Thursday, November 29, 2012

Sex in Africa: Crime, Sin, Censure and Punishment

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

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

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

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

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

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

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

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


Tuesday, November 27, 2012

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

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

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

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

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

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

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

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

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

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


Saturday, November 24, 2012

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

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

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

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

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

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

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

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

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


Friday, November 23, 2012

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

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

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

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

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

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

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


Tuesday, November 20, 2012

UNAIDS Adopts Broad Brush Approach to HIV Stigma

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Sunday, November 18, 2012

Good AIDS, Bad AIDS and African AIDS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Sunday, November 11, 2012

Limited Funding & Political Support; Will Circumcision Program Collapse in Uganda?

The main drivers of the voluntary male circumcision (VMMC) program in Kenya appear to be money and politics. Those implementing the program are not particularly convinced of the effectiveness of the program, but they know that millions of dollars have been stumped up for it, and they want some of it. Political leaders have agreed to support circumcision, ostensibly on the grounds that it reduces HIV transmission, but probably because there are good political reasons for doing so.

For a start, most Kenyans are circumcised, and they believe that someone who is not circumcised is a mere child, and not fit to run the country. The Luos don't traditionally circumcise and this is often held against them when it comes to elections, though it is unlikely that tribal disagreements will dissipate just because Luo leaders agree to be circumcised.

It's hard to know where female political leaders fit into this particular scenario, but they seem to be behind VMMC as well. Women I talked to seem oblivious to the fact that VMMC does not even claim to reduce HIV transmission from males to females. They have been convinced that fewer HIV positive men will automatically result in fewer transmissions to women. That this depends on the assumption that almost all HIV transmission is through heterosexual sex does not seem to bother them.

Something no one seems to be aware of, male or female, is that the Luhya, their neighbors in Western province, practice circumcision. Yet HIV prevalence there is high overall, and more than five times higher among women than among men. More Luo women than Luo men are infected, but the difference is only about 40% (as opposed to over 80% among the Luhya). If I was a Luo, I wouldn't place that much faith in the effectiveness of VMMC, especially when it comes to reducing infections in women.

Things appear quite different in Uganda, and I wonder what is really going on there. Has the safe male circumcision (SMC) program really managed to attract 380,000 Ugandan men? It seems likely most of them were boys, which is the case in Kenya. But the two main drivers in Kenya are less prominent there; according to the SMC coordinator, "Pepfar [President's Emergency Plan for AIDS Relief] has given us funds to circumcise 750,000 men. We will mobilise other funds from the government, UN agencies and partners".

Will 'other funds' be forthcoming to circumcise an additional 3.45 million men (or boys)? We could be talking about between 200 and 400 million dollars, at a time when funding is shrinking. In addition, Uganda hasn't exactly made themselves very popular; three major donor countries have just suspended funding pending investigations and a lot of money has gone missing, though nothing close to the figures required to fund a big circumcision program. While Kenya may have a kind of first mover advantage, it seems Uganda and other countries may not even get enough funding to circumcise the millions of people planned.

Abandoning the VMMC program would be good news for countries like Zimbabwe, where HIV prevalence is high, money is in short supply and HIV prevalence is higher among circumcised men than it is among uncircumcised men. There are plenty of better things to spend money on.

But in Uganda, apparently SMC does not even have political endorsement. The program is not integrated with other health services (which makes it little different from other HIV programs), but it is not even integrated with other HIV services. Apparently President Yoweri Museveni has criticized the program, which is surprising, given his enthusiasm for earlier programs that looked even less likely to be effective than circumcision.

Given the money, political support, aggressive promotion and popular rhetoric about circumcision in Kenya (to say nothing of the fact that most people seem quite uninterested), perhaps their claimed achievement of 450,000 circumcisions over about four years is credible. But without political support and with only a fraction of the money required, it would be surprising if Uganda's SMC program got any further once the money runs out. If it does, what will they cut back on: trained staff, already in short supply? Or will they cut back on facilities, equipment, safety, follow up care, or just all health provision that does not relate to circumcision? Perhaps they can do without the anesthetic, or just reduce the dosage, reuse syringes or gloves?

No amount of aggressive marketing can drive a mass male circumcision program if the money is not there. Without money, political support will quickly melt away. The puny 'public health' arguments for the program, which seem so 'compelling' when supported by a few billion dollars, will be seen in their true light once the funding dries up. If the circumcision program collapses, perhaps Ugandans will even find better ways to spend their dwindling health budget and redeploy their few trained health professionals. But perhaps Ugandans will first try to find out why HIV transmission rates are still so high after years of massive spending on HIV and hardly any spending on other health issues. And that can only be a good thing.

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


Saturday, November 10, 2012

Circumcision: Never Mind the Evidence, Just Feel the Sentiment

What has circumcision got to do with public health? You might be surprised to hear that it hasn't got very much to do with public health at all. There is a huge amount of pro-circumcision sentiment, and probably just as much anti-circumcision sentiment. But evidence for and against the operation on public health grounds doesn't differ very much. In other words, the evidence for and against doesn't suggest that the operation does any more harm than any other unnecessary operation, nor does it do a great deal of good. Those in favor use that to impose their circumcision programs and those against use pretty much the same evidence to oppose them.

But this is a serious problem for Kenya, Uganda, Zimbabwe and a lot of other countries with medium or high HIV prevalence; because there is an enormous amount of money behind the pro-circumcision sentiment, and none behind those opposing it. This means that the evidence for the effectiveness of circumcision in reducing HIV transmission, and in reducing all sorts of other conditions, is used exclusively to push circumcision on populations that are desperate to address numerous health problems, HIV being just one of them, and often not even the most urgent.

Evidence that would count against the wisdom of circumcising millions of African men, at great expense, is either dismissed as being insignificant or ignored altogether. Most of the evidence for and against voluntary medical male circumcision programs is collected by the same teams, handfuls of extremely well funded Americans and a few Africans thrown in to make it look like a collaboration. They have data showing that circumcised men in some countries are less likely to be HIV positive than uncircumcised men, but they also have evidence that in other countries, circumcised men are more likely to be HIV positive. They have evidence that even where circumcision 'works', it doesn't always work very well. And those opposing circumcision also have this evidence.

These circumcision enthusiasts (positively messianic, one might say) even have evidence for the damage that can be done when circumcision is carried out by badly trained, underpaid, poorly equipped medical staff who have many other things they could be spending their time and resources on, but don't, because there is a lot of financial and political pressure to carry out circumcisions. They have data on genital hygiene that suggests the whole thing might be better addressed without carrying out an invasive operation, but such data is likely to remain as inconclusive at it is now. You might think, to balance things out, that those who oppose circumcision would attend to everything else, but you'd be wrong. Infants and children die from acute respiratory infections and water based diseases, assisted by poor nutrition and numerous endemic conditions, such as intestinal parasites. There is no money in 'everything else'.

Mothers frequently die giving birth, or quite soon after. People going to hospitals with one illness often leave with another, which may only be discovered much later, or not discovered until it is too late. Many die in hospital, not always because they had an incurable disease (though you could say that most diseases people go to hospital with in Sub-Saharan Africa are incurable), but because they received such poor quality treatment or because they were infected with something else while there. Most people suffer from, and many people die of, preventable and treatable diseases. It's one of the few things preventing more people from dying of lifestyle diseases. There may be sentiment behind maternal and infant morbidity and mortality, but there is not much money behind them.

The obvious question is, why are we even discussing circumcision, let alone pouring millions of dollars into it, when money is so scarce? I can accept that we don't discuss possible HIV interventions that we don't have any evidence for whatsoever, but not ones for which there is little evidence, but may prove fruitful, given some further investigation. And I can accept that we don't (often) discuss interventions that may work well, but are just too terrible to contemplate, because they are inhumane, unethical or simply wholly underdetermined, as yet, by the evidence.

But wait, doesn't circumcision fall into all three of those categories (and probably a good many others)? We strongly oppose the one child rule in China. We would oppose the removal of one testicle in men on the grounds that it might substantially reduce incidence of testicular cancer (men would still be fertile with one testicle), but this is just not being discussed, thankfully. So why is circumcision? It is inhumane, it is unnecessary  it is painful, it involves the removal of a piece of healthy flesh, it seriously influences a person's interaction with their immediate environment, it costs a lot of money that could be better spent in other ways, it ignores some far more urgent issues that it addresses, if you even accept that it addresses any issues.

The fact is that we are not just discussing male circumcision programs, it is claimed that millions of Africans have already been circumcised on the grounds that it will reduce transmission of HIV from women to men. Kenya claims to have circumcised 450,000 men under the current program. An article in the English Guardian claims that 380,000 Ugandans have been circumcised under a similar program, called Safe Male Circumcision (SMC) there. However, the article finds that progress is mixed in Uganda. This is despite the fact that Uganda are circumcising men at a faster rate than in Kenya and they hope to circumcise one million a year for the next few years.

Uganda's HIV epidemic is curious in the sense that it has probably had more money thrown at it per head than any other African country, yet prevalence remained flat for many years and is now said to be rising. Flat prevalence is very bad news in a country with a rapidly rising population because it can mask the fact that many people are being newly infected, even though many are dying and quite a few are only surviving because they are receiving antiretroviral drugs. It's one of the best examples of the futility of throwing money at an epidemic without being clear about how the virus is being spread, as long as current sentiment is behind the main interventions, which, we must bear in mind, used to be abstinence and a few other buzzwords thrown in for good measure.

Antiretroviral treatment programs in Uganda have also not always been as successful as some would like us to believe. HIV transmission in discordant couples, where only one partner is infected, has not always been substantially reduced among those who are receiving treatment. Also, fewer than half those who need treatment are receiving it. There have even been many interruptions in treatment where drug supplies have been unreliable and where programs are not consistent or sustainable. Throwing drugs at people can be about as ineffective as throwing money at them.

We were always told that abstinence and related programs were examples of 'evidence-based' public health, but they were not. They were what could best be called 'sentiment-based'; those with the money felt that people (Africans, of course) should not be having so much sex (however much they may have been having), that they shouldn't be having so many children, that they should use contraception more, that they should do, not what Westerners do, but what it was felt Africans clearly weren't doing, whatever that might be. Yes, it's a bit cryptic, but it appears that sentiment was on the side of abstinence. People still appear quite comfortable with the views that HIV is almost always transmitted sexually, that Africans have a lot of illicit sex, and that therefore it's no wonder HIV prevalence is so high in some parts of some African countries.

Or, to put it another way, HIV prevalence is only high in some parts of some African countries, and even though we know that HIV is not generally transmitted through heterosexual sex, don't Africans have loads of illicit sex, multiple, concurrent partnerships, underage marriages, widow inheritance, polygyny and whatever else? Yes? Well, then the answer is obvious. But circumcision is supposed to prevent the very kind of HIV transmission that should hardly ever happen, female to male transmission during penile-vaginal sex.

HIV is sexually transmitted (among other ways), but it is very rarely transmitted from the receptive to the passive partner in penile-vaginal sex. Heterosexual or homosexual, HIV is generally transmitted from the penetrative partner (generally male) to the receptive partner (male or female). That means women face a very high risk of being infected if they have unprotected sex, anal or vaginal, with a HIV positive man. And men face a very high risk if the have unprotected receptive anal sex. But it is very difficult for a woman to infect a man. The fact that so many men in Africa are infected when their only known risk is penile-vaginal sex with women doesn't just pour cold water on mass male circumcision, it raises the question of why non-receptive sex should be so risky only in some parts of some African countries.

You may find UNAIDS and other 'official' figures, and certainly plenty of published rhetoric, claiming that 'we' or 'everyone' or 'all promiscuous people' or something like that are at risk; but *we* are not, unless we are the receptive partner, and the penetrative partner is not using some kind of barrier method, such as a condom.

This is a crucial distinction that various institutions which receive copious quantities of money for public health programs fail to make clear. Many HIV positive men may claim to have been infected because they had sex with a sex worker, or something like that. But in the days when further investigations would be carried out, this was generally found to be untrue; men who are not intravenous drug users and who are not engaging in unprotected receptive anal sex are very rarely HIV positive. And very few men indeed (if any) have been demonstrated to have been infected by a woman as a result of having penile-vaginal sex with them.

If women don't pose a high risk to men, why are millions of African men infected, even though they have only had penile-vaginal sex with women? If women were not able to infect men easily, this epidemic would never have got off the ground; no sexually transmitted virus could become an epidemic if it can't be transmitted in both directions. It would have been confined to a few high risk groups, as it currently is in most Western countries (men who have (receptive) sex with men, intravenous drug users, but not, generally, sex workers). Huge numbers of heterosexual men should not be infected when they don't face serious risks. This is the question that needs to be answered in order to decide what is the best intervention. And the answer to this question is unlikely to be 'circumcise all the men'.

What's 'different' about Africa is that it is not clear how women infect men with HIV, because they hardly ever do outside of Africa. Of course, many women were probably not infected through heterosexual sex either, and that's also a problem to which mass male circumcision is not going to be a solution. If you are asking the right questions about HIV, and UNAIDS, WHO, CDC, the World Bank and others know that these questions are the right ones, mass male circumcision will not even be on the agenda. So why is it the entire agenda (for the moment)?

HIV is not, and has never been a 'gay plague', but it is a 'receptive partner' disease. This is not a new discovery, it is what has been known from the earliest years of the pandemic. So why have they spent so many years and so much effort telling us that it is sexually transmitted, that we are all at risk and that Africans are most at risk because they [fill in with your favorite prejudice]? Originally, HIV wasn't even a sexually transmitted disease because it was so infrequently transmitted to people who might infect someone else, and those they infected sexually were unlikely to have infected anyone else (generally being women). To avoid transmission, people need to know what the risks are and how to protect themselves; telling them lies will not help, something international health institutions should have noticed by now, if reducing transmission is one of their aims.

So why am I angry? Because this has been known all along, that it is receptive sexual partners who are at risk, not all and sundry. It has also been known all along that HIV could be transmitted most efficiently through unsafe healthcare and, while healthcare practices changed in Western countries, it went off the agenda in African countries due to a combination of structural adjustment policies and general lack of interest. It was known that about half the HIV positive infants were not infected by their mothers, they were infected through unsafe healthcare, and the same people who found that are out are the very people promoting circumcision and who promoted abstinence and whatever 'evidence-based' initiatives that attracted popular sentiment (and funding).

We knew all along, when there were only a few million HIV positive people in the world; we knew how people were being infected and we didn't raise a hand to protect them. We knew that it wasn't 'all about sex', but we allowed HIV to become a 'gay plague' in the West and then a matter of African sexuality, with consequent levels of prejudice and stigma (to say nothing of sentiment, positive and negative). We know, at least, UNAIDS, WHO and the rest know, that a significant proportion of HIV transmission is not through sex, but this is not currently being investigated. Male circumcision programs are not driven by public health considerations, but by massive amounts of money, attracted by current pro-circumcision sentiment. Meanwhile, HIV continues to spread. We know how to avert many new infections, but we prefer, it seems, to allow the virus to spread, as long as we can continue to exercise our prejudices.

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


Monday, November 5, 2012

Mass Male Circumcision: Moral and Cultural Intolerance

The English Guardian's development section has an article on Arturo Escobar, a theorist cited as believing that development is little more than "the west's convenient "discovery" of poverty in the third world for the purposes of reasserting its moral and cultural superiority in supposedly post-colonial times". This could equally apply to the funder of the development section, Bill Gates. But also, it could be applied to the way HIV is viewed by big funders of programs to increase condom use, influence sexual behavior, (ostensibly) reduce family size, provide expensive birth control methods, some of which are deemed inappropriate for Westerners, and generally treat Africans as if they are a bunch of delinquents who are in need of a 'short sharp shock' from their otherwise benevolent, unelected, rich, intolerant (etc) benefactors.

Are those running voluntary medical male circumcision programs (VMMC; the word 'mass' is now deprecated, it seems) really in a position to play God? And what puts them in that position? Is it the fact that they have large amounts of funding? The support of political and even religious leaders? Or is it the fact that they really really want to carry out these programs and they will continue to find 'data' that appears to support what they fully intended to do anyway?

As a mere mortal, I realize I probably appear highly impertinent with my stupid questions. But I would still like to know, if circumcision reduces HIV transmission, why does it not work everywhere? In some countries HIV prevalence is indeed higher among uncircumcised men. Kenya and Uganda were chosen for randomized controlled trials for the very reason that they were two such countries. But there are also countries where HIV prevalence is higher among circumcised men, and countries where there is little or no difference in HIV prevalence between circumcised and uncircumcised men. Yet, the VMMC programs are planned for all (Africa) countries with sizable populations of uncircumcised men. [The full trial papers are available here for Kenya, here for Uganda and here for South Africa.]

It may be equally impertinent of me to ask why we are told that circumcision may possibly reduce HIV transmission (in some countries) because there are Langerhans cells in the foreskin, so removing it may give some protection against infection with HIV and other infections. But why does this not give protection to all circumcised men, rather than just some of them? And why is this not used to argue for female genital mutilation, or at least the removal of outer and inner labia, and any other part that is considered as unnecessary as the foreskin is in males? I'm glad it's not used, but is there justification for a war on male Langerans cells, only?

It is very basic science that there is no hypothesis about circumcision and protection against HIV transmission, unless you consider 'male circumcision may sometimes give some protection against HIV in some parts of some countries, although it often doesn't, and we don't really know why this is the case' to be a hypothesis. So it is perfectly legitimate to ask 'by what mechanism is circumcision thought to work'? So if the answer is still 'we don't know, and it fails just as often as it succeeds', there is nothing at all impertinent in asking why VMMC programs are going ahead, with billions of dollars at their disposal. Why are they going ahead?

I can understand why programs like VMMC concentrate on sexual transmission of HIV and completely ignore non-sexual transmission, through unsafe healthcare and various cosmetic and traditional practices. Circumcision itself is often unsafe, whether it is carried out in traditional settings or in clinics; it is often carried out because it is a traditional or religious rite, rather than because of claims about some kind of public health benefit. But the much hyped randomized controlled trials carried out in Kenya, Uganda and South Africa did not even exclude HIV transmission events that were not sexual. Circumcision, even according to partisans, could only protect against sexual transmission. It may even expose people to additional HIV risks that they would not normally face.

We can trade data about the pros and cons of circumcision forever. But why are we discussing a VMMC program that is already up and running, rather than still flailing about for a viable hypothesis? We don't use the argument about Langerhans cells in women possibly leaving them exposed to HIV in order to investigate the possibility of removing various parts of their genitalia, because we consider female genital mutilation of any kind to be horrific physical abuse. Granted, male circumcision is not the same as FGM, but why is it not considered to be abusive to insist that HIV is always transmitted sexually, that Africans have a lot of 'unsafe' sex and that therefore circumcising all uncircumcised men will result in a substantial reduction in HIV transmission? And even if we are convinced of all that, what makes us think we have the right to impose our program on people in African countries?

The important questions are not about how beneficial or how damaging VMMC may be; those questions are too late for many people, anyway. But we need to be asking if what we are doing is still based on notions, tacit or otherwise, of moral and cultural superiority? If HIV transmission is not mostly a result of unsafe sexual behavior, there is no justification for most HIV interventions in African countries. But nor will most of those interventions have much impact on HIV transmission. Bad science may be behind a lot of programs carried out in the name of public health and development, but it doesn't explain why we openly discuss dubious scientific claims and continue to ignore moral, cultural and perhaps other issues that may be the real drivers of programs such as voluntary medical male circumcision.

Why are we doing this? Do we suddenly love (uncircumcised male) Africans (in certain parts of certain countries) so much that we are reaching out to them, ready to stand between them and all harm? Or are we doing it because we can, because we have the money, because we love circumcision and what it stands for, because our reputation depends on it, and various other, not so laudable motives? What will it take for all these issues to be addressed, issues that should have been addressed before this ill-gotten program was ever dreamed up? VMMC is, as things stand, an intolerable imposition on people whom we clearly consider to be inferior to us.