Correlation of 'Unsafe' Sex With HIV Transmission Does Not Prove Causation

A couple of HIV researchers have come up with a 'plan' to reduce HIV transmission: no sex for a month, or 100% condom use for a month. This plan hit the media some months ago because I discussed it in July, but it's definitely media friendly. The argument runs that a month of safe sex, or of no sex at all, could "help reduce the spread of HIV by skipping the period immediately after an individual acquires the virus when they are most infectious".

The researchers, Alan Whiteside and Justin Parkhurst, reckon 10-45% of infections result from sex with people during this brief period, when infected people are most infectious. Apparently these estimates are based on 'models'.

They bemoan the fact that nearly 50% of Swazi women aged 25-29 are HIV positive, despite past prevention efforts. However, these past prevention efforts included abstaining, being faithful to one partner and using condoms (without too much emphasis on the condoms in most instances). This was the much vaunted 'ABC' strategy, also considered media friendly in its day.

UNAIDS have coined the term 'Treatment 2.0' to refer to the sad bunch of 'strategies' they expect to use to reduce HIV transmission in the future. And, like 'Web 2.0' that inspired the name, there isn't really anything new about Treatment 2.0. It's just the same old stuff in slightly different packaging. This also seems to be true of the plan to advocate no sex for a month or 100% condom use for a month.

I accept that 'abstain for a month' sounds far more achievable than just 'abstain' and that 'use condoms for a month' sounds far more achievable than 'use condoms'. But Demographic and Health Surveys don't show that ABC and similar strategies didn't work very well: they suggest that there is little correlation between knowledge about safe sex, safe sex behavior and HIV transmission. In other words, behavior change communication (BCC) has been a total failure, in every country where it was implemented.

In common with the rest of the HIV prevention rhetoric, the insistence that transmission in African countries is all about sex seems to be mistaken. Some HIV transmission may be sexual, but not all. Therefore, HIV prevention strategies could include some that target sexual behavior. We would still be left with the problem of which ones, given that none have been particularly successful. But it's a start.

More importantly, though, a lot more attention needs to be paid to the question of how much HIV transmission is down to sexual behavior and how much is not. What are the other drivers of HIV transmission? There's clearly an issue with transmission through unsafe medical procedures, such as injections, because the WHO has reported that 70% of injections are unnecessary and 17-19% of them are unsafe in sub-Saharan Africa.

What about other medical procedures? Service Provision Assessments for African countries show that many health facilities lack trained staff, equipment, safety guidelines and the ability to carry out infection control measures. Many non-African countries have had huge levels of nosocomial HIV transmission, transmission as a result of health procedures. If it can happen in Western countries and Asian countries, why not in African countries?

Perhaps Whiteside and Parkhurst are right about selecting a specific time period, such as one month, but wrong about confining it to sex. Perhaps we could have a medical safety month, as well. This would be a good opportunity to estimate the effect such a measure would have on HIV transmission. The only problem is that health facilities don't have the capacity to provide safe healthcare for a day, let alone a month.

And that's a problem for a no-sex/safe-sex month, too. African countries don't have much capacity when it comes to national campaigns. They don't have the health facilities, the educational capacity, the infrastructure or anything else that would be required (though it has alway been a bit of a mystery as to what could ensure 'safe sex' in any country, for any period of time). There are many indications of how poor health services are, such as the number of people who suffer from and die from preventable and curable diseases, especially water borne and respiratory diseases.

Another indication, though, is the high rates of preventable and curable sexually transmitted infections. It is known that these can increase HIV transmission, in addition to causing a lot of poor health, misery and even death.

Perhaps Whiteside and Parkhurst are having a bit of a joke when they refer to Muslims 'abstaining' from sex during Ramadan, even though they only abstain during daylight hours. Does avoiding sex during the day constitute 'reducing risky sexual behavior'? HIV prevalence is often lower among Muslims than among non-Muslims and this may be related to sexual behavior, but it's unlikely to be related to sexual behavior alone. HIV, unlike many other sexually transmitted infections (STI), is difficult to transmit sexually but relatively easy to transmit through unsafe medical procedures.

Imagine this scenario: if high levels of unprotected sex were to give rise to high levels of sexually transmitted infections aside from HIV, this might result in a lot of people visiting hospitals and clinics for diagnosis and treatment. If those health facilities were inadvertently transmitting HIV, it would appear to be the sexual behavior that was driving the epidemic when, in reality, it was also unsafe medical procedures.

Populations that engage in unsafe sex are doubly at risk of being infected with HIV if transmission of other STIs is also high, or is thought to be high. Sex workers, men who have sex with men, intravenous drug users, perhaps even truck drivers, who have also been branded as 'risk' groups, pay regular visits to STI clinics to receive both preventive and curative measures.

So there's a bit of homework for Whiteside, Parkhurst and the extremely well funded bunch that make up UNAIDS and the HIV industry: are we assuming that correlation (of sexual behavior with HIV transmission) is equal to causation? When people are clearly at risk of being infected with HIV through sexual behavior, we are assuming that that's always how they are infected, so we are not looking for any other explanation. Perhaps it's time we looked at other possibilities.

If we don't look at other possibilities for HIV transmission, we may continue to think that it's all to do with sex. As a result, we may continue to fail to prevent the bulk of infections while patting ourselves on the back for appearing to prevent some. Ultimately, UNAIDS and the rest of them want to know the truth, right? Aids is not just about making money or careers, is it? It's unlikely that large numbers of people will abstain from sex for a month, or even use condoms consistently for a month. But even if they do, HIV transmission will remain high enough to maintain a serious epidemic.

Will a New HIV Boss at WHO Make a Difference?

The World Health Organization (WHO) has a new head of HIV called Gottfried Hirnschall and he gave an interview recently to IRIN. Apparently he feels that, as a prevention message, abstinence is unrealistic. That's good, but not good enough. Abstinence didn't just fail because it's unrealistic. There's no reason why the option of choosing not to have sex under certain circumstances shouldn't be part of a comprehensive sex education program. It's just better if it's not called 'abstinence' and if it isn't the only trick in the box.

There are probably many reasons why HIV prevention programs have failed in African countries but the one reason that WHO, UNAIDS, CDC and all the main HIV institutions refuse to countenance is that not all HIV is transmitted sexually. They go as far as admitting that a small amount is transmitted non-sexualy, but not enough for them to bother spending money or time on. And sure enough, Hirnschall mentions male circumcision and 'treatment as prevention'.

But what does treatment as prevention involve? Because HIV positive people who are responding to antiretroviral treatment (ART) eventually have a low viral load, they are very unlikely to transmit HIV to their partner. If it were possible to test every sexually active member of a population regularly, say once a year, anyone found HIV positive could be put on treatment.

There are just two small flaws. One is that persuading the majority of sexually active people to be tested even once, even to save their lives, has proved elusive. The second is that the majority of people who are currently in need of treatment are not yet receiving it. Much of the funding for HIV treatment that was so fothcoming in recent years has been cut or flatlined. Just as the WHO released new guidelines that would put more people on ART, there isn't even enough money to keep some people already on treatment in drugs.

People on ART need to take the drugs every day for the rest of their lives. If they miss their dose too many times, resistance builds up and they need to move to a different drug regime, a far more expensive one. It is very difficult to get credible figures on what percentage of people in African countries are adhering to ART. But numbers of people dying from Aids is suspiciously high in some countries. It would be one thing if those providing people with the drugs could afford the second or third line drugs for those who develop resistance. But some countries are in the position of not even being able to afford first line drugs.

Hirnschall is asked about the shortage of money and he mentions 'task shifting', things like training nurses to do what doctors have been doing up till now. For people who don't mind being seen by a doctor or who really don't need to see a doctor, that's fine. Most people in developing countries don't get to see doctors anyway, they are too scarce. But even nurses are scarce and they are pretty stretched already. Perhaps more nurses will be trained and these ones will not be poached by rich countries.

So much for treatment, though it's not very much. But will those advocating putting more people on treatment get around to preventing new infections? Ok, they like to say that treatment is also prevention, but from a practical point of view, this will not work. People are becoming infected faster than others can be put on treatment and if money for treatment becomes scarce, where will prevention be then?

First of all, not all HIV is transmitted sexually. It needs to be established how much is coming from non-sexual routes, such as unsafe healthcare and other things. And this needs to be dealt with because it sure as hell won't stop by handing out condoms, circumcising men and telling people how to run their sex lives. Hirnschall thinks that a HIV vaccine would be ideal. But what would be ideal would be to establish where most HIV infections are really coming from so that, even if there were a vaccine, we wouldn't need to waste so much money on it.

Second of all, if Hirnschall is worried about where all the money is going to come from if donors are thinking of pulling out he should get on to the issue of generic drugs. He talks about negotiating with big pharma. What's the point of negotiating with them? They want the highest price they can get, they know people in developing countries can't pay it but they think donors can. They will never reduce their prices to a reasonable level. The only way to ensure that drugs are made available at an affordable price is to open up the market to generic producers.

Of course, big pharma don't want that, they don't want to compete, they want to hide behind the protectionism of intellectual property 'rights'. There are companies well able to produce enough generics to supply everyone who needs ART, to scale up treatment and to continue treating people who go on to need second and third line drugs, as many people eventually will. This has to happen some time. It should have happened a long time ago. Will Hirnschall just drag his heels the way all the others are doing?

Is the WHO's new head of HIV just going to give us more of the same? Or is he going to question the behavioral paradigm that says that most HIV is transmitted sexually? And is he going to stop 'negotiating' with the blood suckers in big pharma and open up the drugs market to competition? If his aims are to reduce HIV transmission and eventually eradicate it, and to treat as many HIV positive people as possible, he will have to take both these steps.

You've Been Bad: No Sex for a Month

One of the noticeable characteristics of many HIV researchers is that they seem to have a liking for telling people how to run their sex lives, who to have and not to have sex with, when to have sex, where to have sex and what sorts of sex to have. Crucially, they feel the need to tell people in developing countries these things. They certainly don't tell people in rich countries, unless they are men who have sex with men (MSM) or commercial sex workers.

This is because, typically, HIV researchers toe the line on HIV transmission: that in high prevalence countries, it is almost all transmitted through heterosexual sex but in low prevalence countries, it is mainly transmitted by MSM, intravenous drug users and perhaps commercial sex workers. These researchers seem to see themselves as arbiters of good sexual behaviour and they can even threaten to come along and circumcise anyone who misbehaves, as long as they are not already circumcised, of course. If they are circumcised they are considered to be better behaved than the uncircumcised, anyhow.

So two of these intrepid researchers have come up with a plan to have an official 'no sex month'. The thinking behind this is that HIV positive people are most infectious when they have just been infected. At this stage, they will probably not know they have been infected and even if they test, they will probably not receive a positive result. Anyone going through this stage of HIV infection during a no sex month will avoid transmitting the virus, at least for a while. Once they have gone through to the next stage, they will be far less infectious and, hopefully, they will be tested before they reach the third stage, during which they will be highly infectious again.

There are people to whom this proposal will not appeal, specific groups that these researchers will probably want to include. Commercial sex workers will be unlikely to forgo a month of earnings, for example. (And intravenous drug users could be relatively unaffected by the cunning plan.) But the researchers point to the Muslim month of Ramadan, where Muslims abstain from sex during daylight hours. I wonder if they have done any research into whether this has had any impact on HIV transmission, aside from their assumption that because HIV is often lower among Muslims, Ramadan could the the key. And is daytime sex more likely to result in HIV transmission than nighttime sex? Or perhaps daytime sex is seen as more in need of censure.

Well, because we are talking mainly about African countries, it will probably be seen as perfectly reasonable to 'test their hypothesis' on the people. After all, they clearly have too much sex, of the wrong kind and possibly even during the day. Why these researchers see their proposal as a one off is not clear. But they are wrong in saying that it 'does not create additional stigma'.

The behavioural paradigm, which says that HIV is mainly transmitted heterosexually in developing countries, is what causes the main stigma that attaches to HIV. It is because people in developing countries are being told that they have too much sex, and sex of the wrong kind, that HIV is stigmatized, that people are made to feel that they are bad people, who must be censured and punished, if necessary.

More importantly, the behavioural paradigm is completely unfounded. HIV is not mainly transmitted by heterosexual sex in developing countries. The extent to which HIV is transmitted non-sexually is not clear precisely because researchers like the two in question refuse to consider non-sexual transmission as being important enough to research.

If, as a result of this 'experiment', HIV rates are found to have dropped, this will not necessarily mean that sexual transmission will have been cut. Non-sexual transmission, for example, through unsafe medical practices, could also go down during the no sex month. Sex workers and MSM, if they do give up sex, will have less need to visit sexually transmitted infection clinics to receive jabs and contraceptive injections (very popular among sex workers). These are likely routes to HIV infection through unsafe injections. Will the research take such circumstances into consideration?

Perhaps the researchers would like to carry out another experiment on this obliging and convenient population of human beings: perhaps they would like to have a medical safety month. During this month, it would be ensured, not just that every health care worker takes the utmost care during every procedure, but that there are enough health care workers everywhere and all of them have enough equipment so that they don't need to reuse anything or do anything that could put their patients at risk. During this month, Everyone in the country would have access to safe health care, no one would have to resort to some quack wielding a much reused needle and no one in the health care industry would have to take any risks because of lack of resources.

Apart from seeing how this affects HIV transmission, it would be interesting to see what sort of demand there was for treatment and what levels of diseases and other health conditions would be revealed. But if no sex months provide a 'potential strategy', then so do medical safety months. Indeed, medical safety months would have benefits that go far beyond HIV transmission. Perhaps we could have clean water and sanitation months, where people are provided with enough water and sanitation facilities to reduce some of the biggest killers in the developing world. The possibilities are endless, we could have infrastructure months, electricity and lighting months, connectivity months and many other types of month.

The researchers assure us that a no sex month would produce "easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign". And I'm sure all the other types of month would also supply vast quantities of data, such as maternal health figures, infant mortality figures, child mortality health figures, nutrition figures, disease mortality figures, more data than you could shake a circumciser's scalpel at. In fact, I don't think you would need to threaten people at all, I really think they would go for these dedicated months without any incentive. They may even demand that such benefits be granted to them all the time, not just for a month.

Even the researchers themselves warm to their theme and suggest that such months could be adapted for different populations "depending on what is driving the epidemic". So, among miners in South Africa they suggest a 'no commercial sex' month. But how about a no mining month? Then they could have a significant impact on the TB epidemic, which is driven by the mining industry and is said to spread hand in hand with HIV.

The researchers conclude that "In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic". But are these researchers open to new ideas? Are UNAIDS and CDC open to new ideas? The biggest new idea, which is only new in the sense that it has been ignored by those who are best placed to apprehend it, is that HIV is not only transmitted sexually, that the behavioural paradigm is wrong. No new discovery needs to be made: these people and institutions simply need to tell the truth. A 'no lies' month from UNAIDS would do more to reduce HIV transmission than all their HIV 'prevention' programs, past, present or future.

HIV Risk From Lies and Half Truths

In the run up to the World Cup in South Africa, the excuse for talking exclusively about sexual behaviour and HIV risk and ignoring any other risks, such as the risks of medical transmission, seems to be that sexual transmission is the most common form of transmission in African countries.

The view that sexual transmission is so common that non-sexual transmission is almost negligible is debatable and the official figures are based on guesswork rather than proper research. But even if the figures were correct, it would be stupid to ignore non-sexual risks just because sexual transmission is more common.

Driver error may be a common cause of road traffic accidents but I wouldn't want to ignore the fact that my breaks are worn out just because it is a less frequent cause of accidents.

We know that the UN worries about medically transmitted HIV enough to warn its own employees about it:

"Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. 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. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections."

So why not warn soccer fans and other visitors to South Africa and other African countries? More importantly, why not warn all Africans, most of whom have no option but to use their medical facilities, no matter how inadequate they are?

Sure, international health institutions want people to trust their health facilities enough to get medical treatment when they need it, to get tested for things like HIV and to take the advice of health professionals. But is that a reason to deceive the public?

The public might be afraid that official sources are lying to them or that they are keeping something back. But official sources are lying to them and keeping something back. All over Africa, there have been clear outbreaks of medically transmitted HIV. These have been covered up or just ignored and no investigations have been carried out.

Even if only a handful of HIV infections were caused by medical transmission, people should be made aware that the possibility exists. They should be in a position to protect themselves, to insist on sterilized equipment and other safe practices. If they don't even know that unsafe medical procedures occur, they will not know that they need to protect themselves.

But there is little question about whether medical transmission of HIV is common in African countries. Medical facilities have long been underfunded, understaffed and otherwise inadequate. It would be more surprising if very few transmissions of HIV occurred than if a sizeable number occurred. The only question is about how common medical transmission is compared to sexual transmission.

In the long run, people will have more confidence in public health information and in public health facilities if they are told the truth now. Those trusted to provide people with the information they need to stay healthy are not presently entitled to that trust. Maybe people will question the safety of health facilities once they realise that things have been kept from them. But as things stand, they are right to ask questions.

If it is risky for UN employees to trust medical facilities that are not approved by the UN, it is also risky for soccer fans. And if it's risky for visitors to Africa to mistrust medical facilities, it is also risky for Africans. No amount of abstinence, faithfulness to one partner or condom use will protect people from medically transmitted HIV. HIV can be, and often is, transmitted by medical and dental treatment and by cosmetic treatment such as tattooing, piercing and hairdressing, in African countries. It is not just transmitted by 'unsafe' sex.