Could HIV Policy Be Driving HIV Transmission?

Early on in the HIV pandemic it was thought that if people were to be told about the risks for HIV infection and how to avoid them, they would do so. Those involved in public health, professional and non-professional, took steps to inform people about both sexual and non-sexual modes of transmission and what they could do to reduce their personal risk. Improvements in health facilities were also made to eliminate accidental infection through various invasive practices as much as possible.

In a paper on knowledge of blood-borne HIV transmission risk, Dr Devon Brewer comments that "many Ugandans adopted injection practices that likely reduced their risk of HIV acquisition following the 'massive anti-AIDS education campaigns that began in 1985 [that] warned people about the dangers of sharing unsterilized needles and syringes'" (citing a paper by H Birungi). Brewer notes that "these behavior changes were accompanied by concurrent declines in HIV transmission".

Things changed later and non-sexually transmitted HIV risk is now said to have been taken care of. The entire HIV orthodoxy is built on an assumption that is covertly recognised to be incorrect: the behavioral paradigm. This is the view that HIV is almost always heterosexually transmitted in African countries and that non-sexual transmission, which is not uncommon in non-African countries, hardly ever happens in Africa.

Brewer found that in countries where it was known that certain behaviors carried a risk of HIV infection, sharing razor blades in this instance, HIV prevalence was lower. It is not clear to what extent sharing razor blades contributes to HIV epidemics and there are many other such risky behaviors, for example, the use of contaminated injecting and other medical equipment, contaminated cosmetic equipment, such as tattoo needles and ink, and various others.

But Brewer also found that "countries with high proportions of respondents endorsing condoms also tended to have higher HIV prevalence than countries with low proportions endorsing condoms." This is difficult to explain and, if you accept the behavioral paradigm, you might suggest that it means people do not avoid risks that they have been told how to avoid.

My take on the phenomenon is that those in areas with the highest risk of HIV infection, cities and more populated, accessible areas, are also those most likely to have heard the constant messages about condoms. And apparently they even use them more than those in rural, less populated and less accessible areas. But as HIV is less likely to be transmitted through sex and is very likely to be transmitted through unsafe healthcare and the like, those endorsing condoms also face risks not faced by people in rural areas.

Well, 'safe sex' messages may not have had much of an impact in high HIV prevalence countries. But this is not a reason for not advising people of the risks. In the same token, the fact that most people do not have much influence over those who provide them with health services is not a reason for failing to advise them of the risks involved, and the risks of sharing razor blades, for that matter.

People are entitled to know that HIV is far more likely to be transmitted through contaminated blood than through any kind of sex and that there are steps they can take to reduce risk to themselves and their friends and family.

The HIV orthodoxy think nothing of stigmatizing entire nations, a whole continent, blaming massive levels of HIV transmission on massive levels of unsafe sexual behavior. Yet they balk at the suggestion that those providing health services need to be reminded to avoid any risks of transmitting HIV and other blood-borne diseases. They accuse anyone questioning the behavioral paradigm of branding health care providers, while at the same time branding every HIV positive African as promiscuous, stipid and cruel, as mere spreaders of disease.

Brewer concludes, "Health officials have an ethical duty to warn the African public about blood-borne HIV risks. Where such efforts are currently absent, they should be started immediately; where such efforts are underway, they should be emphasized further and sustained. Public education campaigns should not only highlight blood-borne HIV risks comprehensively but also communicate practical strategies for avoiding the risks."

Public health professionals in African countries are in very short supply, underpaid, overworked, undertrained and underequipped. Conditions in public health facilities wouldn't even be approved for veterinary use in Western countries. Warning about health care transmission of HIV is not pointing the finger at health professionals.

If anything, it is pointing the finger at the over-qualified and extremely well paid policy 'experts' at UNAIDS and other institutions. This doesn't answer the queston of why so many people in the HIV industry have failed to do anything about non-sexually transmitted HIV; perhaps they can answer that themselves. But progress in eradicating HIV transmission will not be made until the truth about HIV transmission is acknowledged.

Good News for UNAIDS: We Know How to Turn Off the Tap

An article in the New York Times suggests that the "war on global Aids" is falling apart. Although drug prices have fallen dramatically and the number of people on antiretroviral drugs has risen, this effort to give HIV drugs to everyone that needs them has proved to be unsustainable. In countries like Kenya and Uganda, most of the funding was provided by donors who are now reducing funding, partly, they say, because of the global financial crisis.

But the article suggests that the financial crisis is not the only reason. Big donors are disillusioned at their lack of success, despite spending huge amounts of money on the problem. "For every 100 people put on treatment, 250 are newly infected"; prevention programmes have either been too expensive or almost completely ineffective or both. Donors are now going to turn their attention to cheaper diseases.

Using an often used metaphor, Dr David Kihumuro Apuuli, DG of the Uganda Aids Commission says that "You cannot mop the floor when the tap is still running on it". The executive director of the Global Fund to Fight Aids, TB and Malaria is "frustrated", a researcher from the National Institute of Health is "pessimistic", Obama's Aids Ambassador is "worried", the executive director of UNAIDS is "scared" and the former executive director "has seen optimism soar and then fade".

Well, David, Michel K, Anthony, Eric, Michel S, and Peter, there is a way to reduce the flow from the tap, even if we don't know how to turn it off completely. This may eventually reduce the flow to a trickle and the number of new HIV cases every year could become so small that there is no longer an epidemic. Yes, a new direction is required, but this new direction has already been researched carefully and described by a number of experienced researchers.

Here's what we need to do: we need to re-evaluate the considerable evidence that unsafe medical practices are contributing a lot more to HIV transmission than is currently estimated by UNAIDS. We also need to include in this re-evaluation unsafe cosmetic practices, especially those that, either accidentally or on purpose, draw blood and thereby contaminate instruments.

Aids spending has concentrated overwhelmingly on treatment for much of the last three decades. And much of the money spent on preventing new infections went on mother to child transmission and some rather hopeless exhortations to abstain from sex, reduce numbers of partners and use condoms. Safe sex and increasing condom use are very important for reducing sexually transmitted HIV but they are completely useless when it comes to non-sexually transmitted HIV.

To continue the rather tired metaphor, UNAIDS and many other concerned parties have been turning the tap the wrong way, because anyone infected non-sexually can go on to infect others through sexual contact. Those who are now disillusioned because the number of people becoming newly infected every year still exceeds the number receiving treatment may be inspired when they see this trend slowing down. They may be persuaded to continue paying for more treatment if they think that the numbers of new infections will go down every year from now on.

It has been obvious for a long time that the small number of countries in the world where the vast majority of HIV positive people live are not inhabited by people who have unbelievable numbers of sexual experiences with incalculable numbers of sexual partners. Indeed, only a very dedicated adherent to some long discredited and rather racist views of African people could even countenance such an explanation.

So, HIV prevention is not so intractable as some would have us believe. Yes, it's hard to influence sexual behaviour to any great extent. But if less HIV transmission can be put down to sexual transmission then a lot of money currently being spent on the programmes that are not working can be saved for something worthwhile. And money spent on health services now will result in immediate savings. Ensuring safer medical and cosmetic practices will prevent both direct infections and the indirect infections caused by those infected directly, either sexually or non-sexually.

I call on UNAIDS and all those working in the field to take the official advice, to 'Know your epidemic (or pandemic), know your response'. To understand why HIV has been spreading the way it has in high prevalence countries, we need to look at the most efficient ways of spreading the disease: blood contact. A combination of unsafe medical practices and unsafe cosmetic practices is continuing to spread HIV simply because the official view is that HIV is predominantly spread by unsafe heterosexual sex in high prevalence countries and that blood exposures are so rare as to be insignificant. You know your response has failed, therefore, how well do you know your epidemic?

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

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

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

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

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

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

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