UNAIDS Suppresses Revolution in HIV Prevention

In 2002, a number of articles were published in the International Journal of STD and AIDS (IJSA) that questioned the contribution of sexual transmission to HIV epidemics in African countries. They raised the possibility that non-sexual transmission, especially unsafe medical injections, contributed a far higher percentage of HIV transmission than previously recognised.

Given the amount of evidence presented in these articles, one might expect HIV epidemiologists and infection control experts all around the world to sit up and take note, broaden their research interests or even rethink some of the current ideology.

But very little indeed happened. An improbable number of people put their names to a short article denying that non-sexual HIV transmission plays a significant part in African countries' HIV epidemics. The authors reasserted that sexual transmission 'continues to be by far the major mode of spread of HIV-1 in the region'. Worse still, they reassert the need to increase efforts to reduce sexual transmission of HIV.

Almost a decade has passed since these IJSA articles were published and quite a number of additional articles have appeared, also casting doubt on the 'behavioral paradigm', the view that HIV is almost always transmitted sexually in African countries. These have been almost entirely ignored.

If the view of UNAIDS and the HIV industry is that HIV is mostly transmitted sexually, per se, that it is primarily a sexually transmitted infection (STI) which may sometimes be transmitted non-sexually, that would be easier to deal with. They would be quite wrong and the evidence against their claim would be undeniable (which is not to say they wouldn't deny it).

But things are not that simple. UNAIDS and the HIV industry claim that HIV is mostly sexually transmitted in African countries. They accept that non-sexual transmission occurs in non-African countries, especially among intravenous drug users. Contaminated blood is one of the most efficient routes for HIV transmission, so it is obvious that HIV positive people sharing injecting equipment run a very high risk of transmitting the virus or being infected with it.

Yet again, though, while going with the argument that transmission occurs when drug users share injecting equipment, the HIV industry does not accept that HIV transmission through reuse of contaminated medical equipment occurs to any great extent in Africa.

The WHO (World Health Organization) admits that up to 10% of blood transfusions in developing countries may be contaminated, and therefore be responsible for transmitting HIV and other pathogens. The WHO also accepts that as many as 17% of injections may be unsafe and they even estimate that about 70% of injections in developing countries are unnecessary.

Now, I'm not saying that the HIV industry believe that unsafe medical practices don't occur. They are so worried about unsafe medical practices in developing countries that they warn their own employees and associates against using medical facilities unless they are UN approved.

This is why I accuse UNAIDS and the HIV industry of institutional racism: they believe that non-sexual HIV transmission occurs but they won't accept that it's a problem for Africans. This is an important distinction because they accept that medical practices are so unsafe in African countries that they won't allow their employees and associates to risk using them. But these same medical facilities, they claim, pose little or no risk to Africans; at least, not to the extent that they or anyone else should do anything about it.

No matter how you look at it, that is institutional racism. Evidence that should give rise to a revolution in HIV prevention programmes in African countries has been ignored. Instead of targeting risks, such as those that could be found in plenty in medical facilities, UNAIDS and the HIV industry have chosen to ignore anything that doesn't relate to sexual transmission of HIV, in Africa.

The majority of HIV positive people globally are from Africa and most of them live in Africa. Medical standards are so low in many African countries that a lot of people receive little or no health care, good or bad. Ironically, this may protect a lot of people from HIV and other viruses, such as hepatitis C virus. Certainly in Kenya, HIV is lowest where health care coverage is lowest and the virus tends to spread very slowly to places where people have little or no access to medical facilities.

The majority of HIV positive people in African countries are women. This is why I accuse UNAIDS and the HIV industry of institutional sexism. The view that HIV is almost always spread sexually (in African countries) is translated into the view that women spread HIV. The stigma that HIV inevitably brings with it derives from the behavioral paradigm. If most HIV is transmitted by unsafe sex, it follows that most HIV positive Africans have a lot of unsafe sex (there has to be a lot of unsafe sex because HIV is not easy to transmit sexually). If most HIV positive people are women (and the ratio of infected females to males is usually very high), HIV is mostly transmitted by women.

Of course, most women have sex with men and they are unlikely to transmit HIV to other women directly. And the many men these women do not transmit HIV to can not go on to transmit it to others. But questions about why so many more women are infected, why so few men in some areas are infected (if they are so sexually irresponsible, etc), why some infants and children are infected when their mother is not, any questions that make the behavioral paradigm seem less tenable, are either dismissed by the HIV industry or just not raised.

Instead of a revolution in HIV prevention, we now have reaction, a refusal to consider the role of non-sexual HIV transmission in African countries. We are left with a preponderance of 'prevention' programs that don't work, not because they are inherently ineffective (though they are) but because they bear little relation to how HIV is being transmitted. I accept that I don't know what proportion of HIV is transmitted non-sexually. But nor do UNAIDS or the rest of the HIV industry. I am asking that they deal with the evidence that has been presented to them, rather than sweeping it under the carpet.

In 2002, a new form of HIV denialism was institutionalized by UNAIDS. It was based on prejudices relating to race and gender. According to the institution and its followers, HIV is an STI; but only in African countries. HIV can also be transmitted by unsafe medical treatment; but only to non-Africans. The earlier denial of the connection between HIV and AIDS was bad enough, but the UNAIDS brand of denialism is internally contradictory. You can't even articulate it without being struck by the crudeness of its logic. However, if the rantings of the recent Vienna AIDS conference are anything to go by, this denialism is the state of the art.

UNAIDS: Mythmakers or Liars?

We have spent the last few days in Bukoba, talking to people about their memories and perceptions of HIV. Unfortunately, after decades of being told that HIV is primarily spread sexually, most people firmly believe that this is the case. They believe that HIV came from ‘somewhere else’ (Uganda, America, Europe, truck drivers, sex workers, men who have sex with men, etc), a widespread belief. In Bukoba, they believe (mostly) that it came from Uganda and this may be true. Alternatively, HIV may have spread from Tanzania to Uganda at the same time as it was spreading from Uganda to Tanzania. It seems likely that HIV spread in waves at various different times and its impact in a particular place depended on many of the conditions extant in that place at the time.

The problem with ignoring non-sexual transmission of HIV, through unsafe medical practices or through cosmetic or other practices where blood or bodily fluids may be involved, is that people end up not looking out for such risks. Even where they recognise their existence, they don't know how to protect themselves. For instance, people know that hairdressers should sterilize their equipment between clients but their neither the hairdressers nor the clients know what is required for equipment to be properly sterilized.

Contrary to widespread belief, HIV does not die after seconds or minutes of being separated from the host. It can live for hours or even days on instruments that dry out. And it can live for weeks if it remains wet. If a hair trimmer is used on a person with a disease that is transmissible through blood contact, it needs to be boiled. Just cleaning it in water is not enough, nor is wiping it with methylated spirits or bleach. Yet, people are convinced that this is enough. They even admit that they don't know one way or another what is done with the instruments. Manicurists just turn up with a bucket of instruments and do their work before going on to another client. They don't have the equipment necessary to sterilize their tools, nor do their clients seem to be aware that this is very dangerous.

One person we talked to said that she uses a hair relaxant that burns the skin and makes it liable to break. Hair relaxants are popular here, to produce straight hair. So combs and anything else used would need to be carefully sterilized, but the facilities for doing this are often not available. As a hairdresser, she was unaware that it is not just blood that can transmit infection. Pus is even more dangerous. She was under the impression that if people had sores on their head, this was not risky unless there was also blood. Decades of warnings about the risk of HIV infection have concentrated almost exclusively on sexual behaviour and sexual risk. So people are not adequately prepared for non-sexual risks.

Similarly, risks from unsafe medical procedures could be much more of a threat than sexual risks. People's perception of medical risks is that they will be taken care of by health professionals. This may be true in some cases, but not all medical procedures are carried out by health professionals or in ideal conditions. You can get injections, and possibly other services, from people who run 'pharmacies', often just stalls that have a few medicines. Needles may well be changed between patients. One certainly hopes so. But are syringes always changed? Many people say they don't know and they don't feel they are in a position to question doctors and other health professionals. And many injectible products are sold in multi-dose vials. But it has long been known that vials can become contaminated. This can easily lead to HIV and other diseases being transmitted to many people.

People may face threats that they don't even realise are there. And they may face threats that they have never been told how to deal with. There are ways to take precautions against non-sexual transmission of HIV (and other blood borne diseases) but HIV education campaigns concentrate almost exclusively on sexual risk. Although some people can trot out a list of other HIV threats, including shared razors, toothbrushes, cosmetic equipment and medical equipment, these are considered to be relatively unimportant compared to the risk of sexually transmitted HIV.

UNAIDS publishes a list of recent HIV related publications, along with the abstracts and some editorial comments. This list very rarely includes papers that discuss non-sexual HIV transmission, concentrating instead on the many articles that look at sexual risk or what is perceived as sexual risk. So, for example, there's an article about sex work and the 2010 World Cup in South Africa. There are warnings about the risk of becoming infected with HIV and other sexually transmitted infections, but none about the risk people may face if they have to go to a medical facility for treatment or if they visit a tattoo parlour or if they get their hair cut. And South Africa is a country with very high HIV prevalence.

Another article that UNAIDS highlights is about sexual behaviour trends in France from 1970 to 2006. Sexual behaviour became more 'risky', especially for women, during the period. The same trends in a high HIV prevalence country would have been blamed for high levels of HIV transmission. But because this is a low HIV prevalence country and European, no such pronouncements are made. Non-penetrative sex also appeared to become more often practiced, which, of course, is less of a risk when it comes to HIV or sexually transmitted infection risk. But in some African countries, sexual risk behaviours are low but HIV prevalence is high.

When the survey takes place in a country like France, people's responses tend to be believed. Similar surveys in African countries can elicit similar results, but the responses tend not to be believed if they don't correspond with the data collected on HIV. When, as is often the case, people in African countries say they have not had sex, they have not had risky sex or that they took precautions against risk, and they turn out to be HIV positive, it is assumed that they are lying, mistaken or forgetful. Yet, many of them are likely to be telling the truth but they were infected by some non-sexual route, medical, cosmetic or the like.

Similarly, women have often been infected with HIV while they are pregnant. They are tested early on in their pregnancy and initially found to be negative. But they are subsequently found to be positive when they are retested later. The earliest period of HIV infection is the most virulent. If a woman becomes infected while she is pregnant, the chances of HIV being transmitted to the infant is far higher than if she seroconverted some time before becoming pregnant. The conclusion of this paper is that couple counselling may reduce unprotected sex during pregnancy. But have the authors considered the possibility that some of the women were infected non-sexually? Did they even test the husbands to see if they were also HIV positive? Of course, if the husbands were HIV negative, the belief that HIV is usually transmitted sexually leads to the conclusion that the woman must have had sex with someone other than her husband. This is one of the reasons HIV has become so stigmatized. Husbands often accept the received view about HIV being mainly sexually transmitted. They believe the ‘experts’, not their wives.

There are many hints that a good deal of HIV is not sexually transmitted in African countries. So it's surprising that UNAIDS, WHO and others still hold on to the view that non-sexual transmission accounts for a very small proportion of all incidence. In most African countries, various prevention programmes have been run, some for many years. But these programmes are almost all aimed at influencing sexual behaviour. Very few are aimed at medical transmission and even fewer at cosmetic transmission. And these programmes have been quite unsuccessful. A number of papers have asked questions about which prevention interventions work and, on finding that none of them make much difference to HIV transmission, they keep looking for new ways of preventing sexual transmission. They don't seem to consider the possibility that at least some transmission is not sexual, though they admit that conditions in medical facilities are too dangerous to allow UN employees to risk using them! These papers are right to conclude that gender, poverty and alcohol consumption are important when it comes to sexual transmission of HIV but they are probably not so relevant when it comes to non-sexual transmission. Or, at least, they would be relevant for quite different reasons.

Similarly, a lot of research has shown that behavioural differences don't explain variations in HIV prevalence among young people in African countries. High levels of sexual risk behaviour can be found in places with low HIV prevalence and low levels of sexual risk behaviour can be found in places with high HIV prevalence.

How much evidence does it take for the 'experts' at UNAIDS to conclude that their long held view is wrong, that most HIV is not transmitted by heterosexual sex? How much evidence do they need to find it worth their effort to investigate places where many young children are found to be HIV positive when their mothers are not? If UNAIDS recognises the dangers of allowing its own employees to use medical facilities in African countries, when will they admit that Africans living in those countries also face risks?


It’s very disturbing to hear people saying that they think HIV was created in a laboratory in America and spread deliberately, for whatever reason this might have been done. But it’s hard to shake people’s beliefs in conspiracies when they are constantly being told things that don’t make sense. Many people here know that Africans are not so different from people in other countries that their sexual habits could be almost wholly responsible for the very high rates of HIV transmission you see in some countries. But those who feel they know most about the disease assure them that this is, indeed, the case.

Those who feel they are HIV experts continue to assert the racist view that some Africans have so much more risky sex than people in other countries, it’s no wonder that HIV prevalence is very high in some places. Africans are being lied to, just not in the ways they think. The people who are tasked with eradicating HIV know that the risk of non-sexual transmission of HIV is so high that they need to protect their own employees. They just don’t tell Africans that. As a result, Africans continue to take risks that they could and should avoid. When people know about the risks they face and they know how to take steps to avoid them, HIV transmission rates will go down. But as long as the sexual behaviour paradigm clouds all HIV prevention activities, several more people will be infected with HIV for every one who receives treatment.

UNAIDS To Reconsider Evidence on Non-Sexual HIV Transmission: Only Joking!

My post was getting a bit long yesterday but it is also important to remember other blood related risks that may transmit HIV, hepatitis B and C and other blood borne diseases. For example, sharing a razor or perhaps certain cosmetic instruments, tattooing equipment and body piercing equipment that haven't been sterilized, can all be risky. Yet, UNAIDS don't mention any of these possibilities in their 2009 Aids Epidemic Update.

It seems extraordinary that, given the efficiency of transmission of blood contaminated instruments and the relative inefficiency of sexual transmission, UNAIDS should be happy to dismiss medical transmission as very small and to fail completely to mention cosmetic or other modes of transmission. Have they even checked, and can we see the data collected? We just don't know how much these phenomena could have contributed to HIV epidemics in countries with very high prevalence.

In Kenya and Tanzania, haircutting and other cosmetic processes don't just take place in hairdressers and salons. Women go to each other's homes for such things and you even see people doing their grooming in public. In Dar es Salaam, several times, I saw men shaving the head of another man with a hand held, two sided razor. They would then swap over and both would end up with a lot of cuts on their heads. It's impossible to estimate how much this could contribute unless it is properly investigated.

Yet UNAIDS can happily report the various modes of transmission and say that sexual transmission can even account for 94% of all transmission in Swaziland. That means that the extremely risky (male to male and male to female) anal sex that must take place accounts for only a few percent, at the most. Hospitals and clinics in Swaziland must be so well run that they also account for a few percent. Barbershops, tattoo parlours and hairdressers hardly ever contaminate anyone, perhaps never. And this is in a country with over 25% HIV prevalence! Come on, UNAIDS, this is just not credible.

But UNAIDS and many others just keep to the behavioural paradigm which says that in African countries, HIV is mostly transmitted by sexual intercourse whereas in non-African countries it is mainly transmitted by intravenous drug use, men having sex with men, commercial sex work and a few other things. This behavioural paradigm is one of the main sources of stigma and, despite deploring stigma, UNAIDS will not admit that the paradigm is based on a lot of guesswork and a lot of effort to ignore anything that may contradict them.

What UNAIDS need to do is admit that they are wrong, that research does not show that HIV is mostly transmitted by heterosexual sex in African countries. On the contrary, there is plenty of evidence that most people in African countries do not indulge in the levels of unsafe sex, or any kind of sex, that would be required for the behavioural paradigm to be credible. In addition, there is plenty of evidence that medical and cosmetic procedures often take place in unsterile conditions. It is simply not possible for non-sexual modes to account for as small a percentage of HIV transmission as they would have us believe.

HIV Stigma and Institutional Racism

The received view about HIV these days is that unless you are a gay man, a sex worker or an injecting drug user, you are unlikely to be infected. At least, that’s the received view in rich countries. In fact, in their 2009 Aids Epidemic Update, UNAIDS don’t even mention sex workers for North America and Western and Central Europe. They say “[i]n North America and in Western and Central Europe, national epidemics are concentrated among key populations at higher risk, especially men who have sex with men, injecting drug users and immigrants”. Despite this though, heterosexual sex appears to account for about 30% of transmission.

But in poorer countries, especially in Africa, the received view is somewhat different. Here, it is claimed that the most common way of spreading HIV is through heterosexual (vaginal) sex. UNAIDS say “[h]eterosexual intercourse remains the primary mode of HIV transmission in sub-Saharan Africa, with extensive ongoing transmission to newborns and breastfed babies.” They even claim that 94% of transmission is by heterosexual sex in Swaziland.

But the report goes on to suggest, effectively, that low risk sex is high risk sex in Lesotho and Kenya because it accounts for most transmission. “In Lesotho, between 35% and 62% of incident HIV infections in 2008 occurred among people who had a single sexual partner. Heterosexual sex within a union or regular partnership accounted for an estimated 44% of incident HIV infections in Kenya in 2006, while casual heterosexual sex accounted for an additional 20% of new infections”. However, if low risk sex is high risk, this just begs the question of how sexual behaviour could account for so much transmission in some countries but not others. Most people in every country have low risk sex but most countries don't have high HIV prevalence. UNAIDS accept that gay men and drug users are also at high risk, but that they contribute far less to the epidemic.

According to this received view, sex workers in African countries would be particularly at risk, along with their clients and their clients’ other sexual partners. So it’s easy to see how stigma creeps in. If you become infected with HIV, you are probably a prostitute, someone who frequents prostitutes or, even worse, a gay man or an injecting drug user. Because of the stigma attaching to HIV, people are often less quick to see that there are many who could have been infected unwittingly. And the issue of infants being infected by their mother can also be an inconvenience when painting a picture of rampant illicit sex and drug taking.

A former UNAIDS employee, Elizabeth Pisani, says “HIV is mostly about people doing stupid things in the pursuit of pleasure or money”. She also says “In Africa, people are contracting the virus through heterosexual, non-commercial sex”. Pisani is someone who certainly knows how to reinforce stigmatizing views. I’m surprised she ever left UNAIDS.

Of course, heterosexual sex would account for a substantial proportion of HIV transmission. But how substantial is anyone’s guess. Because, holders of the received view claim that HIV infection through accidental blood exposure in poor countries is low or negligible. Back to UNAIDS again: “A small percentage of prevalent HIV infections in sub-Saharan Africa is estimated to stem from unsafe injections in medical settings.” Also: “In an analysis of data from Kenya, medical injections were estimated to be the source of 0.6% of all HIV infections”. Though strangely enough, they admit that medical transmission is far more significant in Uganda.

They even find that in Eastern Europe and Central Asia “[i]n addition to new infections associated with injecting drug use and unprotected sex, key informants and scattered media reports suggest that a notable number of new infections may be occurring as a result of unsafe injections in health-care settings.” However, what they mean by ‘key informants’ etc., actually refers to a whole body of evidence about unsafe injections that UNAIDS are unwilling to countenance, so they ignore it.

In hospitals and clinics in developing countries, instruments that are contaminated with blood and various blood-borne diseases may be reused or inadequately sterilized. Health services are underfunded, understaffed and short of resources. There is no lack of evidence that they are risky places. So how can UNAIDS come up with these figures for medical transmission of HIV? Well, by being selective about what evidence they cite and by ignoring anything they don’t like the look of. High rates of medical transmission, and consequently, lower rates of sexual transmission, doesn’t fit with the view that, in Africa, people have a lot of unsafe sex. And institutions, politicians, churches and funders are interested in supporting sexual behaviour change programmes.

These same people are probably not interested in accepting that some of the problem may arise from unhygienic practices in the very health facilities where they are urging people to go for testing and treatment. The mainstream doesn’t want to see itself as being a significant part of the problem. So UN and WHO personnel, diplomats and other high ranking officers are issued with their own needles and syringes when they are visiting African countries. They are also given instructions to avoid treatment if at all possible.

But Africans themselves are supposed to visit whatever health facility is available to them without even a warning about the risks they face or the precautions they can take. And if they are infected with HIV, they will probably unknowingly go on to infect others.

It seems to me that racist attitudes allow members of institutions such as UNAIDS to assume that Africans have lots of unsafe sex, but that most non-Africans don’t. And racist attitudes allow these institutions to recommend that their employees avoid medical facilities in developing countries, without doing the same for people who have to live in those countries.

In Western countries, people travelling to African countries are likely to be made aware of some of the potential risks of visiting medical facilities there. They can buy information about medical safety and even kits containing syringes, needles and the like, so they can reduce the risks they face further. If it is so important for Westerners visiting African countries to take care when visiting medical facilities, or even to avoid visiting them altogether, why is it not equally important to protect Africans from being infected in these facilities?

Aids Denialism Doesn't Make the Disease Go Away

There are many controversies surrounding HIV, development in general and various other things. So, writing a blog about these can attract some controversial remarks, in theory. In practice, I have received some comments but few that are controversial. When remarks have little or nothing to do with what I have posted, I delete them. If the post is clearly just an attempt to attract attention to some site, product, issue, service or person, I am also likely to delete them.

But a comment I received today, anonymous of course, purported to be about my most recent posting, which discusses levels of HIV transmission from unsafe medical practices. 'Anonymous' may have thought that in questioning certain aspects of HIV funding and the like, I am aligning myself with certain Aids sceptics, who deny that HIV causes Aids, or whatever. Whether this anonymous contributor represents AliveandWell.org or not is irrelevant; I do not agree with what the site stands for and I would not wish to have anything to do with a group of people whose only aim seems to be to further muddy these already turbid waters.

My approach to HIV in Kenya has been that of a general scientist. My interest is in the overall conditions in Kenya and how they changed as HIV arrived, spread and continues to spread. Therefore, I look at history, economics, social practices, lifestyles and many other things, in addition to medical and social science aspects of the virus. I do not have the scientific expertise to address all the details of the AliveandWell site. There are plenty of people who can do that, if they deem the content of the site worth the effort.

As for the idea that HIV and Aids were 'invented' by some wealthy people so they could make money (or even take over the world), I have never heard anything that could make such a hypothesis the least bit plausible. No doubt the AliveandWell site is teeming with such evidence, but I think I have more worthwhile things to spend my time on.

Some of the numerous 'experts' cited on the site may well have a great deal of expertise, I really can't say. Certainly, some of them seem to have lots of letters after their name. But people can make up qualifications, or pay for them. And plenty of well qualified people come out with utter rubbish that can be used by whoever wishes to shore up some rant that they like to call 'theory' or 'hypothesis'.

The anonymous poster says AliveandWell advocates 'scepticism' around HIV but the site is the work of a group of Aids denialists who encourage the use of 'alternative therapies' for HIV positive people. HIV positive people would be well advised to consider the fate of the woman who started the site, Christine Maggiore, who died of Aids, along with her infant daughter. Maggiore refused antiretroviral treatment for herself and for her daughter.

To adopt the stance that Maggiore and her followers recommend is not scepticism, it is idiocy. Some adults may wish to adopt such a stance, which is regrettable. But there is no justification for imposing such idiocy on people who are unable to defend themselves. There is enough disinformation about HIV/Aids in developing countries already without this sort of deception being peddled and I hope people who visit AliveandWell see the site for what it is.

Those are my thoughts on your wonderings, Anonymous.