Redefining 'Health' to Maximise Economic Viability

A paper by Egilman, Bird, Mora and Druar puts into perspective some of the most salient barriers to progress in reducing HIV transmission, especially in countries where rates are highest. The very title of the paper alludes to the social and environmental 'determinants of health', something that the most discussed and best financed 'solutions' to the HIV pandemic generally ignore. As a result, global health aid can be rendered ineffective, even damaging, to healthcare in general and to narrower HIV prevention efforts.

The authors are particularly critical of disease-specific interventions or 'vertical approaches' to healthcare. Many of these, upon singling out a particular disease, such HIV, TB or malaria, proceed to expend copious quantities of money and other resources on these, to the exclusion of any attempt at addressing the reasons why these diseases are spreading.

The money is generally spent on drugs and other commodities, items that require people to be infected with the disease in question before being of any use. Anything that reduces the underlying health risks that people face, such as water, sanitation and hygiene, nutrition and food security, literacy, empowerment, poverty, etc, is ignored.

It's not a new discovery that drugs are a necessary, but by no means sufficient means of eradicating a disease. No disease has ever been eradicated by drugs alone and it seems unlikely that one ever will. Technical solutions, such as mass roll-out of drug therapies (antiretroviral treatment, Pre-exposure Prophylaxis, microbicides, male circumcision, vaccinations, and the like), are expensive. But if there is little or no health infrastructure, each vertical program needs to create its own infrastructure. This is inefficient and can contribute to what could be called the 'Bill Gates effect': everyone gets a pill but no one gets clean water with which to swallow it.

A far better way of characterizing health, which would have given rise to a more 'horizontal' approach, was that enshrined in the Alma Ata Declaration on Primary Health Care of 1978. This defines health as "a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity", involving "the action of many other social and economic sectors in addition to the health sector."

The date of the Alma Ata Declaration is particularly poignant because HIV, which had probably been spreading for decades, was only identified a few years later. Luckily, it was identified in a rich country, as it might have remained unnoticed for many more years if it had only infected people in developing countries.

Also poignant is the fact that the Declaration's definition of health was quite contrary to what became the dominant health paradigm, vertical programming. With vertical programming, disease is the measure of health; if you don't have a disease, you don't receive any of the benefits of health programs. Indeed, if you don't have the right disease, your health or lack of it is of no relevance.

The paper discusses the Gates Foundation approach to HIV and a handful of other headline grabbing diseases. This approach excludes any consideration of the conditions people live in, which allow these diseases to infect and affect so many. It also notes the shocking fact that two thirds of the Foundation's HIV/AIDS funding goes to vaccine research, which is labeled "preventative".

Even if a vaccine were developed and were made available to countries where HIV prevalence is highest, it is unlikely to prevent HIV transmission to any great extent. First, HIV prevention programs need to be able to identify who is most at risk of being infected. Currently, the majority of people infected in countries like Uganda, Kenya and Tanzania are those who would be thought least likely to be infected, those who don't engage in 'high risk' sexual behavior.

The paper discusses many vital issues in public health and development but I'll finish this posting with the authors' observation that "a usually unmeasured negative consequence of aid is the increase in nosocomial (hospital acquired) infections that can accompany immunization programs", and contaminated injections in general. In 2000, it was found that nearly 40% of injections were given with reused equipment and "caused an estimated 21 million HBV infections, two million HCV infections and 260,000 HIV infections, accounting for 32%, 40%, and 5% [of all transmission].”

Vertical programs generally don't measure such phenomena as infections, injuries and even deaths. The authors cite an apposite case of traditional birth attendants in Mexico being issued with one needle a month to administer depo provera, the hormonal contraceptive whose injectible version is common in African and some other developing countries, but strangely uncommon in wealthy countries.

HIV, like all diseases, is not independent of the conditions in which people live and spend much of their lives. That is precisely why health is "a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity".

How cruelly ironic it is that what could have been the most important and well timed decision about health ever made was replaced with a decision to view health as a commercial opportunity. As a result, big money only goes into that which allows the big players, the global pharmaceutical and healthcare industry, big philanthropy and NGOs, academia and international health institutions, to continue to grow and prosper.

HIV Testing: Health Services Lack Integrity, Not Legislation

Making HIV testing mandatory in all health facilities is said to be under consideration by Kenya's National Aids Control Program (NASCOP). Mandatory testing is not currently permitted under Kenyan law. However, people seem confused about what is currently permitted, some people thinking they have to comply with whatever a health facility worker requests and others thinking a test is mandatory under certain circumstances, such as pregnancy.

Mandatory testing is being mooted because voluntary testing has not allowed the country to reach its stated target of 80% of people knowing their status by 2013. But it seems unlikely that requiring people to take a HIV test before receiving treatment for various conditions other than HIV in health facilities will increase the numbers of people testing. It may even result in fewer people seeking health services, including HIV testing and counselling.

It will be very hard now to claw back years of ground lost by insisting that 80-90% of HIV is transmitted through heterosexual sex in African countries. But this is what will have to be done to reduce the stigma that still surrounds the virus. It is this very insistance about African sexual behavior that gives rise to the stigma.

Health providers may worry that people will lose confidence in them, and indeed they may. But continuing to lie about sexual transmission and refusing to investigate the relative contribution of non-sexual transmission to HIV epidemics will not help to solve the problem. If health services are to be trusted, they have to find a way to reverse the years of dishonesty. Making HIV testing mandatory, and especially arguing for it on the basis of the same old lies, will be counterproductive and dangerous.

Many of the problems that arise for large scale health programs, including the extremely well funded HIV related ones, stem from a lack of sustainability. Several countries have run out of drugs at various times. Most lack the capacity to monitor for drug resistance, loss to follow up and various other problems. If more people are tested under current conditions, sustainability will be further reduced.

Similarly heavy handed attitudes have resulted in wiespread confusion about the benefits of condoms and the possible side effects of hormonal contraception. Health services often seem to be unable to follow up on initiatives they start, for example, providing adequate counselling, treatment, care and even food and transport to health facilities for HIV positive people. Another dubious health issue is that of concurrency, which has been widely discredited, although it never had much empirical support.

Male circumcision rollout in Zambia appears to be a perfect example of why people may mistrust large health programs, especially ones relating to HIV and sexual health: "A large minority of participants (30% of adults and 45% of boys) gave incorrect answers to one question; they believed that getting circumcised was risk-free and did not have side-effects."

The best way to reduce stigma and allow people to feel less apprehensive about being tested for HIV is to come clean about the relative contributions of sexually and non-sexually transmitted HIV; we don't yet know the relative contributions. Investigating possible outbreaks of healthcare transmitted HIV would go a long way towards reducing people's fears, which may be quite legitimate.

Health and social services also need to be able to guarantee that people found to be HIV positive will receive the treatment, care and support they need, which can include protection from stigma and discrimination. And health facilities have to be able to provide services that don't themselves carry a higher risk of transmitting HIV than various kinds of sexual behavior. There's a long way to go to regain people's trust, but now is the best time to start if we want more people to be willing to find out their HIV status.

HIV Not Very Like Syphilis; Surprised?

If 80 or 90% of HIV transmission is through heterosexual sex in African countries, as UNAIDS says, patterns of infection might be expected to resemble those found for syphilis, at least to some extent. But data collected several years ago in Kenya suggests that syphilis prevalence is relatively low and that there are many differences in patterns of infection.

HIV is more difficult to transmit through penile-vaginal sex, yet prevlance rates are much higher than those  found for syphilis. But also, syphilis prevalence is similar among men and women. HIV prevalence is far higher among women than men in Kenya, overall, and more than five times higher in one large tribal group. Syphilis prevalence does not differ by urban/rural residence whereas HIV prevalence tends to cluster in urban areas. HIV prevalence in some rural areas is very low indeed.

While syphilis prevalence is highest among HIV positive men, HIV wasn't even found to be a significant risk factor for women. Syphilis prevalence tends to increase with age in men and women, whereas HIV prevalence tends to increase at a later age in men than in women, rising to higher prevalence rates among women than men, before dropping rapidly in older age groups among both men and women.

Syphilis prevalence is higher in Yaounde, Cameroon than it is in Kisumu, Kenya, although HIV prevalence in Yaounde is relatively low and in Kisumu it is very high. In South Africa, syphilis prevalence has declined far more rapidly than HIV in a similar period among antenatal clinic attendees.

Syphilis prevalence of over 10% has been recorded among Kenyan sex workers, among whom high STI rates could be expected. However, figures of 70-80% claimed for HIV prevalence among sex workers in the 1980s in Kenya and in the 1990s in Tanzania have never been recorded for syphilis, anywhere. In fact, in some countries HIV prevalence is not particularly high among sex workers unless they face additional risks, such as intravenous drug use.

Poorer men, and poorer women to a lesser extent, are more likely to have syphilis, as are men with lower levels of education. HIV prevalence tends to be higher among wealthier quintiles and among those who have higher levels of education, in Kenya, Tanzania and other countries.

It is worth bearing in mind that high prevalence of STIs does not mean that people necessarily engage in unusually high levels of unprotected sex. It does mean that health services, particularly sexual and reproductive health services, are inadequate.

I am concentrating on the differences between syphilis and HIV, but there are few remarkable similarities. I don't wish to deny that HIV is sometimes transmitted through heterosexual sex, just to question the extent of such transmission. Because, if transmission patterns are not very like those for syphilis, it would be a mistake to characterize HIV as an STI and design HIV prevention interventions accordingly.

Fruitful Discord At Lomborg's Copenhagen Consensus Center?

Up to now, UNAIDS' method of verifying their data has been the equivalent of printing out lots of copies of their reports and concluding that, because they all say the same thing, they must be true. First on the chopping block should be the HIV Modes of Transmission analyses (MoT), which purport to estimate the relative contribution of various routes of infection, sexual and non-sexual. In reality, the data used is a mishmash of guesswork and hot air.

The first paper to be published for RethinkHIV is by Lori Bollinger, who considers the cost effectiveness of non-sexual HIV transmission interventions. It's long and boring. But it's based on data such as that from MoT reports. Much though I'd like to criticize Bollinger's offering, I'll leave that to the authors of the second paper, Rob Baltussen and Jan Hontelez.

They are mercifully brief in their analysis, though they are far from merciful to Bollinger. They question if analyses such as Bollinger's can "really provide estimates that are sufficiently transparent, valid and reliable at the country level", and express serious doubts about the value of her work.

Baltussen and Hontelez don't feel that the models Bollinger uses "reflect the actual epidemiology" in the countries in question. Thankfully, they also doubt the adequacy of the "estimates of the relative contribution of each transmission route to the overall epidemic". In particular, they question the validity of the MoT reports used.

These researchers also examine the claimed impact of various HIV prevention interventions and remain unconvinced. They even have doubts about the costing data used for Bollinger's cost/benefit analysis. They point out that all these limitations are "inherent to the task at hand and therefore virtually inevitable". Baltussen and Hontelez do well to raise the issue of the usefulness of such data; yet much of UNAIDS' HIV policy is based on it.

The list of limitations goes on and on. While it is not one of the authors' conclusions, every criticism of Bollinger's offering is a criticism of UNAIDS, the HIV industry as a whole, and much of the HIV literature that has launched a thousand failed interventions per year for the last 20 years or so. The 'successes' among these interventions are based on grotesque overestimations that remain unquestioned even when program after program has failed to deliver the goods.

Despite unearthing all these limitations in the work of Bollinger, and much of the work of the HIV orthodoxy, the authors agree with Bollinger's conclusion: "that interventions to reduce non-sexual transmission of HIV are generally economically attractive". Which is great, as long as the "absence of comprehensive data" that Baltussen and Honetlez note is also rectified.

I'm still mystified as to the lack of consensus between the first and second paper commissioned by Lomborg and his gang. However, I'm not complaining. It makes a pleasant change to see researchers challenging each other rather than patting each other on the back. A few more papers like this and UNAIDS may even have to revise their lynchpin: the assumption that most HIV transmission in African countries is through heterosexual sex.

At less than five pages, Baltussen and Honetlez's paper is highly significant. But what influence will RethinkHIV have on the HIV orthodoxy? UNAIDS has discredited and branded anyone who has dared to challenge their racist, sexist and highly destructive stance. Will they do the same to these authors, or even to RethinkHIV? Perhaps Lomborg has miscalculated his credibility; HIV celebs gain their strength by supporting the orthodoxy, not by challenging it.

Incidentally, Lori Bollinger says elsewhere in a throwaway remark "the work we do is not about numbers and equations, but about people." But it is about numbers and equations and it is not about people. When Africans are asked about their sexual behavior, their answers show that they are human beings. They have similar sexual behaviors to other human beings. But researchers conclude that Africans 'underestimate' and/or 'overestimate' in their answers, effectively calling them all liars. (Thank you to Dr David Gisselquist for the Bollinger citation.)

Researchers tend to assume as a starting point that African sexual behavior (yes, apparently Africans are all the same) explains extremely high prevalence of a virus that is difficult to transmit sexually. Without this assumption their research is unlikely to be funded or published. But this has resulted in the current impasse in HIV prevention. The way forward is to investigate non-sexual HIV transmission but to use empirical data, not the stuff UNAIDS calls data.

[For more about non-sexual HIV transmission modes, such as unsafe health care and cosmetic services, visit the Don't Get Stuck With HIV website]

HIV Concurrency Theory is Dead; Can't You Smell it Yet?

In their desperation to explain why HIV prevalence is extremely high in African countries, hundreds of times higher than it is in many other countries, UNAIDS have flailed around and grabbed at any new theory that came their way. One of those theories was that overlapping sexual partnerships are responsible for levels of transmission that cannot be explained by any scientific data that is currently available. This is called the 'concurrency' hypothesis.

There remained the problem of showing that concurrency was exceptionally high in areas where HIV prevalence was high. This is still a problem and strong correlations between concurrency and HIV prevalence, even weak ones, have yet to be identified. But a more acute problem was the question of whether high rates of concurrency really would result in high rates of HIV transmission; is concurrency "especially effective in spreading HIV". The answer is 'no'.

Larry Sawers, Alan Isaac and Eileen Stillwaggon used a modified version of the mathematical model and data used by earlier researchers and added in an element that was missing from earlier work; 'coital dilution'. If someone has many partners, they have less sex per partner, on average. They found that, even with very high levels of concurrency, higher than those found in any population, once you add in slightly lower levels of coital frequency, the result is 'epidemic extinction'.

The orthodox view that Africans have inordinate amounts of sex, and inordinate amounts are required to explain massive HIV epidemics found in some African countries, is not supported by logical or empirical evidence. Only simulation models that use non-empirical evidence, or a very selective use of evidence, can 'explain' very high levels of heterosexual HIV transmission. And models that do use empirical evidence show that the orthodox view is wrong.

The authors conclude that "concurrency cannot be an important driver of HIV epidemics in subSaharan Africa. Alternative explanations for HIV epidemics in sub-Saharan Africa are needed." The concept of coital dilution even explains why "polygyny appears to protect populations from HIV", though UNAIDS often cite polygyny as a risk factor in the spread of HIV (note, this is not an argument for the promotion of polygyny, just one showing that it does not contribute significantly to HIV epidemics in Africa).

Indeed, other phenomena cited as factors that increase the spread of HIV are also put into perspective in this paper. Mobile populations, migrants, especially internal and temporary migrants have often been targeted by HIV campaigns. High rates of HIV in, for example, mining populations, were said to be a result of the sexual behavior of those infected. In the light of this research, miners are more likely to have been infected through shoddy health care practices provided by mine owners, who tend to score very badly in the field of corporate social responsibility.

The graphic depictions of epidemics driven by heterosexual sex alone becoming extinct are fascinating and I recommend the article. But there are other questions that were in need of answering before these researchers did this piece of work: why does the orthodox view of HIV, promulgated by UNAIDS and most of the other wealthy HIV institutions, fly in the face of evidence? And how can a view that is so inherently racist be accepted by so many?

But there's no point in wringing our hands in despair now that we know we have spent such a long time and so much money barking up the wrong tree. What are the 'alternative explanations' that these researchers suggest are needed? Eileen Stillwaggon herself has a whole set of suggestions, after all, why should there only be one way to reduce HIV transmission?

Plenty of other suggestions can be found on the Don't Get Stuck With HIV website, which looks at medical and cosmetic risks for HIV transmission. But at least we don't have to subscribe to the orthodox view of Africans as mere victims of their own stupidity, unsafe sexual behavior and lack of consideration for those around them, including their closest friends and relations.

Wangari Maathai's Awkward Questions About HIV Still Unanswered

Many have mourned the death of Wangari Maathai, a great Kenyan woman. But, while she was best known for her environmental advocacy, I would like to note her alleged unorthodox view of HIV. I don't agree with the views that have been attributed to her, but I can understand how confusion might arise about why Africans are so disproportionately affected by the virus. And I applaud anyone for refusing to accept an orthodoxy so logically obtuse and so gratuitously offensive to Africans, and even to women, who are infected in far higher numbers than men.

Maathai is said to have claimed that HIV was deliberately created by Western scientists in order to harm Africans, perhaps to reduce the population. However, Maathi denied that she believes anything like this and expressed a wish that the source of HIV would be discovered, so that such claims could be rejected.

However, the HIV industry expounds two theories of how HIV epidemics occur. The first theory is for non-Africans, at least, for Western countries; HIV is mainly transmitted through male to male anal sex and through intravenous drug use.

The second theory is for HIV epidemics in African countries, regardless of whether they are very serious or whether they are no more serious than those found in many US cities. According to the second theory, 80 to 90% of HIV transmission is through heterosexual sex and almost all other transmissions are accounted for by mother to child transmission.

The problem with having two theories is that there is only one virus. And while HIV really can be transmitted through heterosexual sex, it hardly ever is outside of some sub-Saharan African countries. What is it about heterosexual sex in some African countries that could account for rates of transmission not found elsewhere?

Well, as it happens, such rates of transmission have been found elsewhere. Massive rates of HIV transmission occurred in Romania in the 1980s and in various other countries at different stages in the pandemic, Russia, China, Kazakhstan, Libya, etc. But these appalling rates were only found to have occurred through non-sexual transmission. They resulted from use of contaminated blood products and medical instruments.

When Maathai was later asked about her views on AIDS, she gave a rather cryptic answer. She said "I have always thought that it is important to tell people the truth, but I guess there is some truth that must not be too exposed." Perhaps Maathai realizes that the HIV industry is aware that HIV is unlikely to be transmitted through heterosexual sex, but that it is very likely to be transmitted through unsafe healthcare?

UNAIDS insists that a very small percentage of HIV is transmitted through unsafe healthcare in African countries. But they also advise UN employees that:

"We in the UN system are unlikely to become infected [with HIV through contaminated blood] since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere."

In other words, the UN is well aware that unsafe healthcare is a risk outside of 'UN approved' facilities. But they only tell UN employees, and not Africans. With that in mind, the racist 'highly-sexed African' theory is no longer required to explain why HIV prevalence reaches such incredible levels in some African countries. Perhaps the prejudice is just too media friendly to give up.

Maathai admits that she is not an expert on HIV, but she is not satisfied with the orthodox view (or views), perhaps because that requires one to see Africans as barely human in their sexual relationships, in their family lives, even in their broader social relationships.

As the HIV expert, Dr David Gisselquist has cogently argued (in personal correspondence): "If the virus were different in Africa, wouldn't we be afraid it [would] get on a plane and come to the US/EU? But we are not afraid - which is a dead giveaway that we know whatever is causing Africa's epidemics is something that stays in Africa."

What 'stays in Africa' is unsafe healthcare services, whose potential role in the worst HIV epidemics still needs to be investigated 30 years into the HIV pandemic. Some HIV transmission could be stopped in its tracks, perhaps a large amount of transmission. Maathai questioned the orthodoxy and was rubbished for doing so. But the HIV industry still needs to answer the question.

Why Would Anyone Want a HIV Test, Given the HIV Industry's Prejudice?

There may be some confusion about HIV testing in Kenya at the moment because some news sources are not too careful about saying whether the 40% figure for people never tested is only for adults or whether it's for the whole population. It's likely that the figure is for adults, but it's also likely to be exaggerated. Some people are bound to test more than once and Kenyan facilities may not be able to link multiple tests by one person.

But another confusion could arise about whether people will be 'requested' to be tested every time they visit a health facility or 'required' to do so. The ThirdAge.com article above cites someone who is advocating for testing to be requested. But an article in the Nairobi Star says everyone visiting their doctor will be required to be tested, which is quite a different matter.

According to an article in AidsMap.com, the situation is actually far more serious than the above two articles would have us believe. It cites findings that only 20% or fewer HIV positive people know their status and that at least 50% have never been tested. AidsMap also reveals that HIV prevalence in Kenya has barely changed in the last 10 years, standing at about 7%, despite the level of resources going to treatment and, to a far lesser extent, prevention.

There's a more sober account of HIV testing in Kenya in The Lancet, published less than a year ago. According to this article, the plan was to have 80% of all Kenyans tested by the end of 2010. But the highest they have ever achieved is a few million people per year. And such huge scale programs are challenging, particularly in a country with crumbling health services.

The article makes it clear that there is a big difference between 'requiring' that people be tested and 'requesting' that they do so; the rights of people to choose whether to test are not guaranteed. Nor is the safety of those found to be HIV positive. Given current levels of stigma associated with HIV, it's still very dangerous to inform your partner about your status. Not only are you more likely to test first if you are a woman, you are also far more likely to be infected than your partner.

More HIV testing and then what? If there were support services for people found to be HIV positive, more testing might be a good way of ensuring that the right people get the services. But many people are tested and receivenothing. And as a result of the HIV industry's highly stigmatizing attitude towards HIV among Africans, people found to be positive are likely to be the victims of abuse, persecution and even death.

People who agree to be tested for any disease have legitimate expectations and those trying to persuade them to be tested need to address these expectations. You won't persuade people to be tested if they know that little of benefit and possibly a lot of abuse is awaiting them. So, given that HIV is not just transmitted sexually, we need to stop telling people that it is.

The message the HIV industry is giving may be dressed up in a lot of sweet words, but it sounds like this: 'this person is a HIV positive African, therefore there is an 80% probability that they were infected sexually, or else they were infected by their mother, so they are a slut or a philanderer or in some other way immoral, but we don't stigmatize them at all for that and neither should you'.

Whether HIV testing is compulsory, as one article says, or merely requested, the problem is that people will still risk victimization if they are found to be HIV positive. Stigma does not arise, as Peter Cherotich of the Kenyan Aids Control Program claims, because HIV testing has been voluntary up to now. It arises because HIV 'prevention' programs insist, falsely, that most HIV transmission in African countries is through heterosexual sex. Changing that message may not have an immediate impact on levels of stigma, which could take decades to efffect. But it's a start.

Why Fabricate HIV Data When You've Got the Real Thing?

In the Kenyan Modes of Transmission Survey, which purports to estimate the relative contribution of each HIV transmission mode, the guesstimate for the contribution of men having sex with men is lumped in with a figure that is said to include prison populations.

This is a ridiculous way of estimating the contribution of these different modes of transmission in particular, though the entire document is unlikely to have any verifiable figures. But, as not all men who have sex with men are in prison, not all prisoners have sex with men and not all HIV transmission, especially in prisons, is transmitted sexually, it's difficult to understand why some well paid consultants even bothered to produce the document.

So when you come across an article entitled "Same Sex Hindering HIV Fight in Prisons", you might wonder where they get their figures from. We are promised a reduction in HIV transmission rates because the prisons are introducing 'counselling'. But will the counsellors inform prisoners and prison staff about non-sexual as well as sexual risks? HIV 'prevention' activities tend not to do so.

In a prison, you don't always have that much option about what kind of health care services you receive. It seems unlikely that you will meet with much sympathy if you complain that services don't include sterile procedures. Equally, you are unlikely to be able to choose who shaves your head, how sterile the instruments are or how careful the hairdresser is.

In fact, given the lack of attention to non-sexual HIV transmission through unsterile health care and cosmetic services, it is unlikely that many prisoners would even notice or be aware of the risks they are facing every time they go to the clinic or the barber's. It's as unlikely as non-prisoners knowing such things.

Also, tattooing is said to be very popular in some prisons, as are other forms of body art that involve breaking the skin. Instruments for tattooing and other skin piercing activities are not easy to come by, nor are materials for making paint. This means that they are likely to be reused, perhaps even sold to others.

Drug taking and various forms of traditional medicine, rituals and oath taking may also contribute to the many risks. The extent of male to male sex is not clear. But it is unlikely to represent anywhere near the highest risk of transmitting HIV and other blood-borne viruses in prisons.

Interestingly, Kenya's prison population is given as just over 50,000, which is not inordinately high for a country of more than 40 million people. And HIV rates are said to be less than 7% in prisons, which is about average for the country as a whole. Bear in mind, though, HIV prevalence in Kenya and other high prevalence countries is usually far higher among females, whereas most prisoners are male.

The rates, then, are higher than among Kenyan males, but the figure doesn't seem in any way extraordinary. In fact, it is low enough to make you wonder if male to male sex really does happen a lot in prisons. After all, it seems unlikely that the prisoners have access to safe sex counselling or to condoms.

But the Modes of Transmission Survey is a highly deceptive document. The figures try to make the case for blaming most HIV transmission on individual sexual behavior. Yet there is a body of evidence that a substantial percentage of HIV transmission is not through sexual behavior. Far more likely modes of transmission are unsafe medical and cosmetic services.

Therefore, HIV prevention efforts need to be directed more towards the real causes of its spread, not those imagined by the HIV industry. It's time to stop playing with mathematical models that use manufactured data and produce some real data on HIV transmission in Kenya.

Let Us Give Up Our Anti-Gay Prejudice, But Not Just Yet

What chills me most about the UK’s lifting of the ban on gay men donating blood is not the prejudice that lies behind such a ban, though that is shocking enough; it’s the fact that the UK does not appear to have much confidence in its health services. Their ’12 month deferral period’ instead of an outright ban does little to assuage any fears people may have.

If the blood transfusion services are not able to screen blood that may be contaminated with HIV and other blood-borne viruses, why just ban gay men from donating blood? What about people who face other sexual risks? And what about people who face non-sexual risks, for example, those who receive health care or cosmetic servicesthat may not be 100% safe?

Another question that this issue raises is about how well the blood transfusion service can assess risk if they will not allow a donor to donate blood even if they are practicing safe sex. Are these health professionals telling us that safe sex is not really safe, or that it’s not safe enough? Or are they just telling us that they can’t really guarantee the safety of the blood? Are the donors even safe?

I raise these questions because there is always lot of dithering about blood-borne risks for HIV transmission, especially relative to sexual risks. During the Football World Cup in South Africa last year, the media drooled over estimations of how many sex workers would be operating in the various cities where matches were being played, how many customers they would have and various other salacious irrelevance.

But nothing was mentioned about the risks people could face if they went to a dental clinic, a hospital, a tattoo parlor or even a hairdressing salon. Half a million people descended on a few South African cities, the country with the highest number of HIV positive people in the world, and no mention was made of the most serious HIV risks that exist.

Of course, many people from Western countries travelling to African countries get advice from guide books, embassies, travel shops and travel agencies. But these don’t usually extend to cosmetic services. Should the UK also ban blood donations from foreigners, travellers, migrant workers and others suspected of falling into one of these groups? Or perhaps they would settle for a 12 month deferral period for them, too?

One commentator points out that HIV is not purely transmitted by men having sex with men. This is true, a small percentage of people infected in the UK are not gay and/or not male. And a large percentage are infected through intravenous drug use. But more importantly, HIV is not purely transmitted through sex; it is not just a sexually transmitted disease.

HIV risk is not confined to sexual risk. And while health and cosmetic services in Western countries are far less likely to use contaminated instruments now, compared to in the 1980s, the very fact that people still see HIV as an STD is worrying. It means that they will not recognize serious risks when faced with them, nor will they know how to avoid them.

Health providers have a duty to inform people fully about sexual and non-sexual risks and how to avoid them. A selective ban, partial or otherwise, on those felt to be ‘most at risk’ represents a failure to give people comprehensive advice about all types of risk and leads to a piecemeal and, as it happens, stigmatizing health policy.