Why Lying About HIV Transmission in Africa is a Form of Extremism

The simple answer: because it is dehumanizing. It dehumanizes Africans to say that HIV is endemic in some countries 'because of the people's sexual behavior'. And dehumanizing people is an advanced step in many kinds of excess, such as discrimination, persecution, racial, sexual and gender based hatred, impoverishment, violence, terrorism, and many others.

As a result of the dehumanization of Africans over the thirty years of recognized HIV transmission, many extremist suggestions have been made about 'containing' the epidemic: mass forced sterilization, castration and isolation, to name a few. Some suggestions have been put into practice: mass testing, 'pledges' to avoid sex, 'payments' to avoid sex, use of Africans as research guinea-pigs, unethical research on humans, mass forced treatment, stigmatization of sufferers and mass circumcision.

As a result of the dehumanization of Africans, there is talk of putting even more people on drugs, whether they are HIV positive or not, even whether they choose to accept treatment or not. These strategies include pre-exposure prophylaxis (PrEP, for more of which, see my other blog), treatment as prevention, microbicides and even vaccines, if such vaccines are ever developed.

African people are not treated like non-Africans: if someone here is diagnosed as being HIV positive, they are told they were infected by 'unsafe' sex. This is not generally how people diagnosed with HIV in non-African countries are treated. Especially if the patient denies having any kind of 'unsafe' sex.

When infants are found to be HIV positive in non-African countries, the mother is tested. It is not assumed that the mother is positive. If the mother is found to be negative, the issue of how the infant was infected is investigated in non-African countries. In African countries, it is implied, even stated, that infant rape can not be ruled out.

When you diagnose a disease in animals, you put them on treatment. You observe their behavior and make conclusions about what steps need to be taken to ensure that such behavior does not continue. But you don't need to take this approach when you are dealing with humans. So why is that they way Africans are treated by the HIV industry, WHO, UNAIDS and various 'academic' institutions?

We have gone a long way down the road of dehumanizing Africans when a mainstream media outlet can publish a story about Swazis 'eating cow dung' because they are starving and need food to take along with their antiretroviral drugs. We have gone a long way down the road when hundreds and thousands of others link to and spread that story throughout the World Wide Web, much like a virus, you could say.

I thought carefully about mentioning Nazis in relation to the story about Swazis. But Nazis really did attribute such things as eating feces to Jews, it was just one instance of the many stigmatizing things they would attribute to those they hated. Hitler really did believe that propaganda need not consist of true things about its target, that a mixture was quite sufficient.

If we are not yet aware that while HIV CAN be transmitted sexually, it CAN ALSO be transmitted non-sexually, we have been deceived by those who purport to be educating us about the virus. We should know that HIV is difficult to transmit through heterosexual sex among healthy people, but that it is much more easily transmitted through anal sex, through intravenous drug use and even through heterosexual sex among people who are suffering from serious health problems, including certain sexually transmitted infections.

Those living in non-African countries should be aware that most of the people who have HIV in their countries were not infected through heterosexual intercourse. This is a reflection of the sort of virus HIV is. It doesn't mean that HIV infects 'bad' people, despite the tone of much media content on the subject.

But if HIV is almost always spread through means other than heterosexual intercourse in non-African countries, why would 80% (or even 90%) of HIV be spread through heterosexual intercourse in African countries, as claimed by the HIV orthodoxy? The fact that a HIV positive person has had sex, even 'unsafe' sex, does not mean they were infected sexually.

We know, we have known since the 1980s, that HIV can be spread through unsafe healthcare such as blood transfusions and unsterilized equipment, especially  injecting equipment. And we have known there are other risks, such as cosmetic treatment with unsterilized equipment, tattooing, especially in prisons, traditional medical and other skin piercing practices, home deliveries, etc.

In addition, we know that healthcare facility conditions are appalling in many developing countries, especially high HIV prevalence African countries. Even UNAIDS advises UN employees to avoid health facilities in Africa. We know that many blood transfusions are administered without adequate precautions taken to avoid infecting the patient with HIV, hepatitis and other diseases, that skin piercing equipment is frequently reused without sterilization.

As long as we continue to point the finger at HIV positive Africans, implying, or even stating that they were infected sexually, we are allowing the virus to be spread. As long as we continue to pretend that we know how people are becoming infected with a virus that should never have reached endemic levels, we are allowing people to become infected. We have not yet investigated non-sexual risks in African countries. Why do UNAIDS studiously avoid doing this?

We dehumanize Africans by assuming things about their sexual behavior when no adequate investigations have been made about other, non-sexual HIV risks and this is just a part of an extreme racist phenomenon of allowing an epidemic that should never have occurred to continue to infect people, kill people and destroy their families and communities. The orthodox account of how HIV is transmitted in African countries is inherently racist. It is also a lie, the propagation of which has profound consequences.

Three Cheers For HIV Treatment, Only One For Prevention

The news that treating HIV early can significantly reduce transmission in discordant couples, where only one partner is positive, is very good indeed. It should provide some impetus for increasing considerably the number of people receiving treatment, and at an earlier stage of disease progression. This should give a high level of protection to people with HIV positive partners, if the 96% protection in the trial is anything to go by.

It remains to be seen whether funding for the number of people currently on treatment will be doubled, especially as the costs of treatment go way beyond the costs of antiretroviral drugs, which have attracted much of the funding so far. And many donors are reluctant to even keep funding at its current levels.

But the same research shows that treating HIV is not enough to prevent transmission to the extent that it can be completely eradicated in the forseeable future. Among the 39 new HIV infections in the study, only about 70% were clearly transmitted by the HIV positive partner. The others were either transmitted by a different partner, or perhaps were transmitted non-sexually.

In addition, in some countries, a very high percentage of new HIV infections occur in stable relationships. But many of these infections occur where neither partner was previously infected. This is what gives rise to concurrency in the first place. But it is not always clear how or why some people are infected when their partner is not.

Of course, some instances may be simply a matter of one partner either having a sexual relationship with someone who is not their partner or being infected in some other way. But other instances are not so easily explained away. In some countries, about half of these occurrences involve women being infected, but not by their partner, the other half men.

Anyone can speculate about the sexual behavior of people who become infected, but many years of studies in many countries involving tens of thousands of people show that HIV transmission is not very closely correlated with sexual behavior that is considered to carry a high risk of HIV infection.

Often, those who use condoms the most, have the fewest sexual partners (sometimes none at all), have the fewest 'risky' sexual experiences and know all they need to know about 'safe' sex appear to be the most likely to be HIV positive. While certain people are being infected sexually, it is by no means clear that this is the main route of infection in other groups.

So HIV treatment is vital for HIV positive people and it may also prevent infection in some scenarios. But it is by no means enough to ensure that HIV transmission levels are lowered to a position where HIV will become a thing of the past. The very fact that so many people are still being infected years after antiretrovirals have been available to millions of people shows that prevention needs to include more than just treating greater numbers of people and treating them earlier.

And not really knowing how most people became infected in the first place is a big gap in our understanding. There is quite an absurdity in thinking that we can make a serious dent in the worst HIV epidemics when we don't really know why so many people are becoming infected, apparently sexually, with a virus that is relatively difficult to transmit sexually.

The news is good for HIV negative people in discordant relationships, but not for HIV negative people who are not in discordant relationships. And while HIV positive people need treatment, many might still question how they became infected in the first place when their partner is not infected. Prevention has received very little attention so far, so let's not allow the scaling up of treatment to deflect attention even further.

Africans Don't Mistrust Science, Just Bigotry Masquerading As Science

The English Guardian has an article entitled 'Epidemics breed public disorder and the breakdown of trust', indeed, 'violent mistrust' of scientists and politicians. The article mentions both the HIV pandemic and Haiti's current cholera epidemic. Cholera is expected to affect up to 800,000 people in Haiti by the end of the year and to cause 11,000 deaths.

A striking similarity between both cholera and HIV is that they spread in countries which were, and continue to be, especially vulnerable. Haiti was already vulnerable before the recent earthquake and hurricane, but things became far more acute afterwards. And the countries with the worst HIV epidemics were vulnerable when the disease began to spread rapidly, for example, most sub-Saharan African countries, or became vulnerable some time later.

The spread of HIV in Eastern European countries is likely to have been facilitated by the breakdown of healthcare services that were available to all during the Soviet era. And in some African countries, the spread of HIV is thought to have been contained in countries that were at war, but that it spread rapidly once peace returned. This phenomenon has not been researched thoroughly but the fact that most health facilities closed during times of severe unrest may have been a factor.

Whether UN personnel from Nepal introduced cholera to Haiti may still be an open question. But the fact that it has infected, and continues to infect, so many makes it clear that people do not have access to adequate supplies of clean water and to effective sanitation facilities. It's the failure to provide people with these vital services that results in high morbidity and mortality, not the mere presence or absence of some pathogen.

Richard Evans' article is as tame as you would expect an article about public health to be in a newspaper whose development section is funded by the Gates Foundation. The foundation is keen on fighting diseases like cholera (and HIV) with vaccines, rather than on addressing the conditions that allow diseases to reach epidemic levels in the first place.

South Africa's ANC may have been wrong in their belief that HIV does not cause AIDS, but not completely wrong about it being part of a white supremacist plot. The Truth and Reconciliation Committee did reveal that the disease was sometimes spread deliberately by HIV positive people, paid to have unprotected sex with HIV negative people. And the public was right to be suspicious of AZT, considering early attempts at using it to treat AIDS killed most patients because the dose was far too high.

Thabo Mbeki may have been wide of the mark in denying the connection between HIV and AIDS but he was not wrong to object to Western stereotypes about African sexuality. These stereotypes are, in fact, the state of the art when it comes to HIV theory. HIV 'prevention' policy still relies entirely on the 'behavioral paradigm', the view that HIV is almost always transmitted sexually in African countries.

Evans' analysis is superficial: you don't need to be a scientist to spot racism. The behavioral paradigm requires the view that Africans (and not non-Africans) have inordinate amounts of sex, with lots of people, and they care little for their own health and welfare or that of their partners or families. Even this history professor should be able to spot that this is not science, it can not be supported by evidence, and all the existing evidence to the contrary has yet to shift adherence to the paradigm.

Thabo Mbeki was not the leader in other African countries where HIV prevalence was higher than that in South Africa, nor in other countries where millions of people are infected. What Mbeki did was wrong, but that doesn't make it right to base public health policy on a crude prejudice, whether that prejudice is against Africans, women, men who have sex with men, injection drug users or any other group.

Evans may have a point about one thing: "Governments and politicians are frequently driven to choose the science that best serves their interest, or their ideological standpoint". But let's not blame science for the fact that the top people in the HIV industry, fronted by UNAIDS, believe something for which there is no evidence for and a lot of evidence against.

Current levels of HIV transmission are not related to bad science, misuse of science or ignorance about science. They are caused by the use of prejudice in the place of science. And it may be wrong to conclude that this is done so that some very rich pharmaceutical companies will get a lot richer. But they definitely will get a lot richer. The problem is not a little bit of dishonesty here and there getting blown out of proportion. The problem is that science developed purely for use by the rich and powerful will ignore or deny anything that is inimical to the interests of the rich and powerful.

Unless You Accept The Stereotype About African Sexuality, HIV Theory Doesn't Make Sense

Ghana has taken steps to reduce hospital acquired infections by publishing guidelines to avoid a phenomenon that affects hundreds of millions of people every year, globally. Airborne diseases are mentioned in the article, blood borne infections are not. But it is refreshing to hear it admitted that hospital acquired or nosocomial infections even occur in African countries.

While everyone accepts that such infections occur, UNAIDS and other institutions deny that HIV is very likely to be spread this way. It would be odd if that were the case, particularly in high prevalence countries, where health facility conditions are appalling. But any public mention of hospital acquired infections is better than the constant denial that HIV could be transmitted this way when it clearly can.

At 1.9%, Ghana has much lower prevalence than East African countries, where it is three or four times that level, or Southern African countries, where it can be 10 to 15 times higher. But even low prevalence countries can experience rapid increases in HIV transmission if it gets into health facilities and is not identified quickly and eradicated.

HIV theory has never adequately explained how generalized epidemics can occur. These are epidemics where the virus is transmitted widely among the population and not just in specifically high risk groups, such as intravenous drug users and men who have sex with men.

People who are not in these groups are at low risk of being infected because heterosexual sex is a very inefficient mode of HIV transmission. But there are several countries in Africa which have a generalized epidemic; in fact, the majority of people infected face only a very low risk of being infected, yet they are infected in huge numbers.

The standard reflex (it can't really be called an argument) from UNAIDS and the rest of the HIV industry is that Africans have superhuman levels of sex with many lifetime partners, many of whom overlap with each other. In addition, Africans care little about their own health and welfare, or the health and welfare of their partners and family members.

Billions of dollars spent on wagging fingers at Africans about how much sex they should have, with whom, what kinds of sex, etc, has had little influence on sexual behavior, although there are wild claims of success. But even where levels of sexual behavior have been assessed, this has never explained the generalized nature of the highest prevalence epidemics, all of which are found in African countries.

However, this hasn't dented the confidence of UNAIDS and others in the industry in the merits of continuing to insist that Africans have eye-watering levels of sex. After all, there are some very expensive pharmaceutical products available now and the many rich countries seem willing to spend billions, perhaps even trillions, on doling out these drugs, regardless of how much or little influence this has on HIV transmission.

Giving drugs to people who are HIV positive doesn't offer pharmaceutical companies the sort of profits they want. Only a few million more people every year are put on treatment using current guidelines. And even though those guidelines have been changed to help the pharmaceutical industry out, the few tens of millions of people who are HIV positive or who will be infected in the next 20 or 30 years is just not enough to satisfy the industry.

Luckily, the HIV industry's prejudice about Africans is almost universally believed. People don't bat an eyelid when they are told that each HIV positive person infects 7 people over the roughly ten years between becoming infected and dying (or going on antiretroviral drugs).

If the probability of a HIV positive man infecting a HIV negative woman is estimated at about 1/500 and that for a HIV positive woman infecting a HIV negative man is 1/1000, all HIV positive people would need to have sex at least every single day, perhaps twice a day, with a lot of people, for up to 10 years.

We know that most people don't have sex that much, nor do most people have that many partners (though some do, not just in Africa) but we have been conditioned to accept figures like how many people each HIV positive person must infect to explain high prevalence figures. And the prejudices about Africans are rarely questioned.

And that's just great for the pharmaceutical industry. Because it has been suggested that if everyone in high prevalence countries is tested at least once a year and put on antiretrovirals immediately, this will cut transmission to the extent that the virus will be almost eradicated in a few decades. This strategy is called 'test and treat' or 'treatment as (or 'is') prevention'.

Even better, some other genius has come up with a strategy called pre-exposure prophylaxis (PrEP), whereby HIV negative people said to be at high risk of infection (from low risk sexual behavior) are put on antiretrovirals, which is said to reduce the chances of their being infected. And perhaps this works, to an extent. The worry is about putting people on these drugs when their risk of infection is very low.

But the market for drugs could now run into hundreds of millions, perhaps many hundreds of millions of people.

So before trying to maximize profits for these pharmaceuticals, it would be worthwhile identifying the exact contribution of all known types of both sexual and non-sexual transmission before putting hundreds of millions of people on drugs. It is not true that each HIV person infects seven more, not sexually, anyhow. If you believe that, you should think about why you do, and whether it could really be true.

High HIV Risk, Low Prevalence, Is Pakistan a Miracle?

According to a situation analysis of HIV in Pakistan, the country is "at high risk of HIV infection" but that presently prevalence is very low. In fact, prevalence is under .1%, which is significantly lower than in the US (estimated at .6%). Only a few thousands of HIV positive people have actually been identified.

Pakistan's epidemic is considered to be 'concentrated', that is, the majority of infections are among members of high risk groups, such as intravenous drug users and men who have sex with men. It has been suggested that the epidemic is 'in transition', but prevalence might just as easily be lower than the estimates would suggest.

There are references to "indiscriminate transfusion of unscreened blood" and "unsafe injecting practices in formal and informal healthcare settings". If these are true, then HIV can not be truly said to have penetrated the country's health services. Those types of transmission would spread the virus very quickly.

Despite the lack of conclusive evidence, it is also estimated that over 50% of HIV transmissions are through heterosexual sex. This could be compared to the 80% (sometimes 90%) estimated by UNAIDS for heterosexual transmission in African countries. The two estimates should certainly be treated with equal skepticism.

It might also be wondered how Pakistan could report indiscriminate transfusion of unscreened blood and high levels of unsafe injecting when these modes of transmission are said to be almost non-existent in African countries. Are Africa's health services so much more advanced than those available in Pakistan? And if they are, why are UN employees warned not to use them? Why do rich Africans opt for medical care in Western countries?

Transmission rates in Pakistan attributed to intravenous drug use and male to male sex are comparable to those found in African countries. But in Pakistan, 27% of transmissions are said to be due to undetermined origin. In African countries, none are so attributed. Epidemiologists much be far more efficient in African countries.

So, aside from having very low prevalence in Pakistan, another stark difference is that in Africa, far more women are infected than men. In Pakistan, it's the other way around, where "86.8 % of reported HIV positive cases are found to be men". Given that probability of transmission from women to men is said to be about half that from men to women, the contribution of heterosexual transmission should be relatively low, certainly lower than 50%.

The differences found in HIV epidemics in Pakistan and, say, South Africa (prevalence 18.1, ie, 181 times higher), are enormous. So enormous that you might ask if it is the same virus that is being referred to as 'HIV' in both countries. My suspicion is that it is the same virus, but we are being lied to about the respective contribution of non-sexual transmission in African countries. Which may be good news for Pakistan, but not for African countries.

Test and Treat Strategy Guarantees a Long and Profitable HIV Epidemic

The multi-billion dollar global HIV industry continues to edge its way towards its ideal solution to HIV: allow it to spread. Genuine prevention success would cut into the industry's profits. But fake prevention strategies, such as 'test and treat' (or 'test all, treat all' or 'treatment as (or 'is') prevention'), will guarantee increasing profits every year.

This pseudo-strategy involves testing 'all' (the figure hoped for is 80%) sexually active people about once a year, or possibly more often. But only three countries in the world have more than 20% prevalence and only 9 have more than 10%. They had better be very accurate about which 80% of the population they succeed in testing, every year.

Also, the industry usually characterizes HIV as a sexually transmitted infection, although it is not always transmitted sexually and might not even be primarily sexually transmitted. But it's the party line and it's paid off very well so far. Talk about sex will get you money, talk about non-sexual transmission, especially through unsafe healthcare, will get you branded as a denialist or some kind of crank.

But even if you accept the behavioral paradigm, the view that HIV is almost always transmitted sexually (in some developing countries, but certainly not in developed countries), you might notice that the industry has always been very bad at saying exactly who is most at risk. It might seem obvious that those who have most 'unsafe' sex are most at risk, but sex worker populations often have low HIV prevalence figures.

Indee in some countries, sex workers plus their clients plus their clients' partners make up a relatively small contribution to the country's overall epidemic. The largest contribution in many mature epidemics, such as Uganda's, appears to come from people in a stable relationship who mainly engage in low risk sex.

So the industry is in the ironic position of having to target those among whom risk of sexual transmission is low, if they are really going to have any impact through their proposed strategy. In fact, the industry will have to target pretty much all sexually active people, partly because they don't know who the people most at risk are and partly because those who are not at much risk at all appear to be contributing most to some epidemics.

There's a contradiction in there somewhere. But as long as it sells drugs and sales rise every year, the industry will not be complaining. Little attempt will need to be made to figure out how HIV is being transmitted and nothing will be done to reduce transmission by actually addressing causes.

The process will simply involve finding people already infected, putting them on treatment, going through the testing process every year and claiming that a whole lot more would have been infected if the strategy hadn't been implemented.

Oh, and don't worry about evidence: the plan is "based on mathematical modelling". "The model developed assumes a population of very high prevalence which is tested once a year and those found HIV positive started on ARVs immediately; with this early antiretroviral intervention, the model shows that in three decades the new infections would be reduced sufficiently to eliminate the epidemic."

What could disprove this model? Who is discussing the fact that epidemics are the result of conditions that themselves need to be addressed, and not just treated with drugs? And who will wish to answer these questions when there is so much money to be made from ignoring them? Test and treat strategies may seem like they are doing nothing to prevent HIV transmission, but for advocates, not preventing HIV is a form of HIV prevention.

Far More Infants Die of Preventable, Treatable Syphilis Than HIV

One of the results of the exceptionalization of HIV is that other health conditions end up being ignored, including sexually transmitted infections (STI). Given the HIV industry's obsession with sexually transmitted HIV, it might be expected that STIs such as syphilis might get a bit of attention.

However, many women can be tested and treated for HIV, and receive prevention of mother to child transmission (PMTCT), without being tested for syphilis and other STIs. These preventable and treatable STIs can be passed on to children, despite most women attending antenatal care facilities at least once during their pregnancy.

WHO estimates that two million pregnant women are infected with syphilis every year and about 1.2 million of them will transmit the infection to their child. Far fewer children are infected with HIV. And the number of deaths from syphilis during pregnancy is higher than the number of infants infected with HIV.

At one time, a lot of attention was given to treating STIs as a means of reducing HIV tranmsission. Trials showed that this had very little impact on HIV transmission and a recent Cochrane Review makes it clear that STI control is not an effective HIV prevention strategy.

But, importantly, the review concluded that there are "other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided."

Syphilis and many other STIs are preventable and treatable, yet they often seem to be ignored. And it sounds as if they have only received much recent attention because of the possibility that they may reduce HIV transmission.

Surely STIs should be prevented and treated where possible because they are diseases, not just because this might have an impact on HIV transmission? HIV is debilitating and incurable, but other STIs are debilitating and curable.

Whether STI treatment has an impact on HIV transmission or not, people should not have to suffer from them or risk passing them on to their partners and their children, especially when this is entirely avoidable. They have a right to prevention and treatment for all diseases, not just HIV.

Unsafe Injections Are Common, Especially in Poor Countries

The weekly Safe Injection Global Network newsletter has arrived in my inbox. As always, I'm stunned by how many new incidents are uncovered every week that demonstrate how dangerous lapses of safety can be in hospitals, even in countries with very well funded health services.

A survey of 87 facilities in the US found that hemodialysis patients were twice as likely to be infected with hepatitis C virus (HCV) as non-hemodialysis patients.

222 endoscopy patients in New Orleans are being contacted because they may have been exposed to HIV, hepatitis or other diseases through unsterile equipment. This is the second such incident this year. The last time, 360 patients were contacted. The period covered this time is over 7 months. The risk may be small, but it was a long lapse, and the hospital is rightly taking no chances.

In Alberta, 226 patients are being screened HIV and HCV because a care worker was found to be positive for both viruses. Again, the risk to patients is low, but these things can't be left to chance. Apparently, the investigation revealed no breaches of infection control practices.

A report suggests that thousands of patients who have attended a certain Veterans' Affairs dentist need to be screened. This is not the first article about the same dentist, but the dentist in question was working for 18 years in the clinic and failed to change gloves and to sterilize equipment between patients.

The problem might even date back to the mid 1970s. Two patients have already been identified as having hepatitis B virus (HBV), but only a few hundred have been screened so far. This whole episode is in need of clarification. Former patients must now be wondering if other practitioners could have done the same, and how long it will take before they are informed.

The use of multi-dose flasks of vitamin C in an Australian health facility has been demonstrated to have resulted in at least three people being infected with HCV. Inadequate infection control was 'apparent'.

The point I am making is that health facility acquired infections occur, there are lapses in procedures, mistakes made and what not. But in Western countries, where such occurrences often don't represent a very high risk to patient safety anyway, an investigation is carried out. Sometimes people are disciplined, controls are tightened up, effort is made to ensure that adverse events don't happen again.

In developing countries, where health facilities are in short supply, underfunded, understaffed, underequipped, lacking in written procedures and trained personnel who can (and do) follow them, the risk that people could be infected with a serious disease is very high when adverse events occur.

The fact that there are very few articles about such events in developing countries, and even fewer about investigations and patients being contacted to be screened, is very suspicious indeed. Only an idiot would conclude that such events never occur. So the question arises as to whether anyone is even checking for them, if they are recognized, if they are reported and if anything can be done, or if anything is done, when these breaches occur.

Another recent article finds that patient safety incidents are underreported and, as a result, policy is biased. In other words, the extent of patient safety issues is not even well established in Western countries, let alone in developing countries.

Finally, an article looks at 'deliberate, extreme' underreporting of hospital acquired infections in Mongolia and the strategies that health personnel use to avoid accurate reporting.

Unsafe injections occur everywhere, but in some countries, effort is made to establish to what extent and to identify remedial action that can be taken. But in many countries, no such effort is made. On the contrary, the whole issue is ignored, denied or swept under the carpet.

In some countries, unsafe injections are very common and are known to cause tens of millions of serious infections, such as HIV, HBV and HCV. But in these countries, no remedial action is taken and, worse than that, UNAIDS and other institutions simply deny that unsafe injections is a problem.

How, in the light of so much evidence that unsafe injections are very common, especially in poor countries, UNAIDS can claim that as little as 2-2.5% of HIV is transmitted by this route, I can not understand. But this bias results in biased policy, policy that concentrates on sexual transmission. And biased policy results in biased spending, with hardly anything going towards non-sexual HIV transmission.

Unsafe injections and other forms of non-sexual HIV transmission clearly make a considerable contribution to HIV transmission in high prevalence countries. It is the job of UNAIDS to work out the exact extent of this contribution and ensure that funding for adequate prevention measures is provided to countries. Otherwise, high HIV transmission rates will continue to destroy the lives of millions of people every year.

Blinded by Influence: the 'Rightness' of Big Funding

Matthew Black has raised some issues in response to my last post, which I would like to answer in detail. It appears that his opinion is based to some extent on a very brief article which denies, but doesn't adequately refute, some of the most pressing arguments against the behavioral paradigm, the view that HIV is almost always transmitted sexually in African countries.

Firstly, in saying that I don't believe all HIV is transmitted sexually, I am not claiming that it is never transmitted sexually. Nor am I saying that it is mostly transmitted non-sexually, by unsafe health care or any other non-sexual modes.

What I am saying is that we do not know the extent of non-sexual transmission and that it is vital to address this lack of knowledge in order to judge how much time, effort and resources are spent on each mode of transmission.

Aside from lack of thorough research into non-sexual transmission, particularly through unsafe injections, but by no means limited to that, no adequate explanation has ever been given as to why heterosexual transmision of HIV is realatively uncommon outside of a few high prevalence countries, mostly in sub-Saharan Africa.

People all over the world have sex, some of them have a lot of sex and it is often 'unsafe'. But rates of sexual transmission appear to be hundreds of times higher in a few African countries, if UNAIDS and the AIDS orthodoxy are to be believed.

Another anomaly is what is known about non-sexual HIV transmission: not only is it far more efficient than heterosexual transmission (regardless of which sets of figures you actually use) but it is also the commonest form of transmission in most Western countries and other countries where prevalence is not excessively high.

Indeed, aside from men who have sex with men, the only high prevalence group in Western countries is intravenous drug users. Even sex workers who are not intravenous drug users are very unlikely to be infected with HIV.

The Service Provision Assessment data I refer to in my previous posting is the latest available from Measure DHS and this kind of survey only takes place about every five years, the same as most demographic and health data relating to HIV (an assessment was carried out last year but the data is not yet publicly available).

But health services are not receiving anything like the sort of resources that are being thrown at antiretroviral drugs. If anything, as populations increase, services are less and less able to cope with demand.

But we don't need to ask if health facilities in high HIV prevalence countries are risky places for those who wish to avoid HIV, hepatitis and other blood borne viruses. The UN itself bears witnes to the fact that they are not trustworthy. The UN warns its own personnel to avoid health facilities that are not approved by the UN itself because of the known risks.

But when it comes to advising African countries about HIV risks, the UN changes its story and says that HIV is unlikely to be transmitted non-sexually, particularly through unsafe injections. Why there is this discrepancy in their advice, we are not told.

But despite the WHO claims in the brief Continuing Medical Education Journal document mentioned above, the WHO has also published material which accepts that 70% of injections globally are unsafe and an unknown percentage, perhaps as high as 15 or 20%, may be contaminated with HIV. Huge percentages of hepatitis B and C are transmitted by unsafe injections. And the WHO is part of the UN.

Mr Black may be interested to know what happens in Western countries when there has been a suspected case of unsterile equipment being used on patients in health facilities. Hundreds, thousands, even tens of thousands of people are contacted and advised to be tested for HIV and other viruses. I cite just one example here, but new ones are reported every month. But I have cited others in the past.

On many occasions in rich countries, nosocomial transmissions have been identified and treated, where possible. Such investigations do not take place in countries that have very poor health facilities, and that's what I and Gisselquist, Brody, Potterat and a number of other people are questioning.

People in Western countries do not tolerate such outbreaks occurring. When they do occur an investigation follows. As a result of the investigation, procedures are improved accordingly. Why are the authors of this CMEJ article prepared to tolerate conditions in African countries, where health facilities are so lacking in every way, that would be unthinkable in Western countries?

And more importantly, how can UNAIDS and others deny that non-sexual HIV transmission is worth investigating in countries where they have not even bothered to investigate it?

The issue, Mr Black, is not just about whether sexual transmission is or isn't responsible for most HIV infections in a handful of high prevalence countries: the issue is that the contribution of non-sexual transmission, especially through unsafe healthcare, has never been properly evaluated in those countries. And just as UNAIDS seem afraid to use African health facilities themselves, they also seem afraid to investigate them.

Public Money Pays the Piper, So Why Do Big Pharma Call the Tune?

Every now and again I read UNAIDS' publications. Not just for the pretty pictures and diagrams, but because I hope that some day they will play a different tune. Mainly, I want to hear that they have modified their claim that 90% of HIV is transmitted through heterosexual sex. That was the figure that appeared in a draft of their 'Getting to Zero' 2011-2015 Strategic plan. In the published version, the figure is 80%.

But that's not really a modification. They just got it wrong. The official line has for a long time been that 80% of transmission is from heterosexual sex and almost 20% is through mother to child transmission (MTCT). Men having sex with men and intravenous drug users, it appears, make a negligible contribution to high prevalence epidemics. In fact, most HIV transmission is said to result from what is essentially low risk sexual behavior. Which is strange, for a virus that is difficult to transmit through penile-vaginal sex.

UNAIDS' claim to use a 'Know your Epidemic, Know your Response' methodology is flatly contradicted by their claims about heterosexual and other modes of transmission. They don't know their epidemics and nor, we can safely conclude, do they know their response. That's why they have failed to have much impact on transmission rates.

Oddly enough, the plan doesn't mention abstinence, ABC or any of the other rubbish that has filled so much of the official literature. In fact, prevention by useless strategies appears to have been replaced with prevention by wishful thinking. Instead of admitting that hardly anything has been spent effectively on prevention since UNAIDS was established, they are implying that treating people is preventing HIV transmission.

In truth, antiretroviral treatment can reduce transmission, but on its own it is unlikely to reduce it very much. Indeed, many of the figures that 'support' various claims made by UNAIDS about heterosexual transmission are years out of date and are assumed or modeled figures, they are not drawn from empirical research. Therefore, UNAIDS also undermines its many claims that their strategic plan is 'evidence-based' or 'evidence informed'.

One area of HIV transmission that presumably fits into the 2% category is non-sexual transmission, through unsafe healthcare, unsafe cosmetic practices, etc. The WHO, in the last year or so, has admitted that an estimated 40% of injections in African countries are unsafe and the organization accepts that at least 5% of HIV infections could come from such unsafe injections. This estimate is for a region, not for any particular country. The figure for some countries is likely to be a lot higher.

Despite claiming that HIV transmission from unsafe injections is very low, UNAIDS warns its employees and those of the UN as a whole to avoid medical facilities that are not UN approved, as I mentioned yesterday (and on other occasions). If there is a risk for UN employees, there is a risk for non-UN employees. So why the discrepancy between the WHO's figures and those of UNAIDS, and why the warning for UN employees but not for ordinary people?


The whole Strategic Plan is similarly biased towards a behavioral view of HIV, whereby it is depicted as overwhelmingly a matter of individual sexual behavior. This is a dated view, it hasn't worked in the past and it is not going to work in the future. It is difficult to see how this Strategic Plan differs materially from anything UNAIDS has published in the past. Most of the references seem to be to UNAIDS publications or similar.

Finally (although there is little positive that one could say about the Plan), it states that "investment in HIV is critical for the strengthening of health systems and achievement of the MDGs." On the contrary, investment in health systems is critical for the treatment and prevention of HIV. Claiming that money spent on HIV is money spent on health systems is neither honest nor based on empirical evidence.

One only need take a cursory look at Kenya's Service Provision Assessment (or the SPA for any other high prevalence country) to see how unprepared they are to play any part in preventing HIV transmission, especially nosocomially transmitted HIV. And they are equally unprepared to treat or care for HIV positive people adequately.

UNAIDS need to pay a little less attention to what politicians, religious leaders and industrialists think they should do and pay a bit more attention to HIV, a blood-borne virus that is sometimes transmitted sexually, especially through anal sex. They have sold enough drugs for the friends in the pharmaceutical industry and it's time to address the one disease they were established to eradicate.

Comfortable With High Rates of Mother to Child HIV Transmission?

According to the UN, "Extra precautions should be taken...when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere." This excellent advice is given to UN employees. But it is not given to people who don't have the benefit of access to 'UN approved' medical facilities.

Is everyone comfortable with this? UNAIDS say that only around 2.5% of HIV transmission results from unsafe medical practices in high prevalence countries. But they think it necessary to warn UN personnel working in high prevalence countries to avoid the health facilities that people in developing countries have to put up with, if they actually have access to health facilities at all.

Sometimes you read about how awful it is that large numbers of infants are still born HIV positive or go on to be infected by their mother (mother to child transmission or MTCT). And it is horrific, but it is preventable. The problem with worrying mainly about the infants is that they are infected by someone else who is already infected, possibly their mother. And their mother's infection was probably also preventable.

So why does UNAIDS not worry about the person who infects the infant? And why is the person who infects the infant possibly their mother? I can't answer the first question but I know UNAIDS don't worry about it because they deny that unsafe health care plays a significant part in HIV transmission, and therefore refuse to investigate possible instances of it and they refuse to give proper estimates for its extent.

And the reason I say the person who infects the infant is only possibly their mother is that many infants have been identified whose mother is HIV negative (for instance in Mozambique and Swaziland). UNAIDS has tied itself in knots trying to argue that many babies are breastfed by a HIV positive person who is not the child's mother, etc. And while that might be a possiblity sometimes, it is unlikely to explain away all such instances.

Many women are known to become infected with HIV when they are already pregnant. Many are infected in the second or third trimester, even in the few months after they give birth. Now, I can't prove that women abstain from sex during and just after pregnancy. But nor do I think UNAIDS can demonstrate that most women don't abstain or, at least, reduce their coital frequency.

Nor can I prove that women don't have large numbers of unprotected sexual experiences with people who are not their partner during and just after pregnancy. But nor can UNAIDS demonstrate that they do. Indeed, the belief that African women, from a handful of African countries, sometimes from limited regions in those countries, engage in reckless sexually behavior ragardless of their own personal risk or circumstances, sounds to me like pure prejudice.

Sarah Boseley of the UK Guardian reports on a study questioning the suitability of antiretroviral treatment for young sufferers, a study which finds that very high rates of resistance result when people born with HIV are still young. And continued incidence of resistance is just a matter of time.

There is good and bad news for Sarah Boseley and for others who think that HIV rates in people born with HIV or who convert in their first few months or years is totally unacceptable: it is very likely that most mother to child transmission is preventable. And most of it is not just preventable in the way such transmissions are preventable in Western medical contexts, through careful support, treatment and medication.

It is very likely that a large percentage, perhaps the majority of transmissions, are a result of unsafe health care practices, injections, transfusions, intravenous drips and various other invasive procedures. After all, who believes that health facilities in high HIV prevalence countries are able to guarantee safety from transmission of HIV and other blood borne conditions? UNAIDS certainly doesn't.

The bad news is that little is likely to be done to reduce this kind of transmission because UNAIDS and other institutions who decide how HIV is transmitted (no, establishing how it is transmitted is not an empirical matter, don't be silly) have failed to investigate non-sexual transmission of this kind. In fact, they have refused to investigate, despite plenty of evidence that there is a case to be answered.

Is everyone comfortable with this? What makes the behavior of UNAIDS and those who follow their directives so despicable is that UNAIDS and other parties are well aware that a lot, perhaps a majority of HIV transmission, is a result of unsafe medical practices. It is not just a matter of sexual behavior. Africans do not have weired sex lives and they do care about their children, sexual partners, families and compatriots. Africans do not want their children to be born with HIV. But UNAIDS don't seem to mind.

Ever Increasing Numbers on Drugs is Not Reducing HIV Transmission

There's been a lot written about increasing the use of antiretroviral drugs, not just to treat people who are HIV positive, but also to reduce HIV transmission as well. One such strategy is called 'treatment as prevention', where those on antiretroviral treatment, under the right conditions, are said to be unlikely to transmit HIV to their sexual partners.

Another is called pre-exposure prophylaxis (PrEP), where HIV negative people take antiretrovirals because that has been shown to slightly reduce the risk for men who have sex with men, though not for women who have sex with men.

Reading the claims about 'treatment as prevention', you might think that it would make PrEP redundant. Advocates of treatment as prevention say that if a large proportion of the population in a high prevalence country were to be tested regularly, perhaps every year, and immediately put on ART if found to be HIV positive, transmission rates would drop rapidly.

But a group of researchers recently looked at sexual risk taking among patients on antiretroviral therapy in Nairobi's Kibera slum. And they note that many HIV treatment programs in such contexts do not include efforts to reduce HIV prevention beyond treating those already infected.

As a result, rates of sexual behavior considered to be risky remain high. It appears that, in their eagerness to get as many people on drugs as possible, the issue of preventing new infections has received little attention. And claims that this is not a problem, or even that it is not the case, sound rather hollow.

The researchers say "ART is often not enough to prevent HIV transmission, especially where there are high rates of inconsistent condom use and multiple sexual partners". Both these phenomena were found in Kibera.

Kibera may receive a lot more attention than most of the many slums in Nairobi. But the people living there only make up a fraction, perhaps a small fraction, of the total number of slum-dwellers in the city. Out of about 4 million inhabitants, as many as 60 or 70% may be living in slums.

It is noted that the tendency to treat people for HIV without also taking steps to reduce transmission is especially a problem in developing countries, which have weak health and social services. HIV prevalence in Kibera is estimated at about 12%, compared to 7.8% nationally.

People living in slums face multiple vulnerabilities, not just vulnerability to HIV transmission. Apparently "people living in urban informal settlements...have earlier sexual debuts, have more sexual partners, are more likely to use alcohol, and are less likely to adopt preventive measures against contracting HIV compared with urban residents in formal settings".

This research found that 28% of patients use condoms inconsistently (or not at all). Condom use was higher among those who were employed and among those who had been on treatment for longer. But women were three times more likely than men to report inconsistent condom use.

Married men were four times more likely to have had more than one sexual partner than married women, although only 9.5% in total said they had two or more sexual partners in the previous six months. Unmarried men were slightly less likely to have had more than one partner than unmarried women.

The context in which this research took place was described as "a relatively well-functioning ART programme with an inherent support structure focusing on patient education and information". But 'risky' behavior was still considered high, especially among those who had recently started ART, who are more likely to infect their sexual partners.

The authors conclude that "the roll out of ART cannot serve as a single preventive intervention, but must be linked with other preventive strategies for increased community effectiveness."

They also warn that "weak infrastructure and challenged health service delivery in informal settlements must be considered by policy makers and the donor community when developing future interventions to avoid the risk of negative effects, such as increased HIV transmission."

Putting more HIV positive people on ARV drugs has, for many years, led to very little money being spent on HIV prevention. While HIV positive people need treatment, and sooner rather than later, hundreds of thousands, perhaps millions of people have become newly infected with the disease.

Now those peddling drugs want to put HIV negative people on the same drugs, insisting that this will reduce transmission further. Drugs may reduce transmission, but neither of these strategies, treatment as prevention or PrEP, are identifying how so many people continue to be infected in somecountries and in certain parts of other countries.

Many African people live in conditions where the risk of being infected with HIV, either sexually or non-sexually, is very high. Neither of the above strategies even attempt to lower people's exposure to risk. Both of these exorbitantly expensive strategies, on the contrary, allow hundreds of thousands of people every year to be newly infected with a deadly disease.

[For more about pre-exposure prophylaxis (PrEP), see my other blog.]

It is Sweet and Beautiful to Die for One's Scientists

A little while back, I blogged about research that identified HIV prevalence 'hotspots', where high figures were clustered together. This research, carried out in Lesotho, looked at hotspots for males and females and found that they were spatially distant, which may seem anomalous for what is said to be a mainly sexually transmitted disease.

Similar work carried out in South Africa was a bit disappointing. Because, even though it is well known that fewer men are infected than women, often far fewer, this research by Handan Wand and Gita Ramjee only looked at hotspots of high HIV prevalence and incidence for women [Apologies for providing the wrong link yesterday.] Excluding men from such research is odd if it is assumed that women are mainly being infected by men.

But it clearly is assumed that all, not just almost all, transmission is through sex. "At all visits, all participants received counselling on risk reduction and as many male condoms as desired. Counsellors emphasized that condoms are the only known method to prevent HIV and sexually transmitted infections (STIs), and that condoms should be used for every act of sex."

There is something small but crucial wrong with this statement: condoms are the only known method to prevent sexually transmitted HIV. But using condoms during sex will not protect against non-sexually transmitted HIV, which could result from unsafe health care or unsafe cosmetic practices.

Indeed, failing to inform people about non-sexual risks means that they are unable to protect themselves from them and this could be a reason why HIV prevalence is so high in some sub-Saharan African countries. Pretending that HIV is always (or even almost always) sexually transmitted flies in the face of all evidence and is probably responsible for a substantial proportion of all transmission.

As for this research, it found some significant correlations between being HIV positive and certain types of behavior considered to increase the risk of being infected with HIV. 'Significant' in the strict statistical sense of the word, but not particularly large correlations. A non-statistician might think the data needs to be re-examined in the light of such apparently minor differences but not our intrepid authors.

For example: "The proportion of women who reported being legally married was significantly higher among those outside the hotspots than within them (16% vs. 12%, p = 0.001). Significantly more women in the geographical hotspots reported being Christian (94% vs. 90%, p < 0.001) and speaking Zulu at home (91% vs. 86%, p < 0.001) compared with those in non-cluster areas."

The article goes on: "The spatial clustering of HIV cases was found to be related to certain demographic and risk behaviours. Number of male sexual partners was not collected in this study; however, being single, combined with high frequency of sexual acts, gives strong evidence for those women having multiple partners, as well as possibly engaging in transactional sex."

'Strong' evidence? How does this 'high frequency of sexual acts' compare to countries with low HIV prevalence? The same question regarding 'multiple partners'? And would the authors come to the same conclusion of 'possibly engaging in transactional sex' if the risk factors in a low prevalence country were similar? I don't think so.

The authors may be leaving the door open to further research about the safety of health care facilities, but then again, they may not: "These results may be due to fundamental differences between the communities with regard to health care centres, population density and other socio-economic factors. These data provide new evidence to support the need to investigate potential sources of infection and to study transmission patterns in the community in order to apply relevant interventions for prevention of this devastating disease."

Let's hope that 'relevant' interventions means interventions that prevent non-sexual as well as sexual transmission, but it doesn't look as if these particular researchers will see things that way.

It is concluded that "Information on the spatial distribution of populations and services is essential to understand access to health services." But if some HIV is being transmitted nosocomially, as a result of inadequate health facilities, this also needs to be established. Otherwise increasing access to health services could result in higher rates of HIV transmission.

The authors don't just need to "determine and target the specific communities that are most in need of education, prevention and treatment activities", they also need to determine exactly what sort of education and what sort of prevention activities are required. Otherwise, at best, things could remain as bad as they are and atworst, they could get a lot worse. Neither of these would be good for South Africa.

Circumcision Enthusiasts: Screw the Evidence, We're Going Ahead

HIV prevalence has been high in Kisumu since early on in Kenya's epidemic. Rates went higher there than anywhere else in the country and they are still about twice as high as the next highest area, and three times as high as the national figure. This meant that a lot of HIV research work has been done in Kisumu. But no explanation has ever been given of why rates should be so disproportionately high there.

Naturally, fingers were pointed at the fact that people in Kisumu must have a lot of unsafe sex. But what is it about Kisumu (or Luo) sex that makes it so different from sex in other parts of the country? Some people have more than one partner, a few have lots. Most don't use condoms very much and many have their first sexual experience when they are still teenagers.

But those things could all be said about most of the other tribes and cities and provinces of Kenya, and about some people in every country. Birth rates, a sure sign of unprotected sex, are highest in Northern, ethnic Somali inhabited areas. There isn't really anything extraordinary about Kisumu or Luo sex that anyone has been able to discover.

Also early on in the epidemic, it was pointed out that Luo men are not usually circumcised. It was suggested that this might make them more susceptible to HIV. Research has shown that HIV transmission can appear to be connected to circumcision status. However, though in some places circumcised men are less likely to be infected, in others uncircumcised men are less likely to be infected.

But this finding didn't make the people for whom mass male circumcision is their personal cursade very happy. The more research they did, the more ambiguous the effect of mass male circumcision appeared to be. But they are still at it. In fact, research suggests yet another thing that was recognised early on in the HIV pandemic: that HIV is probably not always transmitted sexually.

So part of the personal crusade involves explaining away data which suggests that not all HIV is sexually transmitted. A paper published in 2007 asking uncircumcised, sexually active young men about their sexual behavior found that 5% were HIV positive, which is higher than you would expect among people who have not been sexually active for very long, especially among males.

The risk factors are particularly interesting, not just because risky sex is likely to be driving a good deal of HIV transmission, but because some non-sexual risk factors are also likely to be involved. Both medical injections and traditional practices (saro, bloodletting) were implicated. Those who received injections in the last 6 months were three times more likely to be infected that those who had not and those who ever practiced bloodletting were twice as likely to be infected.

Another surprise was that men who reported washing their genitals immediately after sex were also less likely to be HIV positive. This gives some confirmation to the view that circumcision may not be necessary if men take measures to ensure penile hygiene. Little research has been done into this phenomenon but it is not clear why the authors of this research paper are still advocates of circumcision without knowing how and why HIV transmission appears to be correlated with circumcision status, sometimes positively correlated, sometimes negatively.

Catholics were more than twice as likely to be HIV positive as members of other religions and this was not related to condom use. In fact, condom use is not even a reliable indicator of risk.

The authors try to explain away the data about receiving injections by arguing "because this is a cross-sectional analysis, it is also possible that HIV positive men were more likely to report recent injections to treat HIV/AIDS related illnesses". But these are young men. Even the HIV positive among them are unlikely to be receiving injections related to their HIV status.

While 72% of eligible HIV negative people took part in the survey, only 22% of HIV positive people did so. This could skew the results considerably, though it's not possible to know in which direction they would be skewed. But despite this, and despite the indications that HIV is not always transmitted sexually (or 90%, as is usually claimed), the authors are still devoted advocates of mass male circumcision.

If Tanzania Had More Health Personnel, Would HIV Be More or Less Common?

Apparently "One-third of U.S. hospital admissions can expect a medical error, an infection or other adverse outcome". But sometimes up to 90% of these outcomes can remain undetected. This is in the country with the highest health spending per head in the world. What percentage of patients in Tanzania, say, could expect a medical error?

For a start, who is counting? There is generally no way of keeping track of such errors, even serious ones. There are too few health personnel, too few of them are trained and most hospitals don't have the capacity to keep such records or prevent such incidents.

On the plus side, if you could express it that way, most Tanzanians will never see a doctor and won't spend too much time, if any, in a health facility. The percentage of patients suffering adverse outcomes may be higher than in the US but the number of people involved is a hell of a lot lower.

An article about the pastor in Loliondo, Arusha Region, who claims to have a concoction that cures just about anything, points out that the people flocking to drink the potion are not just following the herd; they are desperate.

This is a significant observation. For people in rural parts of Tanzania, and that's over 80% of the population, all health services are elusive, requiring a lot of patience, faith and perserverence, perhaps even some money.

This magic potion is even said to cure HIV/AIDS. It costs less than a dollar, 500 Tanzanian shillings. Of course, people have to pay the costs of waiting for days, not working, paying for accommodation, food, transport, bribes and anything else that someone can screw money out of them for.

But this may not be so different from some antiretroviral (ARV) programs, where the drugs, if you can get hold of them, are free. And ARVs don't guarantee survival either. Under the right conditions ARVs are very powerful, but many Tanzanians don't live in such fortunate circumstances.

This article cites estimates that Tanzania needs 126,000 health workers but only has 35,202, a 76% deficit. The ratio of doctor to patient in some places is as bad as 1 to 62,000 but in Kigoma, that ratio is one to 308,000. Coincidentally (perhaps), Kigoma is also the region with the lowest HIV prevalence in the country.

Per capita health expenditure is $22 in Tanzania, 2.7% of the global average. Much of that, an estimated 75%, comes out of the pockets of people where the majority wouldn't earn much more than a couple of dollars a day. Most illnesses, clearly, go untreated.

When I think of health conditions in East African countries and then look at HIV prevalence, I wonder why HIV prevalence is not a lot higher. And I wonder why HIV prevalence is so much higher in other African countries where far more people have access to health care.

But looking at the figures for adverse outcomes in the US, I'm not so surprised. Good health facilities are dangerous enough, I hate to think of the uncounted hazards people face in bad health facilities. In countries with high HIV prevalence, health facilities could be among the worst places to go.

'Counterfeiting' is a Problem That Can Only Be Solved By Big Pharma

If a business produces something and sells it for a price that covers costs and also gives a decent profit, that's a good model. Others may make the same thing, so a business needs to make the best and work hard to make sure they are not undercut. But most people will pay for something good rather than something that isn't up to scratch, if they can afford it.

However, if a business produces something and sells it for a price that is a complete distortion of the above business model, it is worthwhile for someone else to produce the same thing and charge a lot less. They don't even have to cut costs, they can just accept a lower profit. And those who have no chance of affording the expensive product may well be able to afford the cheaper one.

This is an oversimplification, but it is roughly what the pharmaceutical industry does, charges an outrageous price for something because they can. In addition, the industry depends on a form of protectionism called 'intellectual property rights'. Arguably, this has its uses, even that it is vital, but it is still a form of protectionism.

Often, the research that pharmaceutical companies claim to spend so much on is done by publicly funded, or partially publically funded, institutions. But there is little or no return to the public. And the amount spent on PR and marketing far exceeds what is actually spent on research.

So when someone else makes the same product but demands less for it, the industry reacts by resorting to all sorts of tricks to make sure the competition is destroyed. Competition, when you don't have a high level of trade protection, is not appreciated by the pharmaceutical industry.

The word 'counterfeit', therefore, can mean all sorts of things. It can mean a generic version of a branded drug, a fake version of a branded drug, a substandard version of a branded drug and probably other things. But a generic version of a branded drug is not a counterfeit and claiming that it is one threatens to deny  lifesaving treatments to many people in developing countries.

If drug companies don't want generic versions of their drugs to be produced, they should produce affordable versions themselves. There is clearly a huge market for them and a very good profit to be made. Dropping the price to affordable levels would also make the production of substandard and fake drugs a lot less tempting, perhaps not even worth the effort.

But instead of encouraging the production of generic drugs, the EU and, of course, the entire pharmaceutical industry, want to make sure affordable versions of drugs are not produced. They are currently trying to rope India into signing a 'trade agreement' whereby it will no longer be possible for the country to produce cheap drugs. Yet another form of protectionism.

India is one of the main sources of affordable drugs for developing countries. Some drugs will cost many times, perhaps even tens or hundreds of times more, just because they are protected by the sort of regulation that big industry claims to detest.

There is no doubt that some drugs are fake, made of materials that have no effect or are harmless, and this is unacceptable. But as long as ridiculous profits are made from drug pricing models, people will always find ways of selling their versions, no matter how useless or dangerous. It's not as if copyrighted drugs are always effective, or that they are never dangerous, either.

The pharmaceutical industry, already protected and subsidised in so many ways, wants more public money to be used to 'regulate' drug supplies in developing countries. Multinationals refuse regulation for themselves, but they seem to love the idea of regulating any competition.

Big Pharma have effectively created counterfeiting and many other related problems themselves, it's how they keep their profits so inordnately high. So they should sort it out themselves. If people object to the danger to the health and lives of so many people, they should aim their objections at the industry, the problem, not the mere symptoms of the problem.

The Science and Development Network have a selection of articles on the subject of 'counterfeit' drugs and some of the many issues involved. But the article doesn't really point out that Big Pharma don't lose out from counterfeiting because most of those who buy cheap drugs will never be able to afford the expensive versions.

Can We Guarantee that Public Health is Truly in People's Interest?

There's been an outbreak of measles in Somalia and apparently it may be connected with rumours that the vaccine could cause HIV in children and interfere with their reproductive abilities.

What is your reaction to such a statement? Would you dismiss it as nonsense and say that public health programs aim to prevent and treat diseases, not spread them? Would you say that no one would try to influence the fertility of a whole population, for any reason, and even put their lives at danger while claiming that it is in the interest of public health?

That would be a naive reaction. Some of the wealthiest institutions in the world care a great deal about the fertility of whole populations, especially when those populations are poor. Let me name some: the US Government, the Bill and Melinda Gates Foundation, FHI, PSI, the World Bank, and there are many others.

We don't know what lengths these parties would go to for the sake of their agenda. The Tuskegee Syphilis 'experiment' may seem like something that happened a long time ago, but Ugandans taking part in more recent HIV research were followed to see how long it took for some of them to become infected and how long it took for some of them to infect others. Many of them are now dead, others are still suffering from the disease and transmitting it to others.

What does the WHO or UNAIDS care about who gets HIV, how many people they may go on to infect or how many people die, and whether painfully or not? UNAIDS still insists that HIV is almost always transmitted through heterosexual sex but an estimated 30% of HIV positive infants in Mozambique (who can be matched with tested mothers) have mothers who are HIV negative.

UNAIDS's response in such situations is to suggest that the infants were raped. It's pretty obvious what their attitude towards Africans is, when they know that infant rape is no more likely in African countries and that incidence of rape, even infant rape, could never be high enough to explain such massive rates of infant HIV.

Quarraisha Abdool Karim, one of the people behind the CAPRISA vaginal microbicide gel fiasco, is planning another way of influencing reproductive choices, in the interest of public health, of course. This time, the idea is to hand out sums of money 'to reduce HIV infection in High School Learners'.

This is interesting for public health experts working with TB. This disease if often caused by occupational hazards, such as mining. It might be too extreme to pay people not to breathe when they are working. But you could compensate them for not working on some of the more dangerous tasks. That would at least drive up the value of labour.

Karim's plan, by the way, is not without it's exclusion criteria. Those who are 'cognitively challenged' will be excluded. I wonder if those who could be considered morally challenged would also be excluded, but there's no mention in the brief details on WHO's site.

Several countries have reported involuntary sterilization carried out on people who were said to be HIV positive. But a program in the US, 'Project Prevention', plans to offer people money to be sterilized if they are drug 'addicts' or 'alcoholics'. If 'addict' or 'alcoholic' just refers to users of these drugs, this would be bad enough, though I wonder who is judging. But what if those judging are evangelical Christians?

And the project is hoping to move to South Africa where it will aim at HIV positive women. Why it won't aim at men, I don't know. There are far more male than female drug and alcohol users. But women are always an easier target. Project Prevention's final solution can eventually move on to men.

One of the people behind this 'initiative', Barbara Harris, says "How can anyone object to anything that can prevent innocent children suffering needlessly?" She could try asking UNAIDS personnel in Mozambique the same question. Apparently Project Prevention are already operating in Kenya, where people are offered $40 (about a month's wages, a fraction of what those in the US receive) to take long term contraception.

Doctors needn't worry, they are given $7 to perform the insertion. Let's hope they wear a new pair of gloves with each patient and avoid reusing single-use instruments. They haven't had a great record of taking such precautions in the past. Even simple procedures like this carry serious risks in countries with a miniscule capacity for health provision, one of those risks being HIV.

This charade reminds me a bit of the mass circumcision campaigns currently raging in Kenya. In a country where only a few dollars are spent per head on health, some institutions are willing to pay many times that to slightly reduce (if at all) the probability of infection with one disease out of hundreds.

Measles is a terrible disease and it is especially worrying that the outbreak in Somalia (and other countries) could have been avoided if it were not for some rumour, probably completely unfounded. But public health authorities do not have much credibility when it comes to being able to assure people that there is no hidden agenda. There usually is a hidden agenda and it looks as if global public health is busy sawing off the branch they are sitting on.

The article concludes: "it is sad that in this day and age our children must die because of ignorance and lies". But the rumours in Somalia are based on lack of information. Far worse are the lies and half truths based on thorough knowledge coupled with an unspoken (and unspeakable) agenda. Lies do not exclusively arise from ignorance; the most harmful lies are those from people who know the truth.

If Mass Male Circumcision Fails, Will We Be Told?

In order to implement HIV prevention, treatment and care programs, countries need adequate health facilities, with sufficient numbers of trained staff and supplies of equipment and drugs. Most high prevalence HIV countries don't have these.

A quick look a health statistics for most African countries show that they can't even cope with the most basic health issues, such as clean water and sanitation supply, nutrition or prevention and treatment of common diseases, such as water borne conditions and acute respiratory problems.

It is said that Africa has 24% of the global disease burden but only 3% of the world's health workers. It's common for countries and regions to have only one doctor for every 50 or 100,000 people. There are too few health facilities, they are all short of supplies and service provision can not meet demand, or services are of very low quality, or both.

None of this is particularly new. A glance at health service provision assessments from Measure DHS shows that the countries who have the worst problems often have the worst health services.

So it's not surprising that Kenya's ambitions to circumcise 1.1 million men in the space of a few years is proving quite challenging. An assessment of the first year or two of this program, which claims to have already circumcised 230,000 men, should worry those who have gone through the operation, as well as those who are planning to do so.

There is no mention of the numbers of men who have been infected with HIV or any other sexually transmitted disease since undergoing the operation. This is worrying because the whole aim of the exercise is to reduce HIV transmission. Those who have opted to be circumcised will need to be followed up for some time, but HIV transmission rates in the intervention are are massive.

If the program is going well, releasing the figures could help with enrollment. But if it is not going as well as expected, perhaps some problems should be aired and ironed out now to limit the amount of damage that could be done.

The assessment of health facilities involved in the parts of Nyanza selected for the intervention is not wholly encouraging. One of the 'minimum criteria' for service provision was "Sterilization and infection control compliance." Only two thirds of the facilities have autoclave equipment. No mention is made of whether the equipment is used, or used properly. And going by other similar assessments, most facilities don't have written procedures for sterilization and infection control.

Out of the 81 facilities assessed, none of them possessed all seven of the criteria necessary to provide safe services. Most didn't have enough doctors or clinical officers to perform circumcisions, although they were the only staff authorized to do so prior to the mass circumcision program.

85% of hospitals had enough nurses, so they were trained to perform the operation. How these facilities managed to cope with routine, non-HIV emergencies is not made clear. Indeed, it is to be wondered if all this information about health facilities will have any impact on the health development agenda, or if non-HIV health issues will continue to be ignored.

So far, much of the resources and personnel required have been supplied by donors. Whether the program can be continued using existing capacity, whether the program is sustainable, is debatable. And whether it can be continued safely is something I wouldn't like to bet on. I'm sure those who are being offered the services would have the same worry, if they had access to unbiased information.

The efforts to make mass male circumcision rollout seem successful suggest that a lot more could be done to develop health services in resource poor countries. But the lack of effort to deal with non-HIV health development issues suggests that little will be done. Ultimately, the program could result in similar or even higher rates of HIV transmission. It just remains to be seen how long it will take before useful data becomes publicly available.

Uganda's HIV Epidemic: Mystery or Myth?

I have always worried about the way Uganda is held up as an example to other African countries on account of its early experience with HIV. What happened in Uganda earlier on is not the same as what happened later.

Early on in the epidemic, everything possible was done to reduce HIV transmission, both sexual and non-sexual transmission, in all their forms. Later, non-sexual transmission became more and more excluded and a set of myths about the efficacy of the ABC (abstain, be faithful, use condoms) strategy replaced any semblance of a coherent strategy.

The epidemic in Uganda took off earlier than in most other countries. HIV incidence, the rate of new infections, then declined and several years later, prevalence (the percentage of HIV positive people between the ages of 15 and 49) also declined.

It is not clear exactly why the epidemic took off when it did, nor is it too clear why incidence then peaked and declined. Measures to control the epidemic are likely to have played some part, of course, but how big a part has long been a matter of debate. Prevalence would have declined because of high death rates.

Once global HIV policy was thrown off course by ABC, or even AB or just A, it never got back on course. The burgeoning HIV industry's obsession with sex still rages and non-sexual HIV transmission, for example, through unsafe healthcare or cosmetic practices, is rarely talked about, let alone researched or investigated.

This leaves Uganda in a vulnerable position. The country receives a lot of HIV money, most of which is spent on drugs and care for HIV positive people. And the little left over for preventing new infections is spent on interventions that obviously don't prevent new infections.

Prevalence declines that resulted from high death rates have been reversed by a high rate of new infections. Those on treatment are likely to stay alive for longer, adding to increases in prevalence. But many HIV positive people still die, usually from treatable illnesses.

Not only is Uganda far from eradicating HIV, there is still a very serious epidemic in the country. Prevalence is bumping along, lower than it was during the worst years, true, but it has hardly changed for the last 10 years.

Infection rates in young people is often seen as a proxy for incidence because it's hard to measure incidence directly. But if young people who are just becoming sexually active are infected in large numbers, the epidemic is still very much alive. And 1.5% of people between 15 and 19 are HIV positive, 2.6% among girls and 0.3% among boys.

Of course, many of these teenagers could have been infected by mother to child transmission. But it's unlikely that they all were, unless this type of transmission is a lot more common that has been realized.

We are told that the highest burden of HIV, though, is now among married couples between 30 and 40 years old. In fact, it has been realized for some time that the majority of transmissions in Uganda appear to be a result of sex that is not 'unsafe' by any of the HIV industry's definitions.

HIV is common among those who don't have sex very much, are not likely to have several sex partners, and most of whom only have sex with a long term partner. Many, also, are in discordant relationships, their partner is not infected (or they did not infect each other). And half of the infected partners are female, so there goes the 'all men are promiscuous' theory of HIV transmission.

And that's the problem. If HIV is not primarily transmitted through unsafe sex, interventions that target unsafe sex will have little effect on transmission rates.

Yet the conclusion of Uganda's Ministry of Health is that they should encourage male circumcision, increase use of female condoms and awareness about HIV/AIDS. This may or may not reduce sexual HIV transmission. But after so many years watching HIV transmission stagnate, so many people becoming infected and so many dying, perhaps they could think about changing tack.

HIV is difficult to transmit sexually, yet it seems to be transmitted very rapidly in Uganda. Young people who are just starting to have sex are being infected quickly, which suggests that we are way off when it comes to our knowledge of transmission probabilities. Or perhaps not all HIV is transmitted sexually? Either way, we need to find out why transmission rates are so high in Uganda. Otherwise it will not be the only country with stagnating HIV prevalence figures.

The Futility of Criminalizing HIV Transmission

Yet another blog posting that demonstrates the futility of criminalizing having sex with someone without disclosing one's HIV status. It's quite simple. If you don't want to risk prosecution for the offense, don't get tested. Or make sure you get tested anonymously.

In this case, a man, who says he was infected in the late 1980s (but appears to have survived without antiretroviral drugs until about 20 years later) has unprotected sex, once, with a long term sex partner. How do we know that she wasn't already HIV positive at the time? That doesn't exonerate him, of course, but if she had kept her status secret from anyone, his behavior is punishable and hers is not.

The more people get tested the better. And better still if people get tested regularly if they think they continue to run risks of infection. But if knowing that you are HIV positive means you might accidentally infect someone with whom you haven't discussed your status, it's better to test anonamously.

People are not being criminalized for being HIV positive, they are being criminalized for being tested openly, in a manner that can be traced, should someone wish to trace it. Instead of getting people to test as early as possible, this makes it preferable for them to test as late as possible and to disclose their status as little as possible, perhaps never.

For people in developing countries, it's fairly obvious who is most likely to be punished by such laws. Women are under a lot of pressure to test when they are pregnant, sometimes more than once. For various reasons, it is often difficult, perhaps impossible, for them to keep their status confidential. And there is always the danger that someone else could reveal it.

In fact, if a woman needs any health services, especially before, during and after pregnancy, it is very unlikely that she can remain untested, or that her status can remain confidential, should the matter be scrutinized later.

Women in developing countries are more likely to be infected than men, often substantially more likely. They are more likely to have to test in local facilities (because of relative lack of mobility), where they are known by others.

Far from reducing stigma, this kind of criminalization would increase stigma. People would be under suspicion just because of things that may be known about them, or even because of characteristics that are merely attributed to them.

The orthodox view of HIV in developing countries is that HIV is almost always transmitted through heterosexual sex. But it is people who are felt to be engaging in more sex that will be most stigmatized, sex workers, pregnant women, perhaps young women, because prevalence is so high among them.

In the case mentioned above, both the woman and the man are intravenous drug users. They are both at high risk, far higher than people who engage in a lot of heterosexual sex. If the woman did know her status, it would probably be difficult to prove that.

And if she didn't know her status, perhaps, being an intravenous drug user, it might be suggested that she should have been tested a long time ago. It is claimed she was not tested till 2006, though the unprotected sex act was said to have occurred in 1999.

But why would anyone test if it's safer not to? If there was any chance that criminalization could reduce HIV transmission, there might be some justification for it, though it's hard to imagine what that could be. But in fact, it only makes things worse. It risks punishing people who may have been a lot more careful, or honest, and risks exonerating those who keep their test results to themselves, or don't even bother testing.