinner or Revenge?

"Kenya: Urine Can't Heal You - Catholic Church", says the headline. Apparently some priests have been claiming that urine cures certain conditions. The bishop has said the responsibility of the church is to "advocate for spiritual fitness" and to leave health advice to medical experts. It's a pity they didn't feel the same way about using condoms to reduce HIV transmission. But no one could accuse them of being progressive.

What is more surprising to me is that the Catholic Church doesn't seem to be so bothered about the preaching from the HIV industry about mass male circumcision reducing HIV transmission from males to females. Ostensibly, the circumcision is voluntary. But many feel the program is being imposed on them and a lot of inaccurate and incomplete information is being given out about it, even by some 'medical experts'. Don't the church feel people should have a right to choose, a right to full and accurate information, a right to protection from those who wish to impose their will?

Many of Kenya's tribes circumcise for cultural reasons. However, there are a few that don't circumcise, also for cultural reasons. Sometimes it seems that the cultural practice of circumcising is being held up as in some way superior to the cultural practice of not circumcising. Persecution of non-circumcising people and the use of forced circumcision as an instrument of torture or a weapon of war predates the development of the HIV industry, and even the HIV pandemic. But the claim that circumcision reduces HIV transmission is creeping into the rhetoric reported from gangs of thugs who circumcise men in public, for whatever reasons.

It's very unclear how many people the industry hopes to circumcise. Sometimes they claim that adult men are being targeted; yet many accounts suggests that boys are turning up in large numbers. Parents of infants are also being encouraged to have the operation carried out, even though there is no evidence that this will have any positive impact on HIV transmission. The lowest figures are over 20 million. But some estimate as high as 38 million. And a throwaway remark by the CEO of a producer of 'bloodless' circumcision clamps suggests that hundreds of millions is the ultimate target.

The HIV industry is famous for spending enormous sums of money on red herrings, so there's nothing very surprising at their enthusiasm to spend as much as possible before the bubble bursts. But it must be wondered how many people will be needlessly infected and how many will die as a result of this deflection of vast sums of money. But the Catholic Church has problems of its own. Perhaps that's why it doesn't want to get involved in something that will not result in any of the billions being directed to the church, nor even add to the numbers of poor people who pay monthly dues so priests and other members of the hierarchy can live a comfortable life

But despite all the hype, there have been two big stumbling blocks. One is the obvious lack of funding, supplies, equipment and trained staff, which have delayed some programs in Kenya and Uganda. The other is the sheer numbers involved. Most sub-Saharan African countries can only provide adequate healthcare for a small proportion of people, the ones who can afford private care. For the rest, it's a free for all; you never know what you'll get until you've got it. The logistics of carrying out so many operations would be daunting in a country with a good health infrastructure, let alone those whose health systems have been running down for 20-30 years.

But in most African countries it's not going to be possible. Tossing about notional figures for costs and targets will have no impact on the harsh realities faced by developing countries. Countries that started several years ago are still a long way from their targets. Kenya may seem to be way ahead, their target is only 2 million (though the figures cited can vary considerably), but people are just not turning up in high enough numbers. Those who got in early and received the benefits offered, however dubious, are not being followed by others in particularly high numbers.

In countries where people are most likely to die of preventable and treatable illnesses, it would seem smart to concentrate as much health capacity as possible on these, rather than frittering away everything on a program that will have very little benefit and may have a lot of adverse effects. Women are far more likely to be infected with HIV than men; circumcision is claimed to reduce HIV transmission from women to men, but it is likely to increase transmission from men to women. Surely this is not the optimum way to reduce HIV transmission, is it? Even drinking urine would be cheaper, which may explain the church's objection to it, and would probably do less damage.

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

PrePex Circumcision: a 'Bloodless' Coup

About a year ago, the BBC got so excited about PrePex, a "new, simple, plastic device, which needs no anaesthetic, surgery or stitches [which] will be used to circumcise up to two million men in Rwanda" that they produced an infomercial about it which PrePex now use on their site. It's great to get the free advertising as there are other such devices; but clearly not as well connected with good infomercial producers. Perhaps the BBC haven't heard of clinical trials. (Warning, viewers are protected from most of the operation but may find the overall tone of the video disgustingly smug, particularly when the PrePex CEO comes in; discretion advised.)

PrePex has been all over the place in the media because if one outlet says its good, none of the others want to feel left out. The New York Times have announced that it will be 'tested' in at least nine African countries. I wonder what the criteria for success or failure will be, given the current enthusiasm for circumcising as many men as possible before anyone notices that the intervention will have very little positive impact on HIV transmission from females to males and a highly likely negative impact on transmission from males to females.

Exactly how much money will be thrown at mass male circumcision and exactly how many will be tricked into undergoing the operation has never been clear. Estimates about cost per operation are often around 60 to 80 dollars. But these are highly selective costs and around double that figure is much more likely, not including the costs associated with adverse outcomes in the short and long term. Numbers of adults to be circumcised cited range from 20 million to 38 million.

The oft cited randomized controlled trials of male circumcision show that around 76 men need to be treated for each infection averted. But the director of PrePex claims that around 4 million infections could be averted over a period of several years. This would require over 300 million men to be circumcised. The cost for this could be up to 10 times more than the 3 to 5 billion estimated and would probably mean that babies and children would need to be targeted, not just adult men.

One of the people in the BBC infomercial states that circumcision is the most efficient tool for reducing HIV transmission. It's not clear whether the woman has been taken in by the hype or whether she is saying what she has been told to say. But it seems highly unethical to tell outright lies about the intervention when so much is at stake. The HIV industry can usually be trusted to tell half truths and to omit things that are inconvenient rather than telling outright lies. Perhaps they feel that's less unethical. But condoms and appropriate penile hygiene are far more efficient than circumcision.

It is also highly questionable to persuade parents to consent to their infants and children being circumcised on the basis that this may protect a small percentage of them from sexually transmitted HIV some time in the future, perhaps 20 or more years hence. In fact, the claimed reduction in transmission is for those circumcised in adulthood. High HIV prevalence in countries that already practice infant and/or child circumcision, sometimes higher than for uncircumcised males, may suggest that a bad argument for adult circumcision is being used for an even worse argument for infant and child circumcision.

Those filmed in the BBC's infomercial are all smiles; one man says his penis was ugly but it's now smart. But the biggest smiles are those of Tzameret Fuerst, the CEO of PrePex. I guess that's to be expected when you look at the figures. She talks of 'unwanted tissue' and compares using PrePex to cutting nails. I wonder, if any part of female genitalia could also be called 'unwanted', should PrePex start branching out in that direction? Lack of hygiene and unsightliness are among the reasons often cited for female genital mutilation, too.

It must be remembered that the 'up to 60%' reduced transmission from females to males is from very carefully controlled trials, where those taking part received a lot of care and support that will not be available to those 'lining up' for the operation in the future. So the number of circumcisions needed to 'avert' an infection could become so high that there is no noticeable benefit. But only after a hell of a lot of money is spent (and probably a lot of damage done); and that's what it's all about, isn't it?

The NY Times article claims that no surgeon is needed and that the operation can be carried out by two nurses. This is just as well, given the shortage of surgeons in countries where most of these operations will be carried out. Apparently it is hoped to circumcise 20 million men by 2015. Let's hope other countries are better off than Uganda, where "2,300 Quack Nurses [have been] Exposed". Unfortunately, being exposed as a quack nurse means not having the required certification, rather than any attention being paid to what those with certification know or how they perform.

This is particularly embarrassing for the HIV industry because Uganda is often held up as an example of HIV prevalence declining because the country took all the industry's advice. Now that prevalence is increasing, the industry needs to show how Uganda didn't really take their advice, because they certainly can't admit that their advice was wrong. But I'm sure the media will help them along, they always seem to follow the money. But even the latest cool thing, treatment as prevention, is not looking good in Uganda.

One of the possible reasons for the extremely low levels of success in reducing HIV transmission in African countries might be the insistence that most HIV is heterosexually transmitted. Interventions such as male circumcision are intended to reduce sexual transmission from females to males, not any other kind of transmission. The fact that this will be another intervention that doesn't work will probably not be seen as a problem for the HIV industry or for the CEO of PrePex. But it must worry ordinary African people, perhaps even African leaders.

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

The Implosion of the Killer Vaginas

Why would anyone want to claim that the risk of HIV transmission from a female to a male engaging in penile-vagnial sex is very low? Aside from the fact that it's true, which is not very important if your salary or grant depends on showing that it is not true. Well, women who have been convicted of infecting men through heterosexual intercourse may find it interesting. If the woman, for example, only had unprotected sex a few times with the man, the risk to the man is so low that it would be well worth investigating whether the man had actually been infected already.

If male to female transmission is far more likely, this means that women need to know the kind of risk they face in order to take precautions against infection; and men who are infected need to know that their risk of transmitting the virus is high, even though their risk of being infected is low. In other words, every heterosexual needs to know the relative risk of male to female transmission, female to male transmission and the additional risks where one or more parties have also engaged in anal sex, either male to male or male to female, intravenous drug use, and perhaps various other risky practices such as tattooing, professional or otherwise.

So at one time the New York City Health Department, not only surreptitiously changed the way they recorded new HIV infections to make it look as if male heterosexual infections were increasing, but they implied that such infections had always been higher than they actually were (Sonnabend and Berkowitz article). And apparently NYC's health department wasn't even the only place where this was done. Whatever the reasons for exaggerating a phenomenon that was relatively minor, heterosexual female to male transmission, public perception of the relatively high and increasing risk of male to female transmission was thereby diminished.

While the threatened heterosexual epidemic never occurred in the West, many people were infected there as a result of various high risk behaviors. At the same time, the worst 'heterosexual' epidemics in the world were taking place in developing countries. It was reasoned (by those who knew better), and still is, that if unsafe heterosexual sex resulted in relatively minor epidemics in Western countries, high rates of unsafe sex must be taking place in medium epidemics and astronomical rates of unsafe sex must be taking place in the highest prevalence areas, all of which are in sub-Saharan Africa (yes, the logic is obtuse).

Had questions ever been raised about the anomalous data being produced by NYC health department and others, and they should have been raised by people who were using and reporting such data at the time, claims of hyperendemic heterosexually transmitted HIV in developing countries might also have been questioned. If transmission is fairly efficient from males to females, but very inefficient from females to males, how could a heterosexual epidemic ever have got started; wouldn't it just have petered out in a few generations, being mainly spread from men to women and from infected women to a certain percentage of their children?

It appears that the distorted picture of HIV as a heterosexual threat has been retained, even though its predictive power was entirely discredited in Western countries, where the 'hypothesis' was nurtured and, apparently, shielded from the universal apathy of the mainstream media. It became an easy matter to go from massive rates of HIV transmission to imputations of massive rates of unsafe sexual behavior. Endless research has shown that there are few correlations between rates of sexual behavior and HIV transmission that stand up to scrutiny. Sexual behavior simply doesn't adequately account for the biggest HIV epidemics in the world.

But the view of 'African' sexuality, sexual appetite, attitudes towards women, family and the like that this 'behavioral paradigm' fitted into goes back a long way. It used to be called racism. But as the HIV industry developed, it was presented as an unremarkable part of a respectable scientific theory. The paradigm, of course, is invisible. But you can make it out if you look beyond it; to do this, you only need to ask 'is almost all HIV transmitted through heterosexual sex in African countries' and you can see the paradigm for what it is, a prejudice. You can try this exercise at home, it's perfectly safe.

The article by Joseph Sonnabend and Richard Berkowitz linked to above mentions an interesting incident that occurred in Germany in 1986: "a great deal of publicity was given to an apparent outbreak of AIDS in male U.S. military personnel stationed in West Germany which they attributed to sex with female  prostitutes in major German cities. Eminent authorities made dire predictions. However, it was soon realized that no German men had contracted AIDS from prostitutes and that there were very few HIV-infected prostitutes in Germany. In the case of the servicemen, the price for telling the truth about homosexuality would have been dismissal and loss of medical benefits. It would be naïve to assume that men will always be truthful regarding stigmatized behaviors, such as homosexuality and IV drug use."

Just as it is easy enough to malign Africans, it is also easy to malign sex workers, something that has gone on for millennia. And when you paint virually all African women of a certain age as sex workers of some form or other, you end up with publications like the ones UNAIDS specialize in, explaining the various permutations of sex worker, their behaviors, clients and forms of compensation. To this day, sex workers in many non-African countries have been shown to be unlikely to be infected with HIV unless they face some non-sexual risk, such as intravenous drug use. Why should those engaging in heterosexual sex in African be so different? Well, the question doesn't arise unless you question the behavioral paradigm, of course.

Sonnabend and Berkowitz conclude with some good advice: "in building a picture of the relative risks of various sexual acts people are asked to be frank about the most intimate and private details of their lives. This is incredibly intrusive. To unquestioningly rely on such self reported data is sure to produce a distorted picture of the distribution of cases by risk category. On matters of sex, it's probably true to say that we can deceive ourselves, let alone those questioning us."

Systematically disbelieving Africans who claim they have not engaged in unsafe sex with a HIV positive person is as breathtakingly stupid as systematically believing Western men who claim they must have been infected through heterosexual sex. Just as such claims could easily be followed up in the US, as they used to be, they could also be followed up in African countries. We have a duty to the many heterosexuals in African countries who report no obvious risk for HIV to follow up their claims and find out what risks they really faced, non-sexual as well as sexual risks.

Jacques Pepin, author of The Origins of AIDS, demonstrates how HIV would never have become an epidemic if it hadn't been for unsafe healthcare practices in places like the Democratic Republic of Congo, which spread the virus far and wide. He then claims that levels of unsafe sexual behavior rose to incredible levels in countries where HIV became endemic, a claim for which he presents little evidence. But what he fails to do is deomnstrate that unsafe healthcare practices died out in the 1980s and 90s, at the time that HIV was spreading rapidly in many African countries.

Unsafe healthcare and unsafe sex are perfectly compatible and could work together to produce exactly the sort of epidemics that are now found in many sub-Saharan African countries. While the behavioral paradigm on its own doesn't explain massive epidemics, the combination of unsafe healthcare and unsafe sex could do. All over the world, some people have lots of sex, much of it unsafe. But most of people just have ordinary sex lives. That's as true in Africa as it is elsewhere. So, not only is the behavioral paradigm highly racist, but it is not even necessary to consider such claptrap. But then, many of the HIV 'experts' have known that all along, haven't they?

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

Media Coverage of AIDS Remains Consistent

There's a prescient article written in 1987 by John Potterat which seems to have fallen on deaf ears (and eyes). Entitled 'The AIDS Epidemic and Media Coverage', Potterat disputes the claim that there is about to be a massive heterosexual epidemic in the West. He links the claim to reports from the Centers for Disease Control (CDC) in Atlanta which suggest an alarming increase in cases classified as heterosexually transmitted. Yes, 'classified' as heterosexually transmitted.

The media reports this 'increase' at face value. However, CDC changed the way it recorded HIV infections that were claimed to be heterosexually transmitted. At one time, such a claim would have been further investigated because almost all turned out to be transmitted some other way, through men having sex with men, intravenous drug use, etc. It was recognized that transmissions from women to men through heterosexual sex were rare; but the practice of following up these claims was abandoned. Transmissions from men to women through heterosexual sex were increasing, but at nowhere near the rate claimed for infections in heterosexual men.

So much effort was put into exaggerating the risk to all heterosexuals that the far higher risk to women who had sex with HIV positive men was seriously neglected. The reclassified cases were mostly men, which should have warned those commenting on the issue at the time. Potterat recommends thinking of AIDS, not as a classic sexually transmitted disease, but as one to be associated with specific sexual practices. While receptive anal intercourse is very risky, insertive anal intercourse is not. Vaginal intercourse is risky for women, but not for men.

This is not to say that men can not be infected with HIV through insertive anal or vaginal sex, just that they are not likely to be. It means that the virus is not going to spread quickly among heterosexuals, though it will be more common, a lot more common, among female than male heterosexuals. The branding, implied or otherwise, of various groups said to be at risk, was misplaced. It continues to be certain practices that are risky, not certain groups. HIV transmission rates could stay low among sex workers, men having sex with men and even intravenous drug users if certain practices were avoided and certain others were adopted.

Things are very different in developing countries. The vast majority of HIV positive people in high and medium prevalence countries are heterosexuals. This does not mean they were all infected sexually, but this is what UNAIDS and the conventional wisdom about HIV argues. But supposing conventional wisdom about HIV in developing countries is correct (unlike that in Western countries!), the big question is why heterosexual transmission is so efficient, when it is known not to be efficient in Western countries. While more women than men are infected in high and medium prevalence countries, about 40% of HIV positive people are male (possibly around 8 million men in Kenya).

Well, in a country like Kenya, the Modes of Transmission Survey actually shows that a good many of those men were probably not infected through heterosexual sex. Some are men who have sex with men, some are intravenous drug users, mostly men, and some are prisoners, who are mostly men and who are probably as likely to have been infected through non-sexual as sexual routes, if they were infected while in prison.

This leaves quite a small group of men to infect all those women, perhaps only about half of all the men infected. And that's where additional questions start to arise. Are we supposed to believe that most Kenyan women are highly promiscuous? After all, with such high HIV prevalence rates in some demographic groups, many others must have been exposed, though not infected.

And yet, in survey after survey, 'promiscuous' behavior appears to be far higher among men than among women. You could imply, the HIV industry does, that the women are promiscuous liars. But the same industry implies that many of the women are having sex with someone who is not their husband or long term partner because they are receiving money or some other compensation in return.

It would be odd for so many relatively young women, the highest rates of transmission are generally in younger women, to be engaged in any kind of transactional sex just at the time they are getting married or having their first, second or third child, wouldn't it? But many of those infected are of child bearing age, are pregnant or have had children. Without evidence, and the evidence usually points in the opposite direction, isn't such a prejudiced view intolerable?

Look at it another way: for transactional sex to be economically viable, wouldn't you need a relatively large group of customers and a relatively small groups of people supplying the services? However, the UNAIDS scenario is one where there are probably roughly equal numbers of males and females, perhaps even more females (and the males are less likely to be infected). But only infected males can infect females. So there must be this small group of infected males who are successfully infecting large numbers of females each. And as for the 'transaction', laws of supply and demand would suggest that the women are receiving very little indeed, aside from the obvious infections.

CDC allowed us to be deceived in the 1980s and we are still being led to believe that heterosexual HIV transmission is common and increasing. Could there be something they are still not telling us about HIV transmission in developing countries? The 'promiscuous African' theory doesn't really explain many anomalies, such as the minute return that transactional sex would attract where there are (allegedly) so many willing suppliers of sex being just one example.

We could also ask how many infections in high prevalence countries have been classified as heterosexual when they are not? Why are so many women infected who have only had one, HIV negative sexual partner? Where women were infected through breastfeeding their babies, how were their babies infected? How are HIV positive babies infected when their mothers are HIV negative? Or are we supposed to believe that there  is something about HIV positive heterosexual men that African women find irresistible?

Potterat shows that the various AIDS campaigns in Western countries that claimed we were all at risk didn't work; it's just that the predicted heterosexual epidemic was based on evidence that those who promulgated it knew was manufactured. Many women are probably still not aware that they face far higher risks than men if their sexual partner is HIV positive or is at risk of being infected. But could various campaigns in developing countries also be based on manufactured evidence? They don't appear to be working very well, with large drops in prevalence being mainly attributable to high death rates.

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

Fairytale of New York; Old Sluts on Junk and Africans

An article entitled "HIV prevention pill for heterosexuals at risk too" caught my eye because it reminded me of some email correspondence with people who worked in the US HIV/AIDS field in the 1980s. The short response is that most heterosexuals were not at risk, and most are still not at risk, especially where female to male transmission is involved. One of the correspondents even sent me the figures produced by the New York City Health Department.

These show that in 1991, less than 1% (8 people) of HIV positive men were thought to have been infected through sex with women at risk, compared to 55% who were thought to have been infected as a result of sex with men at risk and 35% as a result of intravenous drug use. In contrast, 25% of HIV positive women were thought to have been infected through sex with men at risk (and 85% of those women were either black or hispanic).

Later, the very low figures for HIV positive men infected by women were amended. As a result, the article above released just a few days ago can claim, though hardly justifiably, that "more than a quarter of new HIV cases each year are heterosexuals". Whereas in the earlier years of the pandemic, the NYC health department would follow up infections where the risk cited was heterosexual, they later ceased doing this. As a result, those claiming that they must have been infected through heterosexual sex were recorded as heterosexually infected.

One could speculate about why public health experts manipulated the figures to exaggerate the heterosexual risk. Perhaps they felt that the general public would have little or no sympathy for men who have sex with men or intravenous drug users? They may also have felt that there would be little sympathy for black and hispanic people, especially women. But now that HIV is such a big money earner for the pharmaceutical industry, the health department's manipulations are coming in very handy.

There has been a concerted effort to rapidly increase sales of antiretroviral drugs, to those who are HIV positive but don't yet need them, to those who only need them temporarily right now and even to those who are not HIV positive but are said to be 'at risk' by public health experts. In the first group, the majority of those newly infected, those who are most likely to transmit HIV, will not be identified early enough for treatment to be of much benefit; shortly thereafter, they will no longer be as likely to transmit the virus.

There's an interesting article in the English Guardian about Big Pharma creating opportunities to recategorize people as being in need of medication, whether they are sick or not. Mental health seems like the perfect field in rich countries. But HIV is a better one in developing countries, where the vast majority of HIV positive people live. And in developing countries with high HIV prevalence, HIV transmission among heterosexuals really is very high, in contrast to wealthy countries. The vast majority of HIV positive people in high prevalence countries are heterosexual and far more females than males are infected.

So in New York, a policy was adopted whereby it was accepted without further investigation if men said they must have been infected through heterosexual intercourse. In contrast, people in Africa who claim they have only had sex with their partner, or that they haven't had sex at all, tend to be disbelieved. Believing everything people say about their sex lives is a pretty stupid policy when there is scope to investigate further. But disbelieving everything people say about their sex lives when there is plenty of scope for investigating non-sexual risks sounds more like prejudice than anything else.

A better name for the prevailing HIV strategy, especially in developing countries, would be 'treat and treat'. Big Pharma honchos are falling over each other to mark out their new territories. The great thing about HIV gold is that you don't even need to bother finding it; you can just employ people to manufacture the stuff relatively cheaply. Evidence quite like the NYC health department's revised figures for heterosexual HIV transmission positively spurts out of research institutions, often to be amply rewarded by Big Pharma itself.

The best strategy right now would seem to be to test as many people as possible and treat those in need of treatment. We should adopt a test and investigate strategy. Because it is also vital to establish exactly how HIV is being transmitted in high prevalence countries, why those who should be least at risk, heterosexuals in long term relationships, are being infected in the highest numbers. This is a mystery for those who insist that 80% of HIV is transmitted heterosexually in high prevalence countries, a mystery that is in bad need of investigation.

The current HIV response may be (or may not be) appropriate for people who face high and identifiable risks, and who live in rich countries where healthcare is readily available to most. But it is entirely inappropriate where millions of people every year are being infected with a virus that is difficult to transmit heterosexually. The result of pretending that everyone is at risk of being infected with HIV is that many people who are infected have little idea of how they were infected and no idea of how to avoid infecting others. Now that various parties have made their fortunes and careers out of lying about HIV, isn't it time to go back to telling the truth? Don't worry, there's plenty of money still to be made, your work has ensured that.

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

Circumcision Enthusiasts; Up Have You Screwed, and Badly

An article by Charlene N Muzyka and others looks at Kenyan newspaper 'analysis' of the limitations of mass male circumcision and the importance of sustained condom use in the online Daily Nation. That there is any analysis involved may be in question; are these newspaper reports merely paraphrasing press releases? Or do they represent a genuine attempt to make sense of what scientists and other circumcision enthusiasts tell us about circumcision and HIV and try to get that across to their readers?

It's worth pointing out straight away that the researchers do not even mention the most significant finding relating to circumcision, something established by one of the three randomized controlled trials that is so often held up as 'proof' that circumcision protects against HIV: it was found that those who waited for 10 minutes after coitus and then wiped their genitals with a dry cloth were far less likely to be infected even than those who were circumcised!

In other words, the best option is penile hygiene, not circumcision. Yet the enthusiasts recommend the less effective, more expensive, riskier and less culturally sensitive option of mass male circumcision. If your first question was always 'why is cleaning a circumcised penis so much more difficult than cleaning an uncircumcised penis?', the answer is 'it is not more difficult; appropriate penile hygiene protects against HIV transmission, regardless of circumcision status'.

Anyhow, the researchers wished "to determine how the limitations of male circumcision are represented, and whether condom use is still being promoted" and to "gain insight into popular understandings of the limitations of this new procedure through newspaper reader comments". This approach highlights a serious problem for anyone who wishes to advocate for circumcision, yet continue to recommend the use of condoms; if they manage to get their point across well, people will immediately wish to know why there is any need to circumcise.

One of the limitations of circumcision is that it is nowhere near as good as condoms when it comes to protecting against STIs, including sexually transmitted HIV (for men only), and it does not protect against unplanned pregnancy (which is a particular for pro-circumcision people like Gates, who is also a eugenicist). All in all, the disadvantages of circumcision, such as the increased risk of transmitting HIV to female partners, highly prevalent myths and misinformation about circumcision held by men and women and the fact that 85% of Kenyan men are already circumcised and are therefore quite uninterested any public health messages relating to being circumcised, seem to outweigh any claimed advantages.

But the propaganda keeps coming out. Flippant apologists say it's a 'once off' operation, unlike using condoms or other prevention measures. But it is clearly not a strategy that finishes once the scar has healed. The authors of the article recommend regular news releases to the media that include clear and accurate information about sexual behavior and condom use. However, the operation is 'once off' in the sense that once it has been carried out, it is irreversable. Once the 2 million or so Kenyans targeted for the operation have been circumcised, who will be listening to any circumcision related advice, however skewed? Will there even still be a budget for follow-up interventions? Pro-circumcision proselytizing suggests not.

Clear messages about condom use should be clear enough to raise doubts about the necessity for circumcision. But continued calls for 'abstinence' should erase any remaining doubts; if abstinence is a useful strategy to anyone (is it?), they certainly don't need circumcision. Genuinely safe sex obviates the need for circumcision. Non-sexually transmitted HIV, on the other hand, will continue to be a risk. Even brains dulled to complete idiocy by the constant misinformation about circumcision will realize that unsafe healthcare will still pose considerable risk of HIV infection, especially in a country like Kenya, given current conditions in health facilities.

The 15% (and declining, but not as fast as the enthusiasts would like) of Kenyans who are not yet circumcised are being misinformed about the virtues of circumcision and they are being left entirely uninformed about non-sexual risks. The 85% may face even higher risks if they believe the propaganda. Certainly, the female partners of circumcised men face an increased risk of being infected with HIV if they and their partners internalize any of the misconceptions about the protective value of the operation that they are being fed with.

But what about the more effective, cheaper and safer option of penile hygiene? Why are those pushing their randomized trials so coy about their absolutely stunning finding; that uncircumcised "men who cleaned their penises after coitus but waited at least 10 minutes to do so got HIV at the rate of 0.39% per year", compared to circumcised men, who got HIV at the rate of 0.66% per year? Why are Muzyka and friends apparently uninterested in this finding, which is surely in far greater need of being reported? Why are newspapers not interested, even if they are just aping press releases?

It's not clear why the researchers who discovered that penile hygiene gives far better protection against HIV transmission than circumcision do not promote this discovery, nor why papers citing the original research don't mention this excellent intervention. They can hardly claim that teaching appropriate penile hygiene is a more mixed message than recommending circumcision, but only in conjunction with condom use, can they? Circumcised or uncircumcised, penile hygiene is best; even the circumcision enthusiasts have demonstrated that.

As for newspaper coverage, it is clearly not informed directly by the paper based on the trial. If it were, the astounding finding would be too sensational to ignore. Which means that it is not the media that the government needs to have 'information sessions' with, it is the researchers themselves and the scientific community that releases the bits of 'science' that it wants the public to hear. The Government of Kenya and other African governments need to ensure that research findings are clearly reported to the public and that the policies that are subsequently based on the findings are appropriate. The plan to circumcise millions of African adults (and children) is not an appropriate reaction to what has been published on the subject.

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

Dancing Bears Demonstrate Effectiveness of 'Evidence on Demand' Policy

Naturally, after spending tens of millions on the recent International Aids Conference in Washington DC, the HIV industry is buoyed up and ebullient. "The goal of an AIDS-free world...is now within sight", according to the Secretary of the US Health and Human Services. Equally naturally, that means the industry needs more money. Conferences like that don't pay for themselves.

Meanwhile, an article on antiretroviral drug resistance in Africa, which is increasing quickly, attributes this increase in part to "limited national infrastructure, a shortage of healthcare professionals, inconsistent supply chains, and weak enforcement of quality standards", which makes a change from blaming the people taking the drugs. It would be interesting if the research resulted in a change to HIV related spending, which tends to concentrate on commodities and ignore things like infrastructure, personnel, health systems and quality.

In fact, even though it refers to the US, another article mentions some 'new iniatives' which include addressing infrastructure, health systems, education and patient support that, presumably, goes beyond the mere distribution of ever increasing quantities of drugs. Not only are all the worst HIV epidemics to be found in some African countries, but some of the worst healthcare facility conditions are also to be found there, not to mention poor infrastructure, low educational standards, poverty and abysmal living conditions.

The much trumpeted 'game-changer', treatment as prevention, will certainly require a lot more than provision of drugs. In a country with very high levels of health spending, such as the US, providing drugs and various other aspects of treatment has had mixed results. According to a 'treatment cascade', of the over 1 million people infected with HIV, 80% know they are infected, 62% are linked to HIV care, 41% have stayed in HIV care, 36% are receiving treatment and 28% have a very low amount of virus in their bodies.

I haven't seen a similar 'cascade' for any high prevalence country. But the percentage who know their status tends to be a lot lower. As for figures at other levels of the cascade, they are probably unknown and certainly questionable. If the aim of treatment as prevention is to ensure that as many people as possible, perhaps as many as 80% of HIV positive people, have a low viral load, it will not be the mere distribution of drugs that will count the most. These countries will also need to address health more broadly than they have done for decades, also education, infrastructure and other areas of development.

A study in Uganda has found that antiretroviral treatment has not reduced new infections in couples. There was no difference in transmission rates between those couples on treatment and those not on treatment. Someone involved in the study has said "It may be difficult to extrapolate the results of randomised controlled trials to real-life situations in low-income countries". Quite. Another study in Uganda found that population viral load did decrease in a 'test and treat' scenario, but it is not clear if this resulted in reductions in transmission rates.

But the first Uganda results seem to carry the customary HIV industry assumption that almost all HIV transmission is sexual. Phylogenetic testing showed that in two cases the virus probably came from the already infected partner and in one case it did not. It is concluded that the one that did not came from an extramarital partner. Did they check? All three could have been infected through some non-sexual route. What steps did the researchers take in order that they could be so sure that all three infections were heterosexual?

A commentator says "Our results do not question ART working as a prevention tool",..."only that the effect can be undermined by social, biological and cultural factors that can underlie transmission", which seems to be an admission that transmission is not entirely down to sexual behavior. But this still doesn't rule out the possibility that some transmission was not sexual at all, that it was a result of unsafe healthcare or other skin-piercing practices.

It seems unlikely that the industry would be spending so much on big parties (or conferences, or whatever) if the show is almost over, or even if the end is 'in sight'. But while the money is still flowing it would be good to think that some of the poorest areas in the world would benefit from a bit of so-called aid spending. Otherwise, once the world is finally 'free' of AIDS, most of those suffering from HIV and its effects will not be among those celebrating.

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

Sexual Behavior and HIV: Retire the Paradigm or the Adherents?

The 'behavioral paradigm', the view that HIV is almost always transmitted as a result of unsafe sexual behavior, has tended to give rise to questions such as 'what kind of behavior could people in high HIV prevalence contexts be engaging in?' rather than 'given that high levels of unsafe sexual behavior do not correlate particularly closely with HIV prevalence, what else could explain extremely high rates of transmission of this virus, often in very short time periods?' Rather, the paradigm makes questions like the latter sound naive.

Yet the kind of hypotheses associated with this paradigm tend not to stand up to scrutiny. In high prevalence African countries, levels of unsafe sexual behavior are often higher in areas where HIV prevalence is low and lower in areas where HIV prevalence is high; those engaging in high levels of unsafe sexual behavior are often less likely to be infected and those engaging in low levels are often more likely to be infected. Types of sexual behavior said to promote the transmission of HIV are often not particularly common in areas where HIV prevalence is high or they do not, in reality, promote HIV transmission at a level that would explain some of the massive epidemics found in some parts of certain African countries.

But those who adhere to the paradigm, many of whom have dug themselves into a long and lucrative career in the HIV industry, can be loathe to accept any apparent failings in the paradigm. Findings showing that a significant proportion of HIV is probably not transmitted sexually and that sexual behavior is not the only, or is not the most important factor in transmission rates, even in sexual transmission rates, tend to give rise to a frantic scrabbling for ever less credible hypotheses. Theories about concurrency and male circumcision spring to mind; though stillborn, there are those whose careers consist of trying to breathe life into their festering carcasses.

Recent research has shown that black men who have sex with men (MSM) in the UK, US and Canada have far higher rates of infection than white MSM, even though they do not engage in higher levels of unsafe sexual behavior; in some cases they engage in lower levels of such behavior. Researchers are looking at all sorts of socioeconomic and structural differences in the circumstances of black and white MSM. But if male to male sexual transmission of HIV is not purely a matter of sexual behavior, then the same is very likely to be true of heterosexual transmission.

Heterosexual transmission is not common in Western countries, despite vigorous attempts to persuade people otherwise. And while the vast majority of people infected with HIV in high prevalence African countries engage in heterosexual sex, it is unclear what proportion of them have been infected sexually and what proportion have been infected by some other route, such as through unsafe healthcare or other skin-piercing practices. But the factors associated with transmission in Western countries, as well as the populations most affected by HIV, differ from those in African countries.

For example, black MSM in Western countries tend to be poorer, less well educated and unemployed, amongst other things. But HIV prevalence in African countries has often been higher among wealthier, better educated people and particularly among employed people, as opposed to those who are unemployed or who are not in formal employment. None of these findings are particularly new in the case of HIV epidemics in African countries; the findings about MSM in Western countries are not all very new either. But what is common to HIV epidemics in Western and developing countries is sexual behavior; not that sexual behavior is the same in both types of country, but sexual behavior is constantly cited as the cause of high rates of HIV transmission.

Nearly a year ago, an article appeared in a Tanzanian newspaper asking if homosexuality is 'unAfrican', how about living on handouts from Western countries (just think of those accepting handouts as being the 'receptive' partner in a relationship). While there is much vocal opposition to legalizing or decriminalizing homosexuality, I would ask why there is far less opposition to the insinuation that almost every mother, grandmother, wife, girlfriend, sister and daughter in high HIV prevalence countries is a slut, who will drop her underclothes and bend over for the price of a few beers?

There is a further insinuation that the men are all feckless and will sleep with just about anyone, whether they have to pay or not. But in the case of men, HIV prevalence is a lot lower. More to the point, self-reported levels of unsafe sexual behavior are consistently higher among men. So the women are not just sluts, they are lying sluts? In fact, subtract the men who have been infected through male to male sex and intravenous drug use (most are male), and it sounds as if many of the women have to actively seek out HIV positive men in order to become infected with HIV in such high numbers.

The tired old paradigm about sexual behavior doesn't seem to give rise to questions about why a virus that mostly infects MSM in Western countries mostly infects heterosexuals in African countries. To the extent that this question is asked, ridiculous types and levels of unsafe sexual behavior have to be posited to explain high levels of transmission of a virus that doesn't spread very quickly among heterosexuals in other contexts. Nor does it ask why levels of 'unsafe' sexual behavior often appear to be lower in areas where HIV transmission rates are higher. But then, those are the kind of questions that this paradigm, so treasured by UNAIDS and the HIV industry, are supposed to dismiss.

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

Treatment as Prevention; a Purely Commercial Imperative

Someone who has posted helpful and perceptive comments on this blog in the past has suggested that I am too much of a 'doubting Thomas' about 'treatment as prevention' as a strategy. So it's worth setting out some of the reasons for my skepticism. Treatment as prevention calls for putting anyone found to be HIV positive on antiretrovirals (ARV) immediately, rather than waiting until they have reached a clinical stage at which these drugs are currently considered appropriate.

Actually, there are too many arguments against treatment as prevention for me to do justice to in a short blog post. So I'll try to keep to arguments that do not require levels of in-depth technical knowledge that I cannot claim to have.

The various stages of HIV infection will be familiar to those who have spent a little time reading up on the subject. The first stage, which only lasts for a few weeks, may pass unnoticed. People going through the primary stage can be very infectious but it is unlikely that they will have any reason to take a HIV test and even if they do, the result may not be positive.

The second stage is said to last for an average of 10 years and during this time HIV positive people are not usually very infectious, which is not to say that they are not infectious at all. But if their HIV status is confirmed, there are tests that can be carried out to gauge the progression of the virus throughout this stage.

At the third stage, the symptomatic stage, various opportunistic infections emerge. Those who receive and respond to treatment in time remain asymptomatic. If they don't receive treatment or if they don't respond to treatment, HIV leads to AIDS, the fourth stage of infection. Those whose CD4 cell count and viral load are being monitored are more likely to receive ARVs in time.

So where does treatment as prevention come in? It's unlikely to have much impact on people going through the first stage as most infections will not have been detected. Those going through the second stage already have a low viral load, so it is both unnecessary and harmful to put them on a lifelong course of drugs; unnecessary because most will not be very infectious and many of those who know their status will already be taking precautions to avoid infection; harmful because there are short and long term side effects relating to ARV treatment and, perhaps more importantly, because resistance to first line ARVs is often just a matter of time, especially in resource poor countries, where monitoring and other resources are poor.

The time for treatment as prevention has generally passed once people go from the second to the third stage because ARVs would already be appropriate by then. Having said that, people in resource poor countries may have to wait a long time to receive treatment and many will die, either despite the treatment or because they never receive treatment. Some developing countries are only able to treat a minority of those who have reached the appropriate clinical stage for treatment and many have only managed to test a minority of HIV positive people.

So even if resource poor countries were to be granted the health services they need to provide HIV positive people with the treatment and care they need, it's not clear where a strategy like treatment as prevention would fit in. On top of that, it's not even clear that putting more people on treatment would be a good thing, unless they have already reached the appropriate stage of infection.

An early version of the treatment as prevention strategy was called 'test all, treat all' (and various other things) because it advocated the regular testing of everyone (or about 80%) in a population and the immediate treatment of those found to be HIV positive. But the emphasis on testing everyone at regular intervals may have been quite a stumbling block. Has any country achieved universal testing, let alone persuaded a large percentage of the population to return for re-testing every year or so?

I am all for treatment, so I would like to see the millions of HIV positive Africans receiving it when it is appropriate. But the consequences of trying to treat everyone, regardless of what stage of infection they have reached, are not well understood. To the extent that they are understood, they are very serious; treatment as prevention is a clear commercial imperative, but it has not been demonstrated to be beneficial in countries with serious HIV epidemics.

As for other arguments against treatment as prevention, there are plenty of articles and blogs on the subject. There's one on some of the problems that such a strategy may have in Zambia if it is scaled up. Dr Joseph Sonnabend has discussed the subject on several occasions. And it has even been debated by people for whom commercial imperatives may be expected to hold considerable sway. There is even solid evidence that there are viable alternatives to HIV prevention strategies such as treatment as prevention that would have a far greater impact on broader health issues than HIV alone.

My critic concludes that treatment as prevention is worth investigating, and I agree. Just as long as those investigating it do not see their task as one of manufacturing evidence for the benefits of doling out very expensive and potentially toxic drugs to as many people as possible. We need to find ways of preventing HIV infection in those who will otherwise soon be seen as potential recipients of treatment as prevention, rather than waiting for them to be infected and then jumping in to 'prevent' any further infections.

Perhaps primary prevention has not been very successful because we have been concentrating on the wrong risks, obsessing about the sexual risks rather than acknowledging that not all HIV is sexually transmitted. Treatment as prevention simply propagates the myth that 80% or more of HIV transmission in African countries is sexually transmitted. We need to find out more about who is being infected and how, rather than assuming that we already know. There may then be a role for expensive and limited strategies like treatment as prevention. But we haven't got there yet.

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