Zimbabwe: Thought Embargo at HIV Inc to Continue Indefinitely

The Zimbabwean health minister, David Parirenyatwa, has exposed his complete ignorance about the country's HIV epidemic by claiming that there is 'rampant homosexuality' in prisons, and that this is making an especially large contribution to high rates of HIV transmission in these institutions.

Naturally, there are some men who have sex with men in prisons, and not just in Zimbabwe. But that is not just because men are more likely to have sex with men when incarcerated for lengthy periods with men, denied conjugal visits and other rights. It's also because having sex with someone of the same gender can itself attract a prison sentence.

However, what the health minister fails to realize is that there tend to be very poor health services in prisons. If he had inspected health services in prisons he would have come to a very different conclusion. Indeed, had he inspected health services outside of prisons he would also have come to a different conclusion about Zimbabwe's massive HIV epidemic.

Prevalence in Zimbabwe had already reached about 15% in the early 1990s (compared to about 1% in South Africa). But it shot up to almost 30% before the end of the decade, then dropped back to early 1990s levels in less than 10 years. The figure has remained at roughly half its peak for the last decade or so.

The death rates required to bring prevalence from 30% to 15% in less than 10 years must have been phenomenal. Did the esteemed (and I'm sure astute) Parirenyatwa notice a sudden rise in prison populations during the 1990s, followed by a profound drop, with a subsequent flatlining thereafter? Or a sudden rise in male to male sex? Or a sudden rise in 'unsafe' sex among heterosexuals?

I don't think so. But I also doubt if the health minister has a clue what was going on in the country's health services then, or perhaps now. Massive increases in HIV transmission during the 1990s was very likely a result of a decrease in levels of safety in health facilities, along with a probable increase in usage of health facilities.

Minister, HIV is most efficiently transmitted through unsafe skin piercing procedures, such as injections with reused injecting equipment, surgical instruments, etc, also through unsafe body piercing and tattooing, and even through unsafe traditional practices, such as scarification, blood oaths and others.

Just how unsafe would cosmetic and traditional practices be in a prison? We can only guess. How safe would they be elsewhere? It's unlikely anyone has checked. If they have, they would have found it difficult to publish the findings.

It's easy to blame high HIV prevalence on 'promiscuity', male to male sex, carelessness, stupidity, malice and other phenomena, so beloved by journalists and others milking the HIV cow, far too easy. But ministers, journalists, academics, and even those who have reached lofty heights in international NGOs and the like, are still permitted to consider the roles of unsafe healthcare, cosmetic and traditional practices. I invite them to do so.

'African' Sexuality: Consensus or Prejudice?

An article by Damien de Walque, entitled 'Is male promiscuity the main route of HIV/AIDS transmission in Africa?', seems curiously behind the times. He refers to the "pervasive if unstated belief in the HIV/AIDS community...that males are primarily responsible for spreading the infection among married and cohabiting couples".

Disturbingly, de Walque goes on to conclude that, because women are as likely as men to be the infected partner in discordant relationships (where only one partner is HIV positive), both male and female promiscuity must be the main route of transmission. This is by no means the only possible conclusion; far more women than men are infected with HIV in high prevalence African countries, but this could be a result of other risks, particularly non-sexual risks.

However, women being almost as likely as men to be the infected partner in discordant relationships was not a new discovery when de Walque was writing in 2011. Gisselquist, Potterat, Brody and Vachon published an article in 2003 entitled 'Let it be sexual: how health care transmission of AIDS in Africa was ignored', which presents evidence from the 1980s showing that women are almost as likely as men to be the positive partner in discordant relationships. They also show that neither is promiscuity the main route.

The article by Gisselquist et al looks back at papers from the 1980s demonstrating clearly that the bulk of HIV transmission in African countries is not sexually transmitted. Data collected about sexual behavior does not support the view that Africa is exceptional. Rather, data about other risks, such as unsafe healthcare, cosmetic and traditional practices was either not collected, or was ignored.

Even the abstract gives a good sense of what was going on in the 1980s (and is still going on). I'll cite it in full, adding italics for emphasis:

"The consensus among influential AIDS experts that heterosexual transmission accounts for 90% of HIV infections in African adults emerged no later than 1988.We examine evidence available through 1988, including risk measures associating HIV with sexual behaviour, health care, and socioeconomic variables, HIV in children, and risks for HIV in prostitutes and STD patients. Evidence permits the interpretation that health care exposures caused more HIV than sexual transmission. In general population studies, crude risk measures associate more than half of HIV infections in adults with health care exposures. Early studies did not resolve questions about direction of causation (between injections and HIV) and confound (between injections and STD). Preconceptions about African sexuality and a desire to maintain public trust in health care may have encouraged discounting of evidence. We urge renewed, evidence-based, investigations into the proportion of African HIV from non-sexual exposures."

Consensus among influential experts should be based on available data; not only did these experts ignore a lot of available data, they failed to collect a lot of data that could have led to a very different consensus. But several long-held preconceptions, for example, about 'African' sexual behavior, may have had undue influence on the consensus of these experts. It is these preconceptions that I am interested in.

By claiming that UNAIDS is going to change its name to UNAZI (as far as I know, they are not going to), I wished to draw attention to the fact that the still current claim that HIV is almost always transmitted via heterosexual contact in African countries (but nowhere else) is based on the preconceived views of some very prejudiced 'experts'. UNAIDS acquired a consensus of experts who had decided, before the institution was established, that they were going to concentrate almost exclusively on heterosexual transmission, and diminish the role of unsafe healthcare and other non-sexual transmission routes.

The big lie about HIV in 'Africa' is that 80% (sometimes 90%) of prevalence is from 'unsafe' heterosexual sex, and most of the remaining 20% (or 10%) is from mother to child transmission. This lie emerged in the 1980s, from 'experts' who knew that it was a lie. The entire HIV industry is still based on this lie three decades later. As a result, most African people are unaware that unsafe healthcare, cosmetic and traditional practices may be a far bigger HIV risk than sexual behavior.

UNAIDS Becomes UNAZI - Focus At Last?

UNAIDS reached 20 and became 21 without anyone really noticing. HIV prevalence had peaked in some of the worst affected countries by the time the institution was established, but many epidemics had only just begun.

For example, HIV prevalence in South Africa was very low in 1990, probably less than 1%. Along with several other southern African countries, prevalence rocketed for much of the following 10 to 15 years, eventually making this zone the worst affected in the world.

HIV epidemics tend to concentrate in certain zones, rather than in certain countries. A large area in southern Africa constitutes one of these zones, taking in much of South Africa, Zimbabwe, Zambia, Botswana, Swaziland, Lesotho, Namibia and parts of Mozambique and Malawi.

But some zones are not best described by national boundaries. The areas surrounding Lake Victoria, for example, make up another zone, bringing together a large proportion of the HIV positive population of Kenya and Uganda (and, formerly, Tanzania).

Many HIV zones are cities, such as Bujumbura and Nairobi, hotspots, surrounded by relatively low prevalence areas. But some zones are more rural and isolated from big cities, such as the Njombe region of southern Tanzania, where prevalence is higher than anywhere else in the country.

All the northern African countries make up a very low prevalence zone, with most western African countries making up a higher prevalence zone. Central Africa and the western Equatorial area are fairly low prevalence, but eastern Africa used to be the highest prevalence zone, and there are still several million people living with HIV there.

So the United Nations Aids Zones Initiative is, presumably, going to make distinctions between 'Africans', who have all been lumped together by UNAIDS. Rather than referring to, say, Kenya's epidemic, there will be the Lake Victoria Zone, the Mombasa Zone, and so on. After all, prevalence in some parts of the country is lower than in many rich countries, such as Canada.

A country like Tanzania, where 95% of the population is HIV negative (and only about 2% of the population are receiving treatment), will now be able to spend health funding on diseases that affect many people, diseases that have long been ignored. Health services there and in other countries should benefit considerably from the creation of UNAZI.

But the most important change will be in the received view of HIV, the view that it is almost always transmitted through heterosexual sex in 'African' countries (though nowhere else in the world). UNAZI will not be able to claim, as UNAIDS did, that there are certain zones on the continent where heterosexual practices are somehow exceptional!

We can look forward to an immediate reduction in the stigma that goes with branding anyone infected with HIV as promiscuous (or as a helpless victim of promiscuity). Whatever explains the concentration of HIV in these zones will be unrelated to sexual behavior; the explanation is far more likely to relate to unsafe healthcare, even unsafe cosmetic and traditional practices (although the first is the main suspect).

UNAZI will be much more than a change in name, or a change in focus. It will also be an exit strategy, a way of attending (belatedly) to the main causes of HIV epidemics, without admitting that UNAIDS and their chums have been lying for so long, of course. UNAZI will probably only last long enough to 'turn off the tap' that UNAIDS never acknowledged, and then quietly re-merge with WHO.

Institutionalizing Violence Against Women (and Men)

It is not news that injectible Depo Provera (DMPA, a hormonal contraceptive) doubles the risk of HIV negative women being infected, and doubles the risk of HIV positive women infecting their sexual partner with HIV. Nor is it news that injectible Depo is mostly used in developing countries, and among non-white people in the US. Therefore, it tends to be used in places where HIV prevalence is higher, and among populations with higher prevalence in low prevalence countries.

Why use injectible Depo when this is well known? Defenders of the product claim that using it cuts other risks, such as unplanned pregnancies, particularly among HIV positive women. They feel this mitigates the risk of transmitting the virus, or of becoming infected. Strange logic, but such is the mindset of the HIV industry, and those who (very strenuously and aggressively) defend the use of injectible Depo.

If various NGOs, public health programs, research programs and others wanted to carry out their work ethically, they would tell the women (and hopefully their sexual partners) about the doubling in risk of HIV transmission, but the warnings given are vague. Therefore, women (and men) are put at increased risk of being infected with HIV, or of infecting others. Many of these same NGOs, their funders and associates would also claim to be opposed to violence against women. But failing to inform them about the increased risk constitutes violence against women (and men).

Stupider still is the proposal to use PrEP (pre-exposure prophylaxis, antiretroviral drugs taken to prevent infection) to reduce the risk that injectible Depo will increase HIV transmission. Why not just use a different hormonal contraceptive, preferably an oral form? Well, one of the arguments for not using an oral form is that some sexual partners may object to women using oral contraceptives, especially if they are married to the woman. It is argued that women can be given Depo Provera once every three months, without their sexual partner knowing.

But will the partner not wonder why the woman is taking oral PrEP? And if they try to find out why she is taking it, may they not also find out that the woman is HIV positive, believes her sexual partner to be HIV positive, or is taking injectible contraceptives? Are we not back to square one?

Where are the narcissistic 'feminist' stars of film, music and other arts when you need them? They are too busy screaming about what sex workers want (or should want) to see real violence against women, happening right in front of them. Many of those being (aggressively) persuaded to use injectible Depo Provera are sex workers (or are believed to be by those doing the persuading). What about their right to know the risks from injectible hormonal contraceptive to themselves and their partners?

It is claimed that using injectible Depo Provera can protect women from violence; but it also constitutes an act of violence against them and their sexual partners. In addition, the 'protective' value of Depo Provera (against violence, not HIV) is lost if the woman also takes PrEP (to protect her against HIV). The use of injectible Depo Provera is an act of institutionalized violence against women (and men). It should not be used as a vehicle for selling pre-exposure prophylaxis.

Paying for Sex and Paying for Chastity: All the Same?

Offering money to young girls in return for an undertaking by them to have less sex, or to take precautions against infection with sexually transmitted infections and unplanned pregnancy, strikes me as inherently contradictory. If you want to make money out of your body, what difference does it make whether you achieve that by agreeing to have sex, or by agreeing not to have sex?

Imagine you wish to make money in these ways: you have clients who pay you to have sex; and you have clients who pay you not to. The two types of client are perfectly compatible. Instead of making eight dollars a day (100 Rand), week or month, you can make sixteen, or you can use the payment as leverage to charge some clients more, or as a subsidy to charge some less.

These 'conditional cash transfers' seem to be based on a number of assumptions. For a start, they seem to assume that HIV is almost always a result of sex, generally extra-marital sex, and generally 'unsafe' sex. They also seem to assume that protecting themselves against being infected with HIV is within the control of the recipient of the money.

What about non-sexually transmitted HIV, through unsafe healthcare, cosmetic or traditional practices? Don't people infected in that way need money too? Shouldn't they be encouraged to avoid health facilities where conditions are dangerous, also practitioners who have a poor record for safety?

By the way, the recipient of money is always female. Therefore, it is further assumed that the male with whom the female has sexual intercourse is usually the 'index case', the one more likely to be HIV positive. (All men are sexual predators and all women are sexual victims, at least in the world of HIV.)

But, as it turns out, most young males in South Africa and other sub-Saharan African countries tend to be HIV negative. Far more females than males become infected, some in their teens, but far more in their twenties, and many in their thirties. So who is doing all this infecting?

This requires another assumption: the girls/women are having sex with men who are older than them, often much older. There are several problems with this attempt at rescuing current HIV 'policy' and thinking: many females do not have sex with men who are much older than themselves; many 'older' men are not HIV positive; and many females are infected even though their sexual partners are roughly the same age as themselves.

Worse still, some girls/women are infected even though they either have not had sex, or they have always taken precautions. In fact, using condoms is more strongly associated with higher HIV prevalence than not using condoms. Those trying to dig themselves out of this hole claim that people who know they are HIV positive are more likely to use condoms. But this claim is not well supported by evidence.

'Intergenerational' marriage and sex, where one partner (usually the male) is older than the other, used to be the darling of the anti-sex brigade. But very little research was carried out into whether it really resulted in higher rates of HIV transmission. When some research was carried out it was found that it may be associated with lower rates of transmission.

Back to the drawing board? Well, no, actually. As well as persuading girls/women not to have sex (or the wrong kind of sex, or sex with the wrong kind of person, etc), there are conditional cash transfers for men who agree to be circumcised. It works, too. Not very well. Not many men will agree to be circumcised for a few dollars.

Unsurprisingly, more men will agree to be circumcised if they are paid more money, and fewer if they are paid less. But most of the men who agree to the operation would have already agreed to it without the payment; they were already convinced that circumcision would be the answer to their prayers (or what they thought were their prayers).

There is cash to stay in school, even though this is not associated with lower HIV incidence. The payments may continue because school is a good thing. But didn't we know that already? Didn't we already know that all children should go to school and that there should be equal access for all children, regardless of their gender, tribe, religion, etc?

There is cash to support prevention of transmission of HIV from mother to child. What about reducing infection in mothers? Many are infected when they are already pregnant, even late in their pregnancy, or just after giving birth. Many infected have husbands who are negative. These women are unlikely to have been infected through sexual intercourse, despite the constant pompous and racist prognostications of the HIV industry.

Sometimes the payment, or some of it, goes to the family. Great, so poverty is a bad thing; and another thing we just wouldn't have known if it hadn't been for this research? The World Bank made a big hoo hah recently about how wonderful eradicating human parasites is, how much better off children are, with improvements in health, academic achievement, etc.

But human parasites are debilitating and result from appalling living conditions. They are also easily and cheaply treated. Aside from the clever medications, provision of water and food of a quality appropriate for human consumption can also significantly reduce the problem. Why so much research to tell us what we already know? Why so much research telling us that a lot of what we are doing are wrong, yet the research, and much of what we are doing, both continue.

Something all of the above failed approaches have in common is that they show that HIV is not very closely related to sexual behavior. It is not just that attempting to influence someone's sexual behavior often fails; successfully influencing someone's sexual behavior also fails to reduce HIV transmission.

Conditional cash transfers that assume HIV is almost always a result of sexual behavior don't just frequently fail to influence sexual behavior, they fail to prevent HIV transmission. Mass male circumcision has been shown to reduce HIV transmission from females to males, only slightly, and only under certain conditions; but it increases transmission from males to females.

These same researchers have been working on the same unpromising initiatives for many years, even decades: Karim, Pettifor, Jukes, Thirumurthy, etc. However, their racist bilge doesn't fail because it is racist, it fails because it is based on assumptions that are not borne out by their own findings. Except in the minds of journalists, there is no 'money, sex, HIV' triad in Africa; HIV is also transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices. Let's try dealing with that.