Bjorn Lomborg and a Bunch of Economists to Eradicate HIV?

When environmentalist reactionaries like Bjorn Lomborg use words such as 'rethink', I become suspicious. For him, rethinking climate change was to sell consultancy to some of the biggest contributors to global warming. So when he uses the word in relation to the subject of HIV, please be aware that he is probably lying, but for good money, of course.

Firstly, Lomborg claims that "Alongside [various technical] advances, policymakers, human-rights advocates, and people living with HIV/AIDS have fought hard to reduce stigma and discrimination." This is not quite true. Some groups have fought to reduce stigma and discrimination. Others have fought hard to appear to fight them, while busily ensuring that both phenomena spread and grow faster than the virus itself.

Among those working hard to spread stigma and discrimination are UNAIDS, who never miss an opportunity to point to 'African' sexual behavior as the explanation for all the most serious HIV epidemics in the world. While ranting about how terrible stigma is, they deny the significance of any modes of transmission aside from heterosexual sex in African countries, though not in non-African countries.

Following in their footsteps are the media, who love an opportunity to write about sex, especially sex that they can paint as deviant or 'other'. Nudge, nudge, it's Africans, we all know about their sex lives, don't we. Religious and political leaders have never been far behind when it comes to sticking the knife in. Sadly, most African leaders have shown little enthusiasm for questioning the orthodoxy either.

Lomborg is also wrong about the "unprecedented amount of funds [being] invested in HIV treatment and prevention." Relatively small amounts of money have been invested in HIV prevention and most of that was frittered away on finger-wagging exercises about Africans' assumed sexual behavior. Treatment, on the other hand, is worth a lot of money. That's why a lot has been spent on it; but the bulk of that has gone into the pockets of Western multinationals, particularly pharmaceutical companies.

Lomborg's pronouncements on HIV are self-serving, much like his pronounements on the environment. And while he may be an expert on the environment, he is not an expert on HIV or any subject he happens to get paid for pontificating about. Yet his "Copenhagen Concensus Center" is going to get a lot of other like-minded academics and 'experts' to 'solve' some of the worst global problems that we currently face.

One of these global problems is HIV, which Lomborg is going to sort out by getting together five economists. Given how badly the global fight against HIV is going up to now, it probably wouldn't matter whether the experts were economists or basket weavers, but economists don't exactly have a great reputation for sorting out economic problems, let alone viral pandemics.

Lomborg's RethinkHIV could be better named because it's a lot more about regurgitating platitudes, recycling 'learned pronouncements' and, more to the point, trying to ensure that the billions that have poured into the pockets of wealthy institutions continues to increase. You'll notice that the only thing bold about the website is the typeface.

They have even partnered with a charitable body called the Rush Foundation, which funds 'disruptive ideas against HIV'. Even their buzzword sounds like something that died in the 1990s. But despite all the rhetoric about "stimulating urgent policy debate outside the existing frameworks and push[ing] thought leaders to think the unthinkable to address the pandemic", their only idea is to produce more drugs (just like Bill Gates and his foundation).

Here's a bit of a 'disruptive' idea for Lomborg and his friends: HIV transmission in African countries is not just about sexual behavior, so check out some of the other modes of transmission. If you really want to end HIV related stigma, try to think of Africans as humans, especially when it comes to sexual behavior. And don't listen to UNAIDS; they haven't a clue. Heterosexual sex does not fully explain the massive HIV epidemics found in some African countries; but non-sexual transmission might help to do so.

Rethinking HIV means challenging the orthodoxy, not compounding it with more of the same. So if there is any thinking to be done, some of the most vocal exponents of the orthodoxy need to be replaced by people who still know how to articulate disagreement with the mainstream, regardless of their discipline. Somehow, I don't think Lomborg or the cronies he selects will fall into this category, Nobel prizes notwithstanding.

Institutional Racism Rules at UNAIDS

The belief that generalized HIV epidemics, such as those found in some sub-Saharan African countries, originate from and are driven by extremely high levels of 'unsafe' sexual behavior has always been undermined by a number of considerations. (Generalized epidemics are those where a significant proportion of the general population is infected, rather than members of high risk groups, for example, men who have sex with men and intravenous drug users).

Sexual behavior is not that different in countries with high and low HIV prevalence; levels of 'unsafe' sex would need to be higher that is possible for human beings to explain prevalence that is substantially greater than 1% of the sexually active population; and there has been no recorded massive increase in 'unsafe' sexual behavior in countries that experienced the worst epidemics, followed by a massive decrease in the same behavior a few years later.

These are embarrassments to the HIV industry, which has been pushing this theory, sometimes called the behavioral paradigm, for more than twenty years. But there is a far better set of factors that have been little studied, though enough to see that they shed far more light on rapid transmission of a virus that is difficult to transmit sexually.

Amongst these factors is blood transfusion. When it was realized that transfusion of blood and use of blood products was one of the most significant modes of HIV transmission in the 1980s, many countries made requisite changes in their health services. But countries with low (and falling) health spending often didn't make these changes, or only did so partially.

In 2006, William H. Schneider and Ernest Drucker published a fascinating history of the use of blood transfusions in Africa and their possible contribution to the HIV pandemic, particularly in its early years. They estimate that "approximately 20 million transfusions [were] done in sub-Saharan Africa during the 1980s" and that "30 to 40 million transfusions occurred in sub-Saharan Africa in the period 1950–1990."

It is still the case today that HIV prevalence is far higher in urban than rural areas. Indeed, in some parts of rural Tanzania and Kenya, HIV is virtually unknown. In South Africa, Lesotho, Malawi and other countries, HIV has been shown to cluster, especially close to main roads and even health facilities. It's worth remembering that 70-80% of people in many African countries live in rural areas.

Transfusions, also, are mainly carried out in urban areas. According to Schneider and Drucker, they probably always have been. There is also some evidence that transfusions and donations were more likely in the military, police, government employees and among mine workers, groups that have suffered from especially high rates of HIV.

Even the finding that transfusions were more likely among wealthy colonials brings to mind the fact that HIV is said to have peaked and begun to decline among white South Africans before it hit the black population.

It was also in the early years of the pandemic that the role of other medical procedures was recognized, such as injections and other skin piercing activities. While this also led to changes in practices in wealthy countries, conditions in health facilities in developing countries haven't changed so quickly. And shortages in personnel, training, equipment and supplies can result in numerous lapses in infection control.

UNAIDS insist that unsafe health care only contributes to a maximum of about 2.5% of HIV transmissions in African countries and the rest is accounted for by heterosexual sex and mother to child transmission. But UNAIDS also warn UN employees that they can't guarantee the safety of health facilities in developing countries. If this is so, Africans are also entitled to know that their health facilities are not safe.

"Extra precautions should be taken, however, when on travel away from UNapproved 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."

There are two separate instances of institutional racism here: firstly, the assumption about African sexuality and levels of 'unsafe' behavior being enough to explain HIV prevalence levels hardly ever seen among non-African populations; and secondly, warning UN employees about the risks of unsafe healthcare and how to avoid them while telling Africans that they don't need to worry about non-sexual risks.

Schneider and Drucker's findings should have triggered an investigation into historical and current conditions surrounding blood transfusion and donation. Other skin piercing practices in health and cosmetic facilities need to be investigated. Those most at risk need to be warned of all HIV risks, non-sexual as well as sexual. And people need to be told how they can protect themselves. Only then will HIV transmission fall enough for the virus to eventually be eradicated.

[For more information on blood-borne transmission of HIV and how to avoid it, see the Don't Get Stuck With HIV website and blog.]

Homophobia in Uganda: the Tip of an Iceberg of Prejudice

According to one of the Wikileaks cables released recently, the wife of Uganda's president, Janet Museveni, was covertly behind the country's infamous Anti-Homosexuality bill. That's not very surprising, given her avowed views on other matters, avidly supported by Ugandan and foreign religious and political interests. (There's a commentary on the cable by a San Diego news site but the authors may have gone a bit beyond the evidence in their conclusions.)

The cable dates back to 2009 and the bill in question was not passed, but disinformation about sexuality, homosexuality and other matters is well entrenched in the minds of many, not just in Uganda or other African countries. Through the disinformation process the bill has often become associated with HIV/AIDS in the press and elsewhere, given the association between HIV transmission in Africa and sex in the popular imagination.

John Naganda, who opposed the bill and advised the president to do so too, said those behind it were obfuscating differences between homosexuality, rape, incest, and pedophilia. But it is worth putting the extreme prejudice against homosexuality and homosexuals in Uganda and Africa as a whole in perspective.

The homophobia here is just a subset of a wider anti-African prejudice that lies behind HIV discourse in general. The obfuscation extends to the sexual behavior of all Africans, especially those who are HIV positive, or even those thought to be at risk of infection. It is commonplace to state or imply that HIV transmission is high in some African countries 'because of their sexual behavior'.

As in any other continent and country, rape, incest and pedophilia are to be deplored. But they are deplored by Africans just as they are by non-Africans. The fact that they occur does not mean that all Africans, or even nationals of any particular African country, condone them. But, no more than there is a correlation between sexual behavior in general and HIV prevalence in African countries, nor will any correlation between rape, incest or pedophilia be found.

Because the HIV industry has (surprisingly) accepted that homosexuality is unlikely to be any more common in African countries than in non-African countries, it has become their constant refrain that 80% (or even 90%) of HIV is transmitted through heterosexual intercourse. The industry has never demonstrated how heterosexual intercourse could carry such a high risk of transmitting HIV in African countries compared to elsewhere, so they also have to invent levels and types of heterosexual behavior that might 'explain' some anomalies.

Uganda and other countries have long been happy to accept the 'bad person' theory of HIV transmission, the view that it is spread by 'evil things', whatever those things may be. As a result, fingers have been pointed at sex workers, long distance drivers, foreigners, migrant laborers, homosexuals and various other groups. Not only do the HIV industry and those informed about HIV (and 'African' sexuality) by them buy into the orthodoxy, but many Africans seem unwilling to oppose such an extreme manifestation of racism.

In Uganda and other high HIV prevalence African countries, men having sex with men account for a very small percentage of transmission. Intravenous drug users also are a small group and account for another small percentage; the two groups may even overlap considerably. But those most at risk are people who are, according to the orthodoxy, not really at very high risk at all, people in long term, heterosexual relationships.

According to the Ugandan Modes of Transmission Report, exactly 1% of HIV is transmitted by a combination of men who have sex with men, their female partners, intravenous drug users and the partners of intravenous drug users. Kenya's report, talking of obfuscation, lumps men who have sex with men along with prison populations (though not intravenous drug users) and comes up with 15%, so it's impossible to compare the two. But as in Uganda, most transmission is attributed to what amounts to low risk exposure.

The kind of stigma and prejudice that arises from the view that almost all HIV is transmitted through heterosexual sex in African countries seems to allow people, even encourage them, to hate, to discriminate, to persecute, to treat like animals, perhaps even to kill, rather than to investigate and understand why over 40% of people in some demographic groups are infected with a virus that should never have become a serious epidemic.

HIV Publicity Recipe: Just Add Sex and Stir Vigorously

The view that HIV is almost always transmitted through heterosexual sex in high and medium prevalence countries in Africa is disturbing because it is assumed to be a true and accurate starting point for most research. If research began without the assumption and then adopted it once it was shown to be useful and/or not inimical to shedding light on HIV transmission, that wouldn't be so bad. But surely, making unwarranted assumptions is something to be avoided by serious researchers?

Some researchers in Uganda analysed various HIV subtypes found in a group of women engaged in 'high-risk' sexual behavior to find patterns that might show how the women were infected. But the assumption was that the virus was transmitted sexually, hence the use of women considered to face high levels of sexual risk ("sex workers and bar workers").

However, many of those who face high levels of sexual risk can also face high levels of non-sexual risk. Many sex workers regularly attend sexually transmitted disease clinics for the treatment and prevention of STIs, to receive injectable hormonal contraceptives and undergo various kinds of testing that can be invasive. In countries where health services are not always well staffed, well equipped or well run, the possibility that instruments can be contaminated is always present.

In fact, the researchers found that 75% of participants had either subtype A or D, which doesn't suggest a huge amount of variation. If most people were being infected sexually by a virus that had been going around for several decades, one might expect a lot more variation. Perhaps this suggests that most people are being infected by a small number of different sources, which might more likely be a clinic or group of clinics?

Or perhaps not. But the research only showed that there was some clustering of subtypes around particular geographical areas. Showing that several people may have closely related viruses does not necessarily mean they all belong to the same sexual network. It could also mean they all attend the same STI clinic or the same hospital. But the most disturbing thing about the research, then, is that no attempt was made to identify any non-sexual risks that participants may have faced.

The researchers are effectively emasculating any possible value their research might have. All they have shown is that some people have HIV virus subtypes that may have come from the same source. This sheds no light on what that source was. The fact that all the participants engage in 'high risk' sexual behavior may be relevant, but we have no idea of how relevant.

Since early on in the HIV epidemic in African countries, the same groups have been rounded up for research that has similarly failed to examine the non sexual risks they may face. Fingers have been pointed at sex workers, long distance drivers, fishermen, people living in border towns, etc. But most, if not all of them, also face non sexual risks. HIV does tend to cluster round main roads and in densely populated areas. But it also tends to cluster around health facilities.

Another group of researchers have questioned the work carried out in Uganda for these reasons. They suggest that the work is not finished until all the risks the participants face have been assessed, not just the sexual risks. Others who may have been involved in transmitting or being infected with HIV need to be contacted and their virus subtype also needs to be identified. This will allow a proper infection network to be drawn up, not just a sexual network.

But what are the chances of people who seem obsessed with the sexual behavior of Africans carrying out research into the possibility that HIV is not always sexually transmitted? If you are faced with a massive epidemic that you assume was spread sexually, you will then make similarly unfounded and ridiculous assumptions about the sexual behavior of those infected. And if you are like these researchers in Uganda, you may forget to reflect on the sheer racism of attributing such absurd levels of sexual behavior to fellow human beings.