Wednesday, March 22, 2017

Drugs for All Deemed More Profitable than Circumcision

Demands to roll out mass male circumcision programs, claimed to reduce HIV transmission, date back at least 20 years. Other claims about the 'benefits' of circumcision go back centuries. But by the time the programs had started several other interventions had been identified that have a far better claim to reduce HIV transmission.
For example, 'test and treat', the practice of putting everyone who tests positive for HIV on ARVs immediately, is claimed to reduce transmission to a HIV negative sexual partner by 96% or higher. (Note, 90 is something of a magic number in UNAIDSland at the moment, with their 90-90-90 strategy replacing various other magic numbers conjured up in the past.)
If the number of HIV positive people in the world is something around 30 million, depending on which estimates you use, and about half of them are claimed to be on ARVs already, there are still around 15 million who can benefit from ARVs. That's worth, say, a few billion dollars.
Although a lot of those opposed to mass male circumcision don't seem to realize this, many of those promoting circumcision are the same people who promoted behavior based programs, particularly those with an emphasis on 'abstinence'. Those programs, although they never completely died out, were a disaster. Even the people formerly pushing them now admit that they probably had no impact on HIV transmission. But they wanted to find another source of funding to replace the vast amounts that used to go into 'prevention', a lot of which was spent on behavior based rubbish.
Circumcision seemed like the answer because the number of people who could be targeted for circumcision could run into hundreds of millions. Every year millions more male children would be available to keep the programs profitable.
At first the promoters claimed they were only targeting sexually active adults, but they quickly found that most of them didn't want to be circumcised. It was much easier to recruit children and now they can turn their attention to infants.
But with test and treat, coupled with PrEP, how can the circumcision enthusiasts still claim that there is any benefit to the operation? They need to target almost the entire male population in countries where circumcision is not widely practiced. They must carry out the operation on about 75 men for every one claimed reduction in HIV transmission.
The other interventions, test and treat and PrEP, are claimed to be targeted at those most at risk. Let's take a look at who is thought to be most at risk, and see just how many hundreds of millions of people that involves, who would need to be taking these drugs for the rest of their lives in the case of test and treat, and for as long as they are thought to be at risk for PrEP.
In western countries there are few groups who are thought to be at risk. The biggest group is men who have sex with men. The second biggest group is injecting drug users. But aside from commercial sex workers, who are given some choice in prevention options in many rich countries, there are not many others.
The picture is completely different in southern and eastern African countries, with high prevalence and/or large numbers of people infected with HIV. This article about a PrEP program in Kenya says the groups of people claimed to face the highest risk of being infected include:
  1. Discordant couples (where one partner is HIV positive and one is HIV negative)
  2. People who frequently contract sexually transmitted infections
  3. People who are said to be unable to 'negotiate' condom use
  4. People who frequently use post-exposure prophylaxis (a short course of ARVs for people who suspect they may have been infected, taken within 72 hours of contact)
  5. People who share injecting equipment
Out of the estimated 77,600 new infections in Kenya it is not clear how many arose among any of the listed 'risk' groups. High prevalence countries tend not to trace contacts, assuming that the bulk of transmissions (about 90% if you exclude infants said to have been infected by their mothers) were a result of heterosexual intercourse.
You could easily add other risks to the above list, for example (most of the following are a risk in developing countries although 7, 10 and 12 are likely to be more common in rich countries):
  1. People who have given birth in a health center/clinic
  2. People who have given birth at home, or anywhere other than in a health center/clinic
  3. People who have received birth control injections
  4. People who have had injections, blood tests, transfusions, dental care, infusions, etc
  5. People who have had operations that involved piercing the skin, major or minor (including circumcision)
  6. People who have received some forms of traditional healthcare that involved skin piercing
  7. People who use injected appearance or performance enhancers (eg botox, steroids, etc)
  8. People who get their head shaved or where skin is pierced and/or weakened by processes
  9. People who receive manicures, pedicures, etc
  10. People who have body piercings
  11. People who practice scarification and other practices
  12. People who get tattoos
Of course, with the second list, you could warn people about the risks and clean up health centers, cosmetic establishments and anywhere skin piercing occurs (the list is surprisingly long). This would seem preferable to putting almost everyone in a population on expensive drugs for many years.
But UNAIDS, CDC, WHO and other establishments object to calls to warn people about the risks they face in health and cosmetic facilities in developing countries. They warn some people from rich countries about the risks in poor countries but they refuse to warn people in poor countries.
Even concentrating on the risks listed in the Kenya article it is easy to identify many millions of people who could be said to need the $775 per annum PrEP, which is the estimated cost of the drugs alone (I don't know what other costs there may be).
So you can see the attraction for the HIV industry. If there were only 5 million people requiring years of ARVs, for some, a lifetime of ARVs, that's several billion dollars for Kenya alone. There are countries with higher prevalence and others with higher numbers of people infected than Kenya.
With only a few billion dollars for mass male circumcision, with its 1.3% absolute risk reduction, or even the claimed 60% relative risk reduction, drugs for the sick and the well seems like a far more lucrative strategy. Even if the benefits realized for mass male circumcision far exceed those unlikely claims, they can't come close to the claimed benefits of test and treat and those of PrEP.
One problem is that you can't roll out PrEP for many of the groups claimed to benefit. For example, in discordant couples the positive partner should already be receiving ARVs. People who share injecting equipment could be better served by a clean syringe and needle program. There may be other examples, where overlapping PrEP and test and treat might raise eyebrows among the more scrupulous in the industry.
And it would be perverse to give PrEP to people while they still attend clinics and other places where skin piercing procedures take place without warning them about the risks and also ensuring that those places start to abide by strict infection control regulations that people in rich countries (and rich people in poor countries) enjoy.
If PrEP and test and treat strategies work as well as we are told, let's hope they do as well in the field as they did in trials. But let's also get rid of these silly mass male circumcision programs. We no longer have to pretend that they will reduce HIV transmission, or even pretend that that's why they were rolled out in the first place. Worse still, the profits are orders of magnitude lower than the drug based strategies.

allvoices

Wednesday, March 15, 2017

HIV: Cuba's Success and Uganda's Failure

Uganda is frequently mentioned in glowing terms in articles about HIV, especially in relation to the late 80s, 90s and early on in the 2000s. In contrast, Cuba is rarely mentioned in glowing terms, although the percentage of 15-49 year olds infected with HIV (prevalence), at 0.3%, is 23 times smaller than the same figure for Uganda, which stood at 7.1% in 2015 (all HIV figures from UNAIDS).
In fact, one could suggest that Uganda never got to grips with the epidemic. They still can't explain why so many people, said to face a low risk of being infected with HIV, have seroconverted over the past several decades. Despite huge amounts of research, money and other resources being thrown at the country, the bulk of published research on HIV in Uganda seems to be focused on assumed sexual behavior and assumed sexually transmitted HIV.
Little or no international funding went into the HIV epidemic in Cuba. The country worked hard to research the epidemic, even before the first HIV positive person was identified there, several years before. Luckily, the country had a well developed health service, with more doctors per patient than any other high prevalence country (including the US). Indeed, the US (where an estimated 1.2 million were living with HIV in 2013) seemed intent on ridiculing Cuba's approach to the virus.
Some of the criticisms were directed at claimed human rights aspects of Cuba's achievements. It was often stated or implied that men who have sex with men were especially targeted by, for example, Cuba's imposed 'quarantine'. The quarantining started when little was known about the course of the illness, but it was relaxed once more was known. A number of personal accounts, some from men who have sex with men, now make it clear that many of the people quarantined are grateful to have received the care they got at the 'sanitaria' (there are links to other similar articles from this article).
An article by Tim Anderson finds that the quarantine did not target men who have sex with men; it also finds that other procedures were carried out in accordance with international guidelines. Anderson notes that Cuba was 'more thorough' in their testing and tracing procedures. Cuba has continued to make improvements in how they deal with the epidemic, which is a low level one, with men who have sex with men being the most affected group.
Sarah Z Hoffman refers to Cuba's HIV program as 'the most successful in the world'. Cuba approached HIV with the aim of reducing the likelihood of those infected going on to infect other people. That may sound like an obvious aim, but the greater thoroughness of Cuba identified by Anderson can be contrasted with a reduction in contact tracing in many countries, where it was claimed that certain groups were being unfairly targeted by such measures.
Cuba also started providing all HIV positive people with antiretrovirals in 2001, which they produced themselves as generic versions. Other countries had to wait a long time before they could provide more than a small fraction of HIV positive people with ARVs, and they had to pay astronomical amounts of money for them for years (although the costs are far lower now).
Hoffman writes "HIV infected people must provide the names of all sexual partners in the past six months, and those individuals must be tested for HIV. People found to have any sexually transmitted disease must undergo an HIV test as well. Voluntary HIV screening is encouraged."
This is one of the places where practices in Cuba differ from practices in most other countries. This is called 'contact tracing' and it's a vital tool of infection control. But in most countries people can claim anything they wish to about their sexual partners, that they have never had sex, that they have only engaged in heterosexual sex, that they have never injected drugs, etc. If people can withhold such information then contact tracing is impossible.
(My previous post is about a rare and valuable contribution to the history of HIV in Africa from John Potterat’s book ‘Seeking the Positives’, much of which concentrates on his work on HIV and STI epidemiology in the US. There’s a link to the chapter here. The approach the US adopted towards HIV could hardly have been more different from that of Cuba. Unfortunately, most other countries, certainly most poor countries, wedded themselves to the US, till death…etc.)
As a result of not tracing contacts, or of not doing so very assiduously, countries like the US, with extremely high transmission rates in certain groups, have never got their epidemic under control. In common with Cuba, the largest proportion of new HIV infections now is among men who have sex with men. Unlike Cuba, there is also a large injecting drug population in the US. But where contacts are not traced, they can not be offered the same opportunity to avoid infection if they are negative, or avoid infecting others if they are positive. Nor can they be 'connected to care' as quickly as possible.
In fact, many of the things western countries write copiously about, such as early testing and treatment, universal testing, elimination of mother to child transmission, universal access to treatment, were achieved in Cuba years ago, but have never been fully achieved even in some western countries. Where HIV prevalence is highest, in southern and eastern African countries, some of those achievements may not be realized in our lifetime.
Unfortunately for the worst affected countries, the rights of individuals are claimed to be foremost. Their contacts, past and future, are not treated as individuals. If the individual has multiple partners and chooses not to reveal that they engage in high risk practices, that’s considered to be the individual’s business. If the individual has had no sexual partners, or no HIV positive sexual partners, then the source of their infection needs to be identified. But in high prevalence African countries tracing of non-sexual contacts is rare. What you do find a lot of in research is findings referred to as ‘biased’, because the researcher expected every HIV transmission to be a case of sexual transmission.
(Despite the apparent desire of most countries to protect people's individual rights in relation to HIV, this approach seemed to go out the window when the virus involved was ebola. Some 'infection control' measures seemed to involve groups breaking into people's houses, forcing them into shabby health facilities, burning their property in public, spraying their houses, breaking up families and communities, etc. Who knows what approach will be taken to the next headline grabbing epidemic.)
So why all the attention and resources for a country that appears to have lost control of HIV a long time ago, and why all the rhetorical questions about Uganda, how their 'success' can be replicated, etc? More importantly, why so little attention for Cuba, and why is it so belated? We can learn a lot from both countries. Instead, we should be asking what Cuba did right, and continues to do right, but what Uganda did wrong, and continues to do wrong.
Cuba's approach to HIV may have been the most successful anywhere. Some would go further and claim that Cuba may be the only country that was seriously threatened by the virus, but gained complete control over the epidemic early on, and retained that control. In the sphere of human rights, also, Cuba has made a lot of progress. Uganda, on the other hand, continues to move in the opposite direction in the fields of public health, human rights, HIV, political stability, economy, etc.

allvoices

Monday, January 16, 2017

Dear Researcher, What Kind of Whore am I?

My last blog post was about a researcher who seems to have found what she was looking for (young girls who claim to have had sex for money to buy sanitary towels) and now uses the finding to get publicity and, presumably, funding, or justification for funding if she has already received some.

Ten percent of the 15 year olds, allegedly, made this claim, which amounts to fewer than 20 people from a survey of 3000. But the researcher took what they said at face value because they were saying the right thing. The researcher is selling menstrual cups (specifically, mooncups) in a high HIV prevalence area.

Another piece of research looked at serodiscordance, where each partner in a couple has a different HIV status, one positive and one negative (or they are each infected with a recognizably distinct viral type). It was found that more women than men are in discordant relationships, which is taken to indicate that women are more 'promiscuous' than men, or more 'promiscuous' than previously assumed.

The researchers concluded that "due to social desirability bias, women in stable relationships practice concurrent partnerships more than reported". In other words, the women whose partner was HIV negative but who were themselves HIV positive 'lied' about their sexual behavior.

The researchers, following the received view of HIV, believe that the virus is almost always transmitted through heterosexual sexual intercourse in high prevalence countries in 'Africa', but not in most countries outside of 'Africa'. Therefore, HIV positive women in a discordant relationship must have been lying.

In the mooncup research, the researcher believed what was heard, and reported it as she heard it. But in the serodiscordance research the researcher did not believe what was heard, so it was classed as a 'bias', no different from saying that those women were lying.

Although there are all kinds of names for various different biases that plague certain kinds of research, it's a bit harder to find names for the biases of researchers, who go into the field armed with their prejudices and the findings that they (and probably their funders and institutions, etc) seek, and proceed to grab what fits their preconceptions, discard what doesn't, and put a spin on anything else that can be salvaged.

A very disturbing paper claims to identify three paradigms of 'transactional sex', for those who thought it only referred to sex for money. They identify:

Sex for basic needs
Sex for improved social status
Sex and material expressions of love

So there you have it! Since the study is not about people who are seen as straightforward sex workers and people who are married, it's difficult to imagine what proportion of females could not be associated with any of these categories. Some authors on the subject conclude that females who don't receive anything for sex (and, I guess, some who do), are coerced into having sex.

This is about sex in 'African' countries, by the way, so you don't need to start thinking about any time you may have had sex that some zealous researcher could fit into one of their little boxes, unless you are 'African'. Of course, if you are male (and 'African') then you are likely to be a John or a sexual abuser.

So how can you tell if you have had sex for reasons that the researcher can not classify as transactional or forced, how to tell if you are a prostitute, a victim, a John or a sexual abuser? Or, looking at it another way, if you are not from an 'African' country, neither are you married, nor a sex worker, have all your sexual experiences been of a kind that these researchers might approve?

Those writing on the subject often talk of females lacking power, and of the intervention they are researching, such as marketing mooncups and the like, as 'empowering'. Indeed, the subject of power often arises in discussions of HIV in 'Africa'. As if we (the reseachers, NGOs, etc) have power and we are looking for downtrodden victims upon whom we may bestow it, if they just give the right answers to our questions (we can also tread down those awful men, too).

Shockingly, these well funded researchers really do wield great power in developing countries. They define what kind of person you are, a victim, an abuser, a prostitute, a john, and they tell others how to use these definitions, giving them a small share of their funding if they allocate people to the correct boxes.

The same researchers decide what they will accept as a valid response, on the one hand, and what they will put down to bias on the other, effectively calling the respondent a liar, unable or unwilling to accurately describe how they see themselves and their place in their own environment.

There are some who seem to go to the field with a blinkered view of HIV in high prevalence African countries, where they refuse to accept evidence that doesn't fit their preconceived notions of 'African' sexuality, where sex is generally paid for (somehow) or forced, always 'unsafe', rarely (if ever) for pleasure and certainly not for love. If you are a HIV positive 'African', heck, even if you just have sex, you are (probably) a whore or a john.

allvoices

Sunday, January 15, 2017

Questionable Research: Are Menstrual Cups A Hard Sell?

In May of 2016, the English Guardian gushed:


The 2015 study that they carried out is more careful in some ways. "Caution is suggested in interpreting the data provided, and particularly for analyses on low prevalence behaviors such as sex for money for sanitary products." The study also reveals that the number of 15 year olds who claimed to have had sex to get money, specifically to get sanitary pads, was fewer than 20.

Another Guardian article appeared in the last few days on the same subject. The articles are both promoting a menstrual cup as an alternative to expensive, disposable sanitary pads, or similar ware.

Access to sanitary ware is vital for the health and welfare of girls and women, and making devices like the menstrual cup available is an excellent alternative to the ridiculously expensive disposable sanitary ware available in most places.

But if it's a right, and vital for health, why dress this up as an attempt to 'rescue' 15 year olds who are said to be resorting to ‘transactional sex’ just to purchase sanitary pads? One of the researchers also claims the girls are often coerced into having sex.

Back in sensationalist mode, the recent Guardian article cites the same author and study:

Note, 3000 women, but fewer than 200 15 year olds. Both Guardian articles are about having sex for money to buy pads, rather than having sex in return for pads. But the abstract of the 2015 article seems to blur this distinction, which I would argue is an important one if we are to judge whether this research is useful, however abused, or highly questionable.

There is also an article from a 2013 study, for which Phillips-Howard is a contributor, which clearly talks about both, having sex for money to buy sanitary ware and having sex for sanitary ware.

However, the 2013 article is quite different because it states that "Girls reported [my emphasis] 'other girls' but not themselves participated in transactional sex to buy pads, and received pads from boyfriends." Claiming that other people do this may indicate that the respondent has simply heard such things, perhaps from peers, teachers, various sources of information about sanitary matters, or even presentations about HIV.

Going back to the two possible phenomena, sex to get pads (from sexual partners) and sex to get money to buy pads, do either of these stand up to scrutiny? The first seems unlikely on the basis of other claims and findings made in the literature cited, such as that few people want to talk about menstruation; males don't at all, even many females generally don't.
Do men buy sanitary pads as gifts for their sexual partners? I imagine this is rare. I have bought sanitary pads in East African shops and people don’t hide their reactions. Perhaps it happens.

Claims about girls engaging in 'transactional' sex can be found throughout the HIV, health, development and anthropological literature, all over the place. Sex in Africa is a common obsession among academics, journalists, policy makers, civil servants, Guardian readers, etc. There are claims that some girls have sex for status, food, mobile phones, phone credit, just about anything that a girl may want (or that they may be said to want).

Is it credible that lots of girls have 'transactional' sex for money, which they then use to buy sanitary pads? Well, again the articles state several reasons to think that they don't, or don't do so very much. After all, they have families with small incomes, they need to buy food, to pay bills, including school fees. Would they prioritize sanitary pads, having gone as far as to engage in 'transactional' sex?

The literature goes from claiming that girls say other girls have sex for sanitary pads or sex for money to buy sanitary pads, to claiming that 10% of 15 year old girls claim that they have had sex for money to buy sanitary pads.

By my reading, the causal link between engaging in 'transactional' sex and purchasing sanitary pads is lost if the girls don't have sex in return for the pads. But if the claim is that they have sex for the pads then the literature itself undermines the claim that some men are happy to purchase them as gifts in return for sex.

We can’t rule out the possibility that someone has engaged in ‘transactional’ sex for money to buy sanitary pads, nor the possibility that someone has done so in return for sanitary pads. But Phillips-Howard's claim that girls are literally selling their bodies to get sanitary pads looks more like a desperate attempt to shore up poor quality research than a genuine argument for the benefits of providing girls in developing countries with the most appropriate means to ensure menstrual hygiene.

allvoices