It's not Condoms that are Failing to Protect Against HIV, it's UNAIDS

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

At the beginning of this month, David Gisselquist took a careful look at UNAIDS' 'Modes of Transmission' model and found it seriously lacking, grossly overestimating HIV transmission among couples in long term relationships in Malawi. As a result of this flaw, the model gives results which appear to support the extremely racist view that most Africans in high HIV prevalence countries, male and female, engage in a lot of unsafe sex, and mainly sex with people other than their partners.

David shows how the Modes of Transmission model currently estimates that 81% of Malawi's 95,000 new HIV infections were accounted for by spousal transmission. If you remove the flaw, the percentage goes down to 20%, leaving 60% of all infections unaccounted for by the model (non-sexual transmissions from mother to child make up much of the remainder). How were all those other people infected, including the women who are said to have infected their babies?

It is very likely that a substantial number of HIV infections in Malawi and other high prevalence countries are a result of non-sexual transmission, such as through unsafe healthcare, cosmetic procedures and traditional practices. The much lauded 'ABC' (Abstain, Be faithful, use Condoms) approach to HIV prevention does not work, not because many Africans actually live up to the stereotypical 'all men are bastards, all women are hapless victims', but because HIV is not always transmitted through heterosexual sex.

Consider condoms, which are a great technology for reducing unplanned pregnancies, many sexually transmitted infections and sexually transmitted HIV, through anal and vaginal intercourse. But a number of surveys have found that HIV prevalence is very high among those who use condoms. Indeed, prevalence is often higher among those who at least sometimes use condoms than among those who never use them. The following chart is from the relevant Demographic and Health Survey for four countries.

In some cases, HIV prevalence is 50% higher among those who sometimes use condoms than among those who never use them, sometimes 100%. Shocking? Only if you think HIV transmission in high prevalence African countries is all about sex. Consider another set of figures, this time for condom use at last sexual intercourse in past 12 months. The figures for those who have not had sex in the past 12 months also raise questions (data from DHS surveys). You could suggest that people are not honest, or that people who are infected are 'abstaining', but it is far more vital to figure out exactly how people are being infected in order to prevent further infections.

Why are HIV prevalence figures so much higher among people who say they sometimes use condoms? I can only tell you what I think; condom use is completely irrelevant to non-sexually transmitted HIV. That sounds obvious, but UNAIDS insist that almost all transmission is through heterosexual sex, yet they stand by figures like these. It is not possible for HIV prevalence to be so much lower among those who never use condoms if almost all HIV transmission is sexual. But there may be an explanation for why those who sometimes use condoms seem so much more likely to be infected.

HIV prevalence is often highest among wealthier, urban dwelling, employed, female, better educated people who live in wealthier countries that have reasonable access to reproductive healthcare services, a relatively low population density and sometimes a higher urban population (but not always). People who answer that description, people who can tick at least some of those boxes (some of the factors are interdependent), it seems, are also more likely to use condoms.

So it is not a case of people with the above characteristics using condoms, yet still being more likely to be infected with HIV, but rather a case of those same people being more likely to be infected with HIV through unsafe healthcare or some other non-sexual route. Once you challenge the sexual behavior paradigm the rest is clear: condoms are irrelevant to non-sexual HIV transmission. It only sounds unintuitive if you keep clinging to the sexist, racist and extremely dangerous reflex about sexual behavior, so beloved by UNAIDS, WHO, CDC, PEPFAR, the Gates Foundation and various universities that have been prominent in the HIV industry.

Given what we so often hear about HIV being inextricably linked with poverty, unemployment, lack of education, isolation, poor access to health services, etc, it is worth emphasizing that the virus may often be more closely linked to the opposite of these factors. Of course, all of these factors are abhorrent and it should be the aim of every wealthy country to ensure that such conditions are alleviated. But if HIV is being transmitted through unsafe healthcare and other routes, all healthcare development must be SAFE healthcare, all HIV education must include information about non-sexual transmission, all employment 

and environments must exclude risks of bloodborne transmission of HIV, as much as possible.

So first we need to recognize that HIV is not solely transmitted through 'unsafe' sex and that it can be transmitted, perhaps far more easily, through unsafe healthcare, cosmetic procedures and traditional practices. ABC 'strategies' do not work because HIV transmission is not all about sex, not because Africans are too careless, promiscuous or ignorant (or even 'disempowered') to follow its patronizing advice. Safe sex has its place, but safe healthcare is a far more urgent issue in high HIV prevalence African countries right now. It's not condoms that are failing to protect people against HIV, but the intransigence of UNAIDS and the rest of the HIV industry.

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

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

According to Avert.com "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.

Depo Provera: English Guardian Aligns Itself With Neo-Eugenicist Policies

The English Guardian may face something of a dilemma when covering the WHO's failure to give clear advice to African women who have been persuaded to use Depo Provera and similar injectable hormonal contraceptives, which appear to be associated with a doubling of HIV transmission from females to males and from males to females; birth control is close to the heart of he who would control population, Bill Gates, whose Foundation sponsors the paper's Global Development section. Not that the article appears in the Gates sponsored section; perhaps there is no such dilemma.

But Sarah Boseley sticks pretty close to the WHO's press release and says that women who use injectables such as Depo Provera should also use condoms. As with the 'advice' from WHO, Boseley notes the use of 'dual protection' against pregnancy, on the one hand, and infection with sexually transmitted infections on the other. For Boseley and WHO, this means using condoms along with Depo Provera. But what neither seem willing to point out is that condoms on their own provide such dual protection.

So why would anyone want to use these expensive and possibly dangerous hormonal injections if condoms on their own give dual protection? Well, according to WHO and other 'experts' in reproductive health (often just a useful term for 'birth control'), condoms are not 'female controlled'; many people don't use condoms if they can help it. So rather than recommending that people who wish to avoid both pregnancy and sexually transmitted infections should use condoms, they recommend that people use Depo Provera, despite knowing that many people who opt for injectable hormonal contraceptives (and various other methods) cease to use condoms?

The oral versions of Depo Provera and similar contraceptives are said to be unsuitable because women need to take them daily and they may forget, or their husbands may object, etc. Injectable versions are said to be women controlled and only need to be taken every three months. In reality, they are to a large extent controlled by those who supply them, often NGOs and other institutions who believe strongly in the population control paradigm of development. Whatever synonyms are used, the concept of control is always detectable.

Boseley claims that women 'choose' Depo Provera and similar products but these pharmaceuticals are aggressively marketed by some of the biggest NGOs working in population control. Use of injectables has increased considerably over recent years but it's difficult to work out whether that's a matter of availability or genuine choice. Given the political and financial clout that NGOs and institutions such as the Gates Foundation have over the lives of people in developing countries, it seems unlikely that birth control is as high on the agenda of people in African countries as it is for the various non-African parties on the bandwaggon. One might even wonder if anyone gives a damn what Africans think about such matters.

It's astonishing just how uncritical Boseley is, in fact. She parrots bits about the WHO's 'expert group', but it was not concluded that hormonal contraception is safe ("Current evidence is not strong enough to prove or disprove an increased risk of HIV from hormonal contraception"). Rather, it has clearly been decided that it is safe enough for Africans and other poor people; it is not much used by white, middle-class Westerners. These products have not been shown to be safe, far from it. But the most important consideration for the WHO is that their goal of population control is not compromised by worries about safety issues, which they have been aware of for decades.

The logical conclusion to be drawn from the WHO's findings is that, if people want to avoid unplanned pregnancy and sexually transmitted infections, they should use condoms. The WHO statement is not based on a logical conclusion; it is a political declaration designed to protect the interests of Big Pharma, big NGOs and big private institutions with a population reduction agenda, and of course, the interests of the WHO itself. As for UNAIDS, they have taken a back seat; HIV prevention has never been their strong point.

Boseley finishes with a few non sequiturs and then supplies a version of the population control enthusiasts' mantra: "About 25% of the 128 million married or cohabiting women in sub-Saharan Africa aged 15 to 49 want but cannot obtain contraception." This self-serving statement doesn't tell us who was asked the questions, who was asking them, what questions were being asked and who chose those questions; a far higher percentage of women (and men and children) face numerous life-threatening issues on a day to day basis. It is likely that some of those issues would carry a higher priority, such as lack of clean water and sanitation, accessible and secure food supply, adequate living conditions, and many others.

When you know how you will get through the next few years, you can plan the next few decades. Family planning is not the panacea depicted by WHO when you are faced with low survival rates for your children and life expectancy for yourself. Population control in the form of birth control and family planning can be dressed up to look like an obvious choice for people in developing countries. But large scale population control exercises are not, neither in intention nor in practice, matters of choice for their putative beneficiaries. Population control is the prerogative of those who also control vital resources and the like, and who wish to limit access to these for people who are at the bottom of the heap.

Consider the role of eugenicist and neo-eugenicist doctrine in developing countries over a period of many decades; population has risen rapidly, regardless. Far from people being given choices over matters such as family planning, self-determination has been systematically denied. But Western maneuverings have failed to control population growth; they have only brought developing countries to their knees, creating new problems and exacerbating existing ones. When the rich and powerful talk piously about choice, it's always worth remembering that they consider their choice to be the only viable one.

WHO Refuses to Give Correct Information About Depo Provera

The WHO has issued a statement stating that the injectable and oral versions of hormonal contraceptives, such as Depo Provera, are safe for HIV positive people and those thought to be at risk of being infected with HIV. This is an odd statement to make when they have known for a long time that this form of birth control has been associated with double the risk of transmission from HIV positive women to HIV negative men and double the risk of transmission from HIV positive men to HIV negative women, where the woman is using hormonal contraceptives for birth control.

The HIV industry, and the population control obsessed development industry before them, have always placed controlling the reproductive behavior of people in developing countries above their reproductive rights and safety. Regarding Depo Provera and similar hormonal contraceptives, fatuous arguments about reducing 'unplanned' pregnancies, reducing reproductive health problems and HIV transmission have been used when the very method itself places those using it and their partners at increased risk of being infected with HIV and other sexually transmitted infections.

WHO did not make their decision on the basis of a "thorough review of evidence about links between hormonal contraceptive use and HIV acquisition"; they held their 'high-level' meeting in private and compelled all those attending to sign a confidentiality agreement, a gagging order. The thorough review would have taken, by their own admission elsewhere, several years to complete. Why the secrecy? Why the deceit? Who has an interest in putting the health and lives of millions of adults and children in Africa at risk? Is this a commercial decision, a political one, a combination or something far more sinister?

Reminiscent of the 'advice' given to African men who have been duped into being circumcised, ostensibly to reduce the probability of being infected with HIV (even though they may be far more likely to transmit the virus as a result), the WHO statement reminds people that Depo Provera and similar need to be used with condoms. However, we know condoms work; why not just use condoms, or perhaps condoms in conjunction with a method that is not harmful? If condoms don't work, why advise the use of a hormonal contraceptive that very likely increases transmission in both directions (or an operation that does little good and a lot of harm?)? We know that Depo Provera use is associated with reduce condom use, but condoms prevent conception and the transmission of sexually transmitted infections, such as HIV and many others.

What is the point of WHO now that they have shown that they do not represent the interests of ordinary women, particularly poor women; the vast majority of Depo Provera users are in sub-Saharan Africa? What about all the NGOs who have creamed off the billions of dollars of HIV money over the last thirty years to promulgate their eugenic policies? Because eugenic is what they are; if you're poor, have fewer children. People need advice, support and information, accurate, reliable information. Otherwise NGOs, WHO, UNAIDS (see UNAIDS' statement on Depo Provera) and the like are pursuing their own agenda, regardless of the interests of those they purport to serve.

Through the administrative fog generated by these grotesquely overfunded institutions, little is clear about Depo Provera except that the above institutions can not be trusted. If you want to advice, you'll have to carry out your own research, but start somewhere else; the very bodies tasked with informing people have failed, indeed, have refused to publicly discuss the information that is available to them. Judge their statements by that failure and refusal. There has never been a better time for African countries to distance themselves from those who see Africans as mere instruments in the agenda of money-making and empire building.

[There are links to some more reliable information on injectable contraception on the Don't Get Stuck With HIV website and blog. More will be made available in the coming days.]