Saturday, March 29, 2014

UNAIDS' 3 Ones: One Disease, One Theory, One Solution

[Cross posted from the Don't Get Stuck With HIV site.]

According to "more than $400 million [of donor funding] was committed to HIV and AIDS in 2007/2008". However, less than a quarter of that funding, probably around 20%, was spent on 'prevention', with the usual assumption that almost all HIV is transmitted through heterosexual behavior. Around 60% is estimated to have been spent on treatment and care, say around $240 million.

It's tremendous that a lot of money is being spent on treating and caring for people who have been infected with HIV. Not all HIV positive people are currently eligible for treatment. Perhaps UNAIDS' claim that 60% of those who are eligible were on treatment at some time, although the figure, however many hundreds of thousands it may be, does not discount those who have died or who have been otherwise lost to follow up.

Around 95% of Tanzanian people are HIV negative. Out of the 1,470,000 people who are living with HIV, between one and two thirds may be on treatment. That's 1-2% of Tanzanian people, at the most. So how do those who control the money decide how to spend the approximately $80 million in order to reduce transmission of HIV; what kind of prevention activities should be prioritized among those 46,300,000 Tanzanians who are still uninfected?

UNAIDS has a slogan (aside from their 'three ones' slogan alluded to in the title above) that goes 'know your epidemic - know your response'. This makes it sound like UNAIDS believes that there are different epidemics in each country, and perhaps even different subepidemics within each country. But their response is always to treat HIV epidemics in Africa as if they are all virtually the same, although they may vary in intensity: but they are all assumed to be 'driven' by heterosexual behavior.

It's not very clear how far $1.70 per head can go towards 'changing people's sexual behavior', but that hasn't stopped UNAIDS and other big players in the HIV industry (and some of them are very big players indeed) from trying. Billions have been spent on wagging fingers at rooms full of adults and children over the almost 20 years of UNAIDS' existence.

Luckily there are a few things that can be done to help establish that HIV is probably not entirely heterosexually transmitted and that most finger-wagging exercises are a complete waste of money (their inherent paternalism is probably not considered to be a disadvantage; perhaps neither is their clearly demonstrated ineffectiveness).

For example, in Tanzania (and most other countries) there are only a few places where HIV prevalence is really high. Here's a list of prevalence by region (the five with the lowest prevalence are the Zanzibar archipelago):

Njombe 14.8
Iringa 9.1
Mbeya 9
Shinyanga 7.4
Ruvuma 7
Dar es Salaam 6.9
Rukwa 6.2
Katavi 5.9
Pwani 5.9
Tabora 5.1
Kagera 4.8
Geita 4.7
Mara 4.5
Mwanza 4.2
Mtwara 4.1
Kilimanjaro 3.8
Morogoro 3.8
Simiyu 3.6
Kigoma 3.4
Singida 3.3
Arusha 3.2
Dodoma 2.9
Lindi 2.9
Tanga 2.4
Manyara 1.5
Mjini Magharibi 1.4
Kusini Unguja 0.5
Kusini Pemba 0.4
Kaskazini Pemba 0.3
Kaskazini Unguja 0.1

And there are further generalizations that can be made about HIV in Tanzania. Prevalence tends to be higher among females, urban dwellers, wealthier people, people with higher levels of education and employed people. It tends to be lower among men, rural dwellers, poorer people, people with lower levels of education and unemployed people.

UNAIDS tends to 'analyze' these features, which are shared by all high HIV prevalence countries, and conclude that wealthier, urban dwellers with jobs have bigger 'sexual networks' (etc) as if every person with HIV must have a 'sexual network' (etc). But there are other figures they could avail of when they are in an analytical frame of mind.

For example, while women are said to be more susceptible to HIV infection for various biological reasons, wealthier, urban dwelling, better edcated women with a job are also much more likely to attend ante natal clinics (ANC) and seek the assistance of some kind of trained health professional when they are giving birth.

Now, you might expect women who attend ANCs and have assisted deliveries to be less likely to be infected with HIV, but you'd be wrong. In many instances they are more likely to be infected, sometimes a lot more likely. Indeed, some countries with the highest HIV prevalence figures also have the highest ANC and attended birth figures, Swaziland, Lesotho, Namibia and Zimbabwe, for example. The contrary tends to be true of low prevalence countries in sub-Saharan Africa.

This is not to say that HIV is never transmitted through heterosexual sex, or that it is always transmitted through unsafe healthcare (even among women). It's just a clear indication that we need to know exactly what contribution heterosexual behavior makes to epidemics, and what contribution may be made by non-sexual routes, such as unsafe healthcare, cosmetic care and perhaps other practices.

The whole concept of a UN agency set up to 'fight' one disease is bad enough. But it's a whole lot worse if they and the rest of the industry continue to squander precious resources on poorly targeted and ineffective interventions. Resources need to be spent on health, defined as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (there's no irony intended in citing WHO here).

Apparently one third of all aid in Tanzania is being spent on HIV, which leaves the other two thirds to be spent on other development areas. So perhaps some of that will eventually be used to address the many poorer, less well educated, jobless people living in rural areas with virtually no infrastructure or social services, but who are HIV negative. They will likely remain negative if even a fraction of available donor funding is spent on working out the relative contribution of unsafe healthcare to the worst HIV epidemics in the world and addressing this issue, however belatedly.


Thursday, March 6, 2014

HIV Strategy: Blaming the Victim and their Individual Behavior

[Cross posted from the Don't Get Stuck With HIV website.]

Since the early days of HIV/AIDS, finger pointing has been the main publicity angle. In Western countries the collective finger was pointed at men who have sex with men. Their reaction was to object to the finger being pointed at them and to insist that everyone is equally at risk. Though some still believe that everyone is equally at risk, it is not true. In Western countries the majority of HIV transmissions have always been among men who have sex with men, with a smaller proportion of transmissions through intravenous drug use.
But things are quite different in developing countries, particularly high HIV prevalence African countries. In high HIV prevalence countries men who have sex with men, intravenous drug users and even sex workers contribute a relatively small proportion of HIV transmissions. In fact, the largest contribution still appears to come from those with little or no risk; mainly monogamous heterosexuals. So the process of finger pointing often turns into one of victim blaming. After all, you can't point the finger at everyone around you, nor at someone who is HIV negative; so the clearest 'evidence' of unsafe sexual behavior becomes HIV positive status.
This gives rise to the task of explaining how a virus that is difficult to transmit through heterosexual sex outside of Africa is so frequently transmitted through that route in Africa. The HIV industry needed to show that 'Africans' must be promiscuous, ignorant and unhygienic. This wasn't too difficult because population control advocates (the word 'eugenics' is no longer fashionable), a significant proportion of wealthy NGOs operating in Africa, had had been playing the over-sexed, under-educated slum-dweller cards for decades.
The processes of pointing the finger at a particular group whose behavior was disapproved of, blaming those infected with HIV for their status, and concluding that HIV is all a matter of individual behavior, threw off course any efforts to reduce HIV transmission in developing countries. Although 'prevention' activities only receive a small proportion of HIV funding, that is still a massive amount of money. But prevention activities have rarely gone beyond exhortations to 'behave' in a particular way. The finger-wagging programs perfected by population control NGOs decades before HIV was identified became, and often remain, the state of the art of HIV prevention.
There has been plenty of research showing that these finger-wagging programs are of little or no benefit (except to the NGOs). An example of such research shows that "peer education programs in developing countries are moderately effective at improving behavioral outcomes, but show no significant impact on biological outcomes". There is a voluminous body of literature showing that you can't simply wag your finger at people and expect them to change their behavior, whether the aim is to address substance abuse, dangerous driving, over-eating or anything else.
Sometimes the association of HIV transmission with individual behavior is further connected with conditions that are beyond the control of the victim, for example, poverty. But this has also given rise to confusion: there is plenty of evidence that HIV in African countries is transmitted among wealthier people. This challenges the idea that HIV epidemics are driven by sexual behavior because, even if wealthy people 'can afford to have a lot of sex and a lot of partners', as the HIV industry would have it, there would need to be some poor people involved in this theory. Rich people don't pay other rich people for sex.
Instead of looking beyond sex, or sex and poverty, it seems some researchers are convinced they will eventually find out how sex and economic inequalities 'drive' HIV epidemics. One paper concludes that "Further work is needed to understand the mechanisms explaining the concentration of HIV/AIDS among wealthier individuals and urban residents in [sub-Saharan Africa]". But they don't seem to consider the possibility that their protohypothesis about sex is simply wrong. They don't seem to think that non-sexual transmission may be a very significant factor in the spread of HIV among wealthier people.
HIV can be transmitted through unsafe healthcare and other skin-piercing processes, such as various cosmetic processes. Wealthy people tend to have better access to healthcare. In fact, urban dwellers also tend to have better access to healthcare. Perhaps this is why the above paper found that HIV is "generally concentrated among wealthier men and women". This may also explain why HIV "was concentrated among the poor in urban areas but among wealthier adults in rural areas" in a number of countries.
Instead of trying so hard (and failing, over and over again) to find out what it is about the sexual behavior of wealthy people and urban dwellers, perhaps researchers should look at non-sexual risks, as well as sexual risks. Could the risks that people face be determined by their wealth and environment, precisely because they are not sexual risks, but healthcare and other risks? These risks are clearly not *individual* risks. They relate to health-seeking behavior, but it is not the behavior of wealthy and/or urban-dwelling people that gives rise to infection with HIV in a hospital or salon; the risk of infection depends on whether the facility is safe or not (which might vary considerably over time).
Some historians of HIV, such as Jacques Pepin (The Origins of Aids), admit that HIV was mainly transmitted through unsafe healthcare for many decades, and hardly ever through sexual behavior. But they don't explain how healthcare transmission magically disappeared in the 1980s even though conditions in many African countries remain very unsafe (although how unsafe they are is still a dangerously under-researched field).
Coupled with the magical disappearance of the risk of HIV transmission in under-equipped, under-staffed and badly run health facilities is the magical re-appearance of the promiscuous, ignorant and dirty African, though for many, this had never really gone away. Pepin vaguely mentions things like 'urbanization' as the main explanation for levels of promiscuity for which there has never been any evidence and which do not explain very high rates of heterosexual transmission of HIV anyway.
Ugandans have recently responded to having the finger pointed at them by allowing an 'anti-homosexuality' bill to be passed, effectively saying 'it's not us, it's them'. Various human rights groups, and even some donors, may belatedly object to such disgusting measures, which are being copied by other African countries. But the objection needs to be directed at the approach to HIV that began a long time ago, and began in Western countries, not in African countries. Men who have sex with men are by no means the only group who have been blamed for HIV epidemics. Other groups include long distance drivers, sex workers, house girls, fishermen, miners, and many others. It's this finger-pointing approach that gives rise to the stigma that those pointing the finger claim to abhor.
Thirty years into the HIV epidemic (I'm adopting the view that HIV is not a pandemic because most people don't face any risk of being infected and prevalence is, and will remain, low in most countries) research institutions, NGOs, international bodies and, perhaps most importantly, donors are still obsessing about sexual behavior and pretending that HIV status is up to the individual when it is clear that a large, but as yet unestimated, proportion of infections is a result of unsafe healthcare and other skin-piercing processes.


Monday, March 3, 2014

UNAIDS' Dubious Claims about HIV/AIDS 2013

[Cross-posted from the Don't Get Stuck With HIV site.]
UNAIDS risk missing their target of reducing "sexual transmission of HIV by 50% by 2015". But there is a way of meeting that target, and they could meet it by tomorrow. If they belatedly admit that HIV is far more easily transmitted through unsafe healthcare, they could begin to estimate the contribution of things like reuse of needles, syringes and other equipment that comes into contact with blood and other bodily fluids.
This would also greatly assist their progress towards their 'ZeroDiscrimination' target too, because even though they can't reverse the damage they have done by insisting that Africans are irremediably promiscuous, the status of this claim as institutionalized racism will eventually become clear, at least to those who are prepared to think the issue through a little (a surprisingly small number of people so far).
After all, reducing 'sexual transmission' is one of their stated goals, whereas UNAIDS has barely breathed a word about transmission through unsafe healthcare in their 20 year, multibillion dollar, celebrity studded reign. They could just quietly (imperceptibly, even) reveal some changes in the way figures are collected and next December 1, a re-estimation of non-sexual transmission of HIV could be the subject most deserving of their customary (spontaneous) standing ovation module.
UNAIDS are uncharacteristically frank about mass male circumcision, which is something of an embarrassing fiasco: "As of December 2012, 3.2 million African men had been circumcised [...]. The cumulative number of men circumcised almost doubled in 2012, rising from 1.5 million as of December 2011. Still, it is clear that reaching the estimated target number of 20 million in 2015 will require a dramatic acceleration." (They don't say how many of the 3.2 million circumcised over quite a few years would have been circumcised anyway but took advantage of the free (anesthetized) operation.) Might this spell an unobtrusive retreat from this dangerous imperialist program?
But one of the heftiest pieces of bullshit in the 'report' (and there is stiff competition) is about "the goal of providing antiretroviral therapy to 15 million people by 2015". They say that "As of December 2012, an estimated 9.7 million people in low- and middle-income countries were receiving antiretroviral therapy, an increase of 1.6 million over 2011. That brings the world nearly two-thirds of the way towards the 2015 target of 15 million people accessing antiretroviral treatment."
The difference between UNAIDS' claim and the truth is expressed in a few words, such as 'were receiving' therapy. If they said that 9.7 million people had been recruited on to a therapy program, that might have been true (or somewhat closer to the truth). But 9.7 million is, at best, the number of people who have at one time been put on a program. Neither UNAIDS, WHO, PEPFAR, CDC nor anyone else knows how many of those 9.7 million ever took the drugs, or for how long, how many dropped out of the program, how many were recruited on to two or more programs or simply died, etc.
No one knows, and no one really cares because 9.7 million is an impressive figure, and it sounds like a good attempt at the 15 million target. There is not much incentive to estimate how many people are alive and on antiretroviral treatment, indeed, such an estimate could prove fatal to several substantial institutions (not just UNAIDS, which seems to thrive on failure to achieve anything at all, aside from spending money and institutionalizing bigotry). Is the true figure 8 million people, 7 million, or some far lower number? Billions of dollars say that no one is going to ask this impertinent question (unless they are not in receipt of any of those billions, and never will be).
Unsafe healthcare does exist in extremely poor, high HIV prevalence countries, surprising as that may seem to those who are used to the mainstream view that HIV is hardly ever transmitted through heterosexual sex in every country in the world, but almost always transmitted through heterosexual sex in a handful of African countries. What contribution does unsafe healthcare make to the worst HIV epidemics in the world, all in sub-Saharan Africa? Would it be the one or two percent UNAIDS grudgingly suggests, or something far higher? We don't know yet. No billions have been offered for the answer to this question.
Using cumulative figures is great, because you get that great 'step' effect when you produce bar graphs, and there is nothing like comforting, progressive steps to convince people that everything is good in UNAIDSland, and in the HIV industry in general. A very achievable 2015 target would be the abolition of UNAIDS and the promotion of safe healthcare. Because unsafe healthcare risks the spread of HIV, something UNAIDS has never got around to accepting. But I suspect that instead, there will be a continuation of the finger-pointing and victim-blaming that has characterized the mainstream approach to HIV in high prevalence countries so far.