Political Smokescreens and the Corporate Barebacking of Africa

English premier David Cameron played the homosexuality card to draw attention to his current flavor of British aid to Africa, but presumably to draw attention away from the fact that the actual amount of aid is shrinking, and perhaps a few other political indiscretions. He probably wouldn't like anyone to scrutinize how much of the aid still flowing is 'ghost' aid, or just a subsidy to British industry and consultancies.

Even less would he like anyone to scrutinize how much money leaves countries like Tanzania, destined for one of those tax havens, most of which are also controlled by Britain, to swell the bulging numbered accounts of wealthy British companies. Of course, some of those companies go bust, but it's Tanzania and Tanzanians who pay the biggest price.

Now the Tanzanian premier, Mizengo Pinda, is playing the homophobia card, which could draw attention away from any number of political shenanigans. The country has "refused to accept homosexuality because the country wants to safeguard its people's moral standards". But is it 'the people's' moral standards that are in need of safeguarding? What about the moral standards of those who have soaked up millions of dollars of aid money every year for several decades?

Will the Tanzanian government ask Britain's Sun Biofuels, or David Cameron's sanctimonious government, to compensate the victims of just one of many land-grabbing operations that both governments ably (and, presumably, profitably) facilitated? Or is the moral 'threat' of homosexuality likely to cause more poverty, more starvation, more disease and more death than all the corporate thieves currently making off with the country's resources while Tanzanians starve?

Just a kilometer down the road from where I work there are cut flower production units, famous for producing cheap flowers for rich countries, with the judicious use of cheap labor, sanctioned by various nice sounding schemes, such as 'export processing zones', trade agreements, etc. A little further away there's a Tanzanite operation, famous for keeping costs low by the use of child labor.

In several regions there are gold mines and Tanzania has the third biggest gold reserves in the whole of Africa. But it's not Tanzania or Tanzanians who get the bulk of profits for these exports, it's not even Africans. There are also uranium mines, coal, natural gas and various other commodities extracted from the country with the use of favorable 'regulation', cheap labor and raw materials, but without the need to pay any more than a few percent to the Tanzanian government, no more than 3% and probably a lot less.

The smokescreen of abortion is used to hide the serious lack of health provision and appalling conditions, especially for the poorest. The smokescreen of contraception aims to hide the use of Africans as a massive market for birth control methods that are considered too dangerous to be used by non-Africans, and there's the use of illiterate and vulnerable people as cheap research fodder for drugs that are ultimately only affordable to Westerners (and sometimes to Western aid budgets).

There's even the (so-called voluntary) sterilization of African women, said to be of global benefit, because population control is the favored development paradigm for many of the best funded international NGOs. Mass male circumcision to reduce 'sexual' transmission of HIV and other diseases hides the fact that the 'global health' industry has no wish to eradicate HIV, or anything else, when it's so lucrative not to do so.

Are all those who are denying Tanzanians their rights, their wealth, their health and their lives homosexuals? Are all thieves, especially the multinational, state-sponsored ones, homosexuals? Is all the 'immorality' one finds in Tanzania so bound up with homosexuality that the issue needs to be raised in parliament and senior politicians need to 'protect' Tanzanians from these terrible threats? Politicians aside, don't Tanzanians realize who is doing the barebacking?

Zille's Rhetoric about Criminalizing Unprotected Sex is Misinformed

South African premier Helen Zille [Sorry, Premier of Western Cape!] shows a worrying level of ignorance about HIV transmission in calling for "men who have multiple sexual partners and refuse to use condoms to be charged with attempted murder." She's right that using condoms reduces the likelihood of sexual transmission of HIV, substantially. But she's wrong if she thinks that HIV is almost always transmitted sexually in South Africa and other high prevalence countries.

Leaving aside the sheer stupidity of expecting to control HIV transmission by making unprotected sex with multiple partners a crime, increased condom use, even consistent condom use, is not always associated with reduced HIV transmission. If HIV were almost always transmitted sexually, as UNAIDS and the HIV industry claim, the effect of increased condom use would be very likely to have the desired effect. But often, HIV prevalence among condom users is the same as among non-users, or even higher.

A study of data from 22 countries shows that HIV prevalence is usually higher among women than among men and higher in urban than rural areas, particularly in high prevalence African countries. Prevalence is also generally higher among the wealthier and the better educated, unlike other transmissible diseases, which tend to infect poor and less well educated people in higher numbers.

But the report is clear on the issue of condom use: use of condoms is generally associated with higher HIV prevalence, among those who use condoms at all, and even among those who use them consistently. In some cases HIV prevalence may be lower, even much lower, but in others prevalence can be much higher. This is not evidence that condoms are not effective. It could suggest that most people don't use condoms often enough. But it is also an indication that HIV may not always be transmitted sexually.

Remarkably, Zille doesn't mention male circumcision, which is another very media friendly thing to throw into a speech. But this report finds that "There appears no clear pattern of association between male circumcision and HIV prevalence - in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher." It is customary for reports to ignore those countries where HIV rates are higher among circumcised men.

Zille and any misguided followers she may have should also read an article showing that sexual risk behavior is generally higher among young people in the US than in South Africa, yet HIV prevalence is many times lower among young people in the US. In South Africa, prevalence among 18-24 year olds was over 10%, compared to less than 1% in the US. Yet, young people in the US become sexually active earlier than those in SA; number of lifetime partners is higher in the US; and use of condoms is lower in the US. There are often greater age differences between females and their partners in SA, but that could only account for a relatively small proportion of transmission.

That article concludes that effective HIV prevention demands an accurate perception of the spread of HIV. This is something Zille lacks. But she's not the only one. Among those also lacking an accurate perception of HIV transmission in African countries are UNAIDS, WHO, Johns Hopkins Medical School, the London School of Hygiene and Tropical Medicine and many others. She's in 'good' company, well-funded company. However, Zille's latest outburst will not reduce HIV transmission and will probably do a lot of damage to SA's HIV reduction efforts.

World Bank: Health Personnel Are Superfluous to Health

There has been a lot of media coverage of countries such as Tanzania (Uganda, Ghana and others) calling David Cameron's bluff on his insistance that British foreign aid should be cut to countries that have laws prohibiting homosexuality. They have told him to butt out of their business. However, if Tanzanians are so concerned about powerful interests interfering with their sovereignty, they would be better off standing up to the far more opressive and damaging strictures of the World Bank.

At around the same time as the HIV/AIDS epidemic was spreading through Tanzania, mainly unnoticed, the World Bank was busy sabotaging the country's post-independence gains in the areas of health, education, infrastructure and social services. This was the bank's policy of 'structural adjustment', which meant that desperate countries, without the ability to repay massive loans, were given massive loans on condition that they cut their public services, regardless of the rapidly growing need for them to be further expanded.

One of the consequences of this was a steady decline in the numbers of people employed in vital areas of public service, such as health. A report into human resource (HR) levels in Tanzanian health services finds that "Between 1994/95 and 2001/02, the active supply of health workers fell from 67,000 [...] to 49,900 health workers [...], an inevitable consequence of the employment freeze imposed by the Government between 1993-1999 in order to balance its budget and receive credits from the World Bank."

The report was a result of research carried out by Sikika in 2010, who have also researched and reported on dangerously low levels of medical equipment and supplies in Tanzanian hospitals. They find that on average, facilities in the area surveyed have less than half of the skilled health personnel they require; they request fewer personnel than they require every year; they receive fewer than they request; many of those deployed, more than three quarters in rural areas, do not take up their position; and attrition rates are high in some professions.

Aside from underfunding of the health sector, the authors suggest that personnel shortages may be partly related to shortages of other resources, such as medical supplies, equipment and pharmaceuticals, which would render many professionals superfluous. This effect could work in both directions, with non-human resources remaining low as long as there are too few personnel available to utilize them.

Funding is undoubtedly a serious issue and Tanzania still only spends 10-12% of its national budget on health, instead of the 15% recommended by the Abuja Declaration. But after more than two decades of neglect, and a budget that continues to be decimated by repayments to the world's biggest loan sharks, the country's health services are unlikely to catch up in the foreseeable future.

The authors make some perceptive recommendations but, without radical reform of unelected bureaucracies, such as the World Bank, IMF, UN agencies, WHO, WTO, and bureaucracies who have no democratic mandate in Tanzania, such as Western governments, the health sector will remain as stunted, malnourished, diseased and incapacitated as many Tanzanian people.

At the mercy of external commercial and political interests, efforts to reduce the spread of HIV/AIDS and to treat and care for those already infected will always be limited. At the same time, the HIV industry's obsession with sex will allow HIV transmission through non-sexual routes, such as through unsafe healthcare and cosmetic procedures, to continue unabated and uninvestigated.

Of course, severe shortages of personnel and supplies don't necessarily mean that hospital acquired HIV infection rates increase. Relatively low rates of HIV transmission in countries like Tanzania (also Kenya and Uganda) may reflect the low capacity of its health services to treat most people. We don't know that for sure; but that's because we have, as yet, no way of estimating the relative contribution of non-sexually transmitted HIV to the worst HIV epidemics.

UK to Impose Gay Rights on Uganda While US Imposes Homophobia

Some may be disappointed by David Cameron's attempt to influence countries that make homosexuality illegal by threatening to cut off foreign aid. Uganda feels that Britain is bullying them and treating Ugandans like children, and I agree. I think homosexuals should be entitled to do whatever they do as long as it doesn't infringe on the rights of others. Nor do I think people expressing their sexuality in whatever way they choose constitutes an infringement on the rights of others.

But why should money that is supposed to be used to improve health, education, social services and infrastructure be used to threaten the government to pass legislation that suits current tastes in Britain? If aid is just a tool to get developing countries to become 'model states' in the eyes of Western countries, this is unlikely to work any better now than it has in the past.

Are Cameron and other Western leaders going to produce a list of desiderata, which can be ticked off as developing countries comply and be rewarded with another project, program, scheme or plan, and a handful of brownie points? The problem with aid in its current form is that it is not working very well. Some might say that is does work, it's just that it was never intended to work for developing countries, that the beneficiaries of foreign aid are the donor countries. That may be so, but what does that have to do with gay rights, or any rights?

Throwing money at the latest CNN moment, Aids, famines, earthquakes, hurricanes and tsunamis, is what it is, sheer posturing. But would Cameron and his fellow statespeople consider it acceptable to say to a country currently being devastated by a disaster, that aid money will be sent as soon as they improve their gender equality situation or their use of child labor (which is probably of far greater benefit to western countries than it is to developing countries)?

People here, and anywhere, can be whipped up into a frenzy about gay rights and all sorts of other things. But these are not the biggest day to day worries faced in poor countries. There's poverty, bad health, low educational standards, rotten infrastructure, inequalities of all kinds, failing governance, corruption and lots of other problems. Gay rights in Uganda are a political issue that can be milked for what it's worth or ignored, whichever political leaders and opinion makers choose at a particular time.

All Cameron is doing is adding to the frenzy. Instead of kicking someone for being gay, they can be kicked for threatening foreign aid monies. But no Ugandan politician, or politician of any country, is just going to back down and say, 'OK, we'll rewrite our legislation, sorry about that'. Bribing and threatening national administrations is not the way to change the attitudes of entire countries and it makes Cameron, and the UK, look stupid. It makes them look as if they don't really understand the concept of 'human rights'.

Cameron needs to go back to the drawing board. Threatening a country with suspension of aid, whatever kind of aid is involved, is not a way of bestowing rights on a population. Rather, it's just another way of taking away people's rights. No doubt, Cameron's tabloid reading supporters will be delighted, but he should keep his tabloid deplomacy for the UK, where he has a democratic mandate.

Interestingly, the BBC reminds us that "Some 41 nations within the 54-member Commonwealth have laws banning homosexual acts. Many of these laws are a legacy of British rule." The problem is not that former British colonies are refusing to be spoonfed, just that they now choose which of the spoonfuls to swallow and which to spit out.

What Cameron could do is go and have a word with his American puppet masters, who have done a lot to stir up the anti-gay fervor in the first place. But before that, he'll have to withdraw his idiotic remarks about withholding aid in return for 'gay rights' in Uganda. Otherwise, rights are whatever those paying the most say they are. Unfortunately, he's going to have to go through quite a transformation to follow this logic.

Injectable Depo Provera: Scientists Blame Media for their Own Indecisiveness

When scientists shout with joy, wave their hands in the air and slap each other vigorously on the back because they have decided that mass male circumcision is great, that concurrent relationships drive generalized HIV epidemics or that one of the latest offerings from the pharmaceutical industry will stop the HIV pandemic in its tracks, the mainstream media report accordingly. That's just how they are; they don't generally report critically, unless some particular flavor of the month is replaced with a new one.

So James Shelton's plea for scientists and the media to give a balanced view about the possible role of injectable hormonal contraceptives (HC) in increasing the transmission of HIV, from males to females and from females to males, seems a little pointless. The media doesn't tell scientists how to report their findings, thankfully. But scientists can't expect to be able to control how the media report theirs. The point of writing a scientific paper is to inform people about research findings. What they do with that information is up to them.

The disagreement about possible undesirable effects of Depo Provera and other injected HCs is not just a disagreement between science and the media. It is also, like a lot of disagreements, between scientists and other scientists. But the people who wrote the recent article in question, Heffron, et al, published in a peer reviewed journal, The Lancet. Although the media refuses to regulate itself and academica has no authority over the media, academia is regulated by other academics. You may not agree with the system, but there is a system.

What Shelton appears to be saying is that Heffron et al's findings don't conform to the mainstream stance that WHO, UNAIDS, USAID, CDC and various others have adopted. He doesn't like what they have reported so he tries to pick holes in the findings. I wouldn't mind if the findings were earth-shatteringly different from many earlier findings, but they are not. The only earth-shattering thing is how long various institutions have delayed issuing decisive guidelines for the use of injectable HC.

Shelton applies (some of) the criteria of Austin Bradford Hill for assessing evidence of causation and his point is clear enough; causation has not been demonstrated. But causation has not been demonstrated in the cases of mass male circumcision, concurrent relationships or the use of various highly lucrative drug programs (such as pre-exposure prophylaxis, treatment as prevention, etc). Yet these attract massive amounts of funding and publicity.

Shelton asks why the media applies so little critical thinking, but surely that's the job of academia, not the media? By the time the media get the press release, or however they are informed of what academia wishes them to know, the critical thinking should have been completed. The media have their own commercial and political interests to consider and these may or may not converge with the commercial and political interests of academia.

But one could ask Shelton and other HIV experts why it has taken so long for them to issue coherent guidance. Doubts about the safety of injectable HC have been around for a long time. Why haven't the various kinds of research Shelton mentions been carried out yet? The sheer volume of denial from academia being directed at what started with one article in the New York Times does not constitute guidance on whether to continue with this birth control method, or to switch to a different method until the safety of Depo Provera and others drugs can be assured.

The tone of those opposed to the findings of Heffron, et al, and others who have questioned the safety of injectable HC suggests that the orthodoxy is not going to change its collective mind on this issue. WHO will meet in January, but they have discussed this on and off for years without ever giving a convincing response to evidence that Depo Provera and similar products may be unsafe.

As with the possible role of unsafe healthcare and cosmetic services in HIV transmission, the HIV industry seems unwilling to scrutinize Depo Provera too closely. They say they are worried about people's sexual and reproductive health, but injectable HC is just one birth control method of many. Perhaps there is something else they are worried about?

WHO on Depo Provera: Deny, Delay, Deflect, Defer, Duh!

Around a month ago, the New York Times ran an article about research suggesting that injectable forms of popular hormonal contraceptives, such as Depo Provera, may increase the risk of HIV transmission to women, and from HIV positive women to men. Faced with the opportunity to give clear advice to women who receive these injections, WHO, UNAIDS, CDC and others have chosen to dither.

Almost all users of injectable Depo Provera and similar products are Africans in low resource countries. This means that they may also face the added risk of unsafe healthcare, reuse of injecting equipment, failure to follow (or even have) procedures to minimize risk of transmitting diseases, especially blood borne diseases such as hepatitis and HIV.

This is not even the first or most egregious instance of these institutions procrastinating over the same issue. WHO published a document in 2007, which was a response to a consultation that took place in 2005. In fact, serious concerns about the use of hormonal contraceptives in general have been raised for over thirty years, and the 2007 document says "The interaction between hormonal contraception and human immunodeficiency virus (HIV) infection has been a concern since the early days of the AIDS epidemic". So the wait until WHO's 'high-level meeting' in January seems minor in comparison to what seems like institutionalized delaying tactics.

Generally, the evidence available has not been very clear and is sometimes contradictory. However, in 2007 they noted that "The available data have been from observational studies conducted among women at high risk of HIV infection." By this, they mean sex workers and clients of STI (sexually transmitted infection) clinics. But the big question about HIV is why prevalence is so high in some African countries, even among sex workers and people with STIs, when this is not the case outside of some African countries?

In other words, being a sex worker, or even being a highly promiscuous person (and therefore at risk of infection with STIs), are not very closely associated with HIV infection among heterosexuals who don't have other risks, such as intravenous drug use, in non-African countries. Whereas, it is mainly heterosexuals with low levels of 'risky' sexual behaior in high prevalence African countries who are HIV positive. How are they becoming infected?

Unsurprisingly, in all the literature I have seen, there is no mention of the possible role of unsafe healthcare in HIV transmission. This is despite the fact that it is the injectable versions of hormonal contraceptives that are associated with higher HIV prevalence. Also, in recent discussions, there has been no mention of a paper published in 2008 which finds that women using injectable hormonal contraception are more than 10 times more likely to be infected with HIV. That's a lot more than the 2 times more likely mentioned in the New York Times article.

WHO and others are worried that people using injectable hormonal contraceptives will stop using them and may not use any alternative form of contraceptive. That is a legitimate worry. But is it preferable to tell people to continue taking these injections when such a high risk of HIV transmission has not been ruled out? What if their 'high level' meeting in January finds that it is better for people to stop using Depo Provera and similar products? Will they apologize to all the people who have been infected in the previous few months, or even years or decades?

We seem to be following the West's agenda, to promote birth control, to espouse the 'population control' theory of development and poverty reduction. But what about the risk of allowing thousands, perhaps tens of thousands of women, to continue using a dangerous product? And what about the future of reproductive health, even general health programs, if the putative beneficiaries find that we have been lying to them?

Gregg Gonsalves on Civil Society; But is it Civil Enough?

In the past, I have had reason to disagree with Gregg Gonsalves, the director of the International [HIV/AIDS] Treatment Preparedness Coalition. I realize that much of what he says applies to the Western, mainly US context. But I am somewhat behind his contention that the global food industry and other big business sectors are not part of civil society, as claimed by the Global Business Coalition for Health (GBCHealth).

The question was asked "Should the industries that profit from unhealthy products be viewed as trusted partners and have a seat at the table during public health negotiations?" and the GBCHealth's answer is yes, that "Companies must have a place at the tables where their future is discussed." There's more of this contemptible, self-serving nonsense but I realize some people reading this blog may already be sick enough.

Industries such as big tobacco, big pharma, the massive food industry, genetically modified organisms and others, will stoop to anything that increases their profits and do nothing that threatens their profits in any way. This does not make them part of civil society, it makes them the polar opposite of civil society. To claim that they should have a stake in the discussions is like claiming that the entire military-industrial complex is part of civil society.

While there are many parties working in and around the HIV industry, many of whom probably do fit into the category of civil society, whose work does little more than increase the dependence of sick people on ever increasing quantities of drugs and nothing at all to prevent sickness in those who are still healthy, Gonsalves seems to have his heart in the right place, though just about (for more about ever increasing dependence on drugs, see my Pre-Exposure Prophylaxis blog).

Actually, even even GBCHealth doesn't try to argue that big tobacco is part of civil society. But they do have the cheek to imply that the food industry has played a part in reducing salt and unsaturated fats, or that they will play their part some day. And they argue that if the industry doesn't play a part, who will? Indeed. And that's exactly why they are not a part of civil society.

Gonsalves objects most strongly to the GBCHealth's use of the struggle for treatment rights for HIV positive people in wealthy countries as supporting the point they are making. All the pharmaceutical industry did, and continues to do, is keep their profit margins high and keep increasing the quantities of drugs sold every year. They have even succeeded in persuading Western governments to divert most HIV related funding to the purchase of drugs to the extent that there is little left for preventing HIV.

I am only somewhat behind Gonsalves' contention because there are many parties who are considered, and not just by themselves, to be part of civil society, for example the Gates Foundation and other 'philanthropic' bodies, certain NGOs, much of the UN and various others, who use their 'concern' about HIV and other issues as a platform for promoting their favorite commercial interests. Perhaps civil society itself is already contaminated enough for big business to feel they should also be included?

Investigating Non-Sexual Risk is the Key to Reducing HIV Transmission and Stigma

In a paper published in 2006, Drs David Gisselquist and Mariette Correa identified five models that purport to demonstrate that the HIV epidemic in India is driven mainly by heterosexual sex between commercial sex workers, their clients and their clients' partners. However, when the authors applied the available empirical data, they found that such heterosexual drivers could only account for a fairly small percentage of transmission.

The models they looked at used exaggerated estimates of the numbers of sex workers, the number of clients, the number of contacts between sex workers and their clients, the percentage of contacts that were unprotected and the number of sex workers and clients who were HIV positive. They also used a very high transmission efficiency figure, which is not borne out by empirical research.

Even using some of the very high figures available, Gisselquist and Correa were not able to account for the estimated number of HIV positive people in India. The claim that almost all HIV is transmitted through heterosexual sex, mainly as a result of commercial sex work, appears to be unfounded. And although estimates of HIV prevalence in India have since been radically revised downwards, it is still vital to identify the main drivers of the epidemic in order to reduce transmission

About 6 years earlier, shocking HIV and sexually transmitted infection (STI) rates were found among 'bar workers' in Tanzania. HIV prevalence was 68%, syphilis was 8%, chlamydia was 12%, gonorrhea was 22%, etc. The fact that both HIV and STI rates were high might be taken to support the assumption that HIV is almost always sexually transmitted. But the article concluded that "few sociodemographic and behavioural variables correlated with STI risk".

As is customary in African countries when collecting self-reported sexual behavior data that doesn't match the expectations of the researchers, the information is considered to be unreliable. Perhaps like the models mentioned above, some figures are overestimates and some are underestimates. But, whereas the unreliable data that conforms to the researchers expectations is used to support policy decisions, data from Africans that is said to be unreliable is ignored or scaled up or down, as required to match the expectations.

In the very different scenarios in India and Tanzania, we end up without an understanding of how HIV is being transmitted and, therefore, what kind of interventions would be most appropriate to reduce transmission, perhaps even eliminate it entirely. Otherwise, we get reports of 'successful' work in the field which is unlikely to have had any real impact, because it fails to address all the drivers of the epidemic.

In the Tanzanian case, not all of the women were sex workers. 58% of them "reported having had one or more casual partners during the past 12 months and approximately 45% reported having received money for sexual favours". But despite the relatively low level of risk, for 68% to become infected, virtually all of them must have been exposed to HIV, perhaps several times. So what kind of exposures did they face? HIV prevalence among men is far lower than it is among women in most parts of Tanzania.

Currently, national HIV prevalence in Tanzania is roughly the same as that among sex workers in India, about 6%. Sex workers in India and ordinarly adults in Tanzania do not face high enough levels of sexual risk to explain high rates of sexual transmission. And only imaginary levels of 'unsafe' sexual behavior and sexual transmission probability could result in 68% of any population being infected through heterosexual sex.

In desperation, the authors suggest that "male clients of female bar workers may function as a bridging group for HIV transmission in the general population". (Notice how these bar workers are assumed to be sex workers, despite evidence to the contrary.) But this kind of model of transmission does not work when trying to explain a generalized epidemic, as Gisselquist and Correa have shown. It only explains a small percentage of transmission. What other risks do people face, not just sex workers?

Smug, self-administered pats on the back, like the one the Gates Foundation gives itself for work with sex workers in India, does not explain how HIV is being transmitted. Rather, it ignores the fact that HIV is being transmitted non-sexually, perhaps through unsafe healthcare and cosmetic practices, as well as sexually. The clear need for an investigation into the roles of various non-sexual routes of HIV transmission has long been demonstrated, over and over again.

How many more years will it take before researchers are willing to divert some of their attention from sexual behavior and look carefully at the non-sexual risks that people in developing countries face? Stigma doesn't arise because of lack of understanding about HIV transmission, it arises because the HIV industry insists that 80-90% of the virus is transmitted sexually. The key to reducing HIV transmission and HIV related stigma is one and the same: investigating the relative contribution of various forms of non-sexual risk.

[For more about non-sexual HIV risk from unsafe healthcare and cosmetic practices, see the Don't Get Stuck With HIV site.]

All States Should Provide Safe and Legal Abortion and Contraception, Says UN

The UN has just issued a report on "the right of everyone to the enjoyment of the highest attainable standard of physical and mental health", with particular reference to "criminal laws and other legal restrictions relating to sexual and reproductive health and the right to health" in the areas of "abortion; conduct during pregnancy; contraception and family planning; and the provision of sexual and reproductive education and information".

The report concludes that "Realization of the right to health requires the removal of barriers that interfere with individual decision-making on health-related issues and with access to health services, education and information, in particular on health conditions that only affect women and girls."

Removing laws that criminalize abortion and various types of contraception could allow women access to safe sexual and reproductive healthcare and reduce the use of back street abortion clinics, which threaten the health and lives of women who use them. I say 'could' because it is doubtful if most women in low income countries, where use of such clinics is thought to be highest, have access to safe healthcare of any kind. But if abortion is no longer a criminal offense, the clinics should become less viable.

The need, or perceived need, for an abortion arises from sexual behavior involving males and females. Yet it is the subsequent behavior of the woman that is penalized. Denying women the right to make reproduction-related decisions and failing to provide the requisite health services is discriminatory. As the UN report says, the woman can suffer if she abides by the laws and be punished by law if she does not.

Unsafe abortions are estimated "to account for nearly 13 per cent of all maternal deaths globally." They also cause serious injuries to around 5 million women every year. The majority of these injuries and deaths occur in poor countries. In Tanzania, abortion complications are in the to 10 reasons for admission in many regions.

It's heartening to hear a UN agency calling for safe healthcare provision of any kind, not just for sexual and reproductive health. The report includes a call for creating all the conditions, trained personnel, equipment and supplies, etc, that will enable the provision of safe healthcare to those requiring abortion, contraception and other information and services.

The report cites evidence showing that access to family planning can reduce maternal deaths by between 25 and 40% and also reduces the number of unsafe abortions. They even cite the 98% effectiveness of condoms in preventing pregnancy, when used correctly and consistently. This is a figure most of the HIV industry avoid in order to stay in favor with donor country leaders, who need to at least appear to conform to whatever moral orthodoxy keeps them in the driving seat.

This report places welcome emphasis on the provision of accessible and safe health services. It also emphasizes the importance of access to information, the education to act on the information and the autonomy to make informed choices. Removal of criminal laws and legal restrictions is only the first step. I wonder if UNAIDS will read the report.

Another Unconvincing Plea for Male Circumcision to Prevent HIV

Yet another article has appeared arguing that male circumcision (MC) is one of the most effective ways of reducing HIV transmission, as if the sheer number of articles published is enough to make the case for the strategy. The number of articles questioning the effectiveness of MC may be smaller, but that could be related to the way HIV funding tends to support those who fight for the orthodoxy, to the death, as it were.

Because MC would only be likely to have an effect on sexually transmitted HIV, at best, those arguing for its effectiveness must also argue that most HIV is sexually transmitted. The usual array of 'evidence' for this is presented. But not so much of the available literature arguing against this view, also subject to the vagaries of HIV funding decisions, is presented.

Date about infections in children whose mothers are HIV negative, virgins, those who always practice safe sex and various other phenomena are in urgent need of investigation before non-sexually transmitted HIV can be dismissed as almost irrelevant, as it currently is by many researchers.

But there are many questionable claims in the article which it is beyond the scope of a blog post to go into. So I'll just concentrate on a few. Firstly, arguments for MC using the 'mainly heterosexual transmission' assumption are not appropriate to infant circumcision. The fact that infant circumcision is cheaper and more 'convenient' does not alter the need for separate arguments for routine infant circumcision, if such arguments exist.

Secondly, much of the evidence presented for the effectiveness of MC in reducing HIV transmission is similar to data on correlations between low HIV prevalence and high rates of female genital mutilation. Yet, no one is using this evidence to argue for the adoption of such a strategy, thankfully. But HIV rates are often far higher among females than males, so female genital mutilation could be made to seem an even more effective intervention than MC, using similar arguments.

Thirdly, countries with high HIV prevalence may not be ready to carry out so many operations, while at the same time guaranteeing the safety of patients. The article cites some eyewatering claims about numbers of people circumcised in Kenya but also notes that:

"of 81 government health facilities surveyed in Nyanza (the target location of MC services), none had the capacity to implement the full package of voluntary circumcision outlined in the national guidelines. Challenges included lack of a theatre, MC kits and supplies, medical personnel to perform the procedure, and data monitoring tools. Due to this, most of the reported 230,000 circumcisions were done by partner organizations largely in high demand settings using mobile teams."

With those findings in mind, is it credible that less than 1% of HIV transmissions in Kenya and other high prevalence countries results from unsafe injections and blood transfusions combined? Kenya may be a showpiece for mass MC programs but will the sort of money put into these programs also be made available in other countries for the next 10 to 20 years? And what about routine infant circumcision, which proponents also insist on?

Finally, some research suggests that, while MC may reduce female to male transmission of HIV, it does not reduce male to female transmission. There have even been suggestions that MC may increase transmission of HIV from males to females. This possibility needs to be investigated before any useful assessment of the effectiveness of MC can be made. Far more females than males are infected with HIV in high prevalence African countries.

It's interesting to pay some attention when reading peer-reviewed articles to the rhetorical tone adopted, the presumptuousness, the triumphalism, the selective use of data and superficial treatment of anything inconvenient, even the self-conscious use of journalese, like "magic bullet", "tool box", "perfect storm" and "surgical vaccine". But there would appear to be a lot of questions remaining to be answered before mass male circumcision programs can safely be scaled up.

[For information on how to protect yourself from HIV infection during medical circumcision, see the Don't Get Stuck With HIV site.]

'Development' Actors to Benefit Most from Underdevelopment?

The Gates Foundation has dabbled in a number of global issues, infamously, genetically modified organisms and other exploitative technologies, also sexual and reproductive health in developing countries (in addition to rich ones). A recent article published by the peer reviewed Lancet gives credence to the far-fetched claim that 100,000 new HIV infections were 'averted' in India as a result of one of the Foundation's vertical programs.

Gates has also attached his name to polio 'eradication', another vertical approach, which aims to eradicate a single disease with the exclusive use of vaccines. Polio has been eradicated in countries with good standards of living and modern water, sanitation and hygiene infrastructures and universal access to these social services. Without these, polio is likely to return, as it has in Kenya and several other countries in recent years.

The partial eradication of a disease can cause added problems because a population can lose its resistance, for example, cholera. There is currently a massive cholera epidemic in Western and Central Africa, the biggest in a long time. Tens of thousands are infected, thousands have died and the fatality rate is exceptionally high, at five percent.

The epidemic area stretches from Nigeria, the most populous country in Africa, down to Democratic Republic of Congo, one of the largest, bordering on over 20 countries. A vaccine for cholera would be great, if and only if people living in these countries also gained access to clean water and sanitation. Without this, eradication will be elusive.

Infection with polio, cholera and malaria, another Gates Foundation 'vertical', even rotavirus and guinea worm, are all related to the conditions in which people live. Providing people with endless vaccinations, pills and powders may be a good way of disbursing the Gates billions and enriching the Gates Foundation's portfolio, but it won't, on its own, eradicate diseases.

Insecticide treated bed nets, which are a good idea as one part of a public health program, are not going to eradicate malaria either. As long as people live in malaria breeding grounds, which many people in African countries do, they are likely to be infected. Even throwing in some insecticides such as DDT misses the point that people who live in slums will get slum diseases.

Gates and others tinkering in development may put some well publicized resources into water, sanitation and hygiene, but nothing compared to the amount spent on vaccines and other technologies. This only emphasizes the fact that if you target a handful of diseases with pharmaceutical products, polio, guinea worm, malaria and rotavirus for example, you can spend billions and fail to eradicate anything because people rattling with pills still need clean water.

Development has become dominated by a number of highly publicized but often narrow issues, with a big name attached, such as Bill Gates, Bill Clinton, Jimmy Carter, Bono, Buffett and the rest. But the issues are bigger than all of them put together. In just one country in Africa, Tanzania, neither the biggest nor the most populous, it would take substantial amounts of money to provide everyone with adequate water and sanitation and to provide them with housing that is not a breeding ground for the biggest killers of all, water-borne diseases, acute respiratory infections and a few others.

But it would take more than money. The aforementioned egos would need to cooperate with the people of Tanzania and the Tanzanian government, rather than just imposing their clever schemes from above. They might then notice that Tanzania is not a big bunch of sick people looking for a 'cure', but a population with basic human needs, food, water, shelter and the like.

Ensuring that people don't suffer from easily prevented diseases by providing them with basic human needs is the 'grand challenge' that will not be met as long as it is not a target. Barriers to development, and there are many, will also need to be removed. But some of those barriers involve large scale marketing of pharmaceutical and other products to unsuspecting people, which appears to be the source of much of the Gates Foundation's funding. Far from being a big player in development, the Foundation may be one of the biggest beneficiaries of underdevelopment. It's sustainable, but is sustaining underdevelopment what we want?

Did Gates Foundation's Avahan Project Really Avert 100,000 HIV Infections?

The Lancet's article 'Assessment of population-level effect of Avahan, an HIV-prevention initiative in India' makes interesting reading, not least because most HIV prevention 'initiatives' appear to be assessed in a cursory manner, as if all effort goes into finding good news and burying bad news. The researchers go to great lengths to present figures and analyses that would allow anyone to judge the merits of Avahan themselves.

The paper is not especially accessible to the layperson, nor is this the responsibility of the authors. Making it so accessible is a job for the scientific media. But they seem shy of doing any more than repeating the publicity mantra about the Gates Foundation's work averting 100,000 new HIV infections over a period of five years in a population of 300-330 million. It's "all thanks to a Bill & Melinda Gates Foundation...project, called Avahan", says the Times of India.

The BBC doesn't gush so much, but nor does it give the reader any reason to question the headline figure, suggesting that The Lancet study confirms that the investment (of $258m according to BBC and The Lancet, $338m according to Times of India) paid off. They cite The Lancet paper's claim that Avahan "had a beneficial effect" and that the findings support "investment in well-managed HIV prevention programmes", neither of which are terribly surprising.

But behind the hype, and even The Lancet article seems to accentuate the positive, what the researchers found was a rather small effect with a very large margin of error. While you would expect a set of interventions to have some effect, as opposed to none at all, this project involved a very large investment over a relatively long period of time.

There are two reservations I have about this study, the first being my overall reservation about HIV prevention interventions; HIV is not all, perhaps not even mainly, sexually transmitted. While this program also targeted risk groups who face non sexual risks, such as intravenous drug users, author Lalit Dandona tells the Times of India "HIV mainly spreads in India through sexual intercourse".

My second reservation is the contention that "interventions like safe-sex counselling by peers, treatment for sexually transmitted infections, distribution of free condoms and needle and syringe exchange programmes among the most-at-risk population prevented the virus from spreading among the general population" (my emphasis); I don't believe that HIV spreads, to any substantial extent, from 'high risk' populations to the general population.

Consider the high prevalence groups in African countries, such as Kenya. They are not 'high risk' populations in the sense HIV researchers use, they are not primarily sex workers, men who have sex with men, intravenous drug users or even truckers. The mystery UNAIDS doesn't like to acknowledge is how people who don't have 'high risk' behaviors can have such high HIV prevalence, considering how slowly HIV spreads through penile-vaginal sex.

High prevalence groups, such as members of the Luo tribe in Nyanza province, do not appear to 'spread' HIV throughout the country, not even to the neighboring people of the Kuria and Kisii tribes or those of the Luhya tribe in the province just North of Nyanza, where HIV prevalence is far lower. The population of Nairobi and other high population density areas do not 'spread' HIV to low population density areas.

While prevalence among Luhya overall is far lower than that among the Luo, prevalence among Luhya women is far higher than it is among men. As a high prevalence group, Luhya women don't even appear to 'spread' HIV among Luhya men very efficiently. There are 10 infected Luhya women for every 1.7 infected men. Many high HIV prevalence groups do not have identifiably high sexual risk behaviors.

Treatment of sexually transmitted infections, while important in its own right, has not been shown to have much impact on HIV transmission. Similar remarks apply to distribution of free condoms; condoms do protect against HIV transmission, but only sexual transmission. And needle exchange programs do reduce HIV transmission among intravenous drug users (though perhaps not as effectively as is sometimes claimed). But these 'high risk' groups have never been demonstrated to 'spread' HIV among the general population.

As the opening sentence of The Lancet paper says "The aim of Avahan...was to reduce HIV transmission in the general population through large-scale prevention interventions focused on high-risk groups." Sex workers, their clients and their clients' partners, intravenous drug users and their partners all together don't account for a large proportion of HIV transmissions in countries where Modes of Transmission Surveys have been carried out.

While much has been made by the media about men who have sex with men also having sex with women, it has not been shown that this plays a significant role in 'spreading' HIV from this group to the general population. The number of men who have sex with men also having sex with women is unlikely to be very high, so the number of women involved is also going to be low. This phenomenon is probably far more significant in the minds of journalists (and possibly researchers) than it is in the real world.

The research does not show any mechanism by which HIV prevalence somehow radiates out from 'high risk' groups to the general population through sexual behavior. Nor does it shed any light on how people who only face low sexual risk levels are infected at higher rates than could be expected. It would be disturbing if the several thousand dollars per infection 'averted' failed to avert any infections, but it is unlikely that the number is anywhere near 100,000.

With HIV, it appears that 'high risk' does not always result in high prevalence, and high prevalence has not always been explained by high risk levels. This is a serious anomaly and HIV research that fails to account for it will be flawed at best, totally invalid at worst.

Resolved: We Must Stop Ignoring Bloodborne HIV in Africa

Why do so many HIV-positive children in Africa have HIV-negative mothers? For example, approximately 30% of HIV-positive kids aged 0-11 years have HIV-negative mothers in Mozambique (see pp. 177-181 in: http://www.measuredhs.com/pubs/pdf/AIS8/AIS8.pdf)


Why are so many virgin men and women found with HIV? In the Republic of Congo, for example, virgin women aged 15-49 years have higher HIV prevalence than all women, 4.2% vs 4.1%
(see p. 101 in: http://www.measuredhs.com/pubs/pdf/AIS7/AIS7.pdf)


The personal stories behind these statistics are hard to fit with the common view that almost all infections are from sex. Why has there been so little attention and response to Africans with unexplained infections?


THE PURPOSE OF THIS NOTE IS TO INITIATE DEBATE ABOUT WHETHER TO CONTINUE TO IGNORE NON-SEXUAL HIV INFECTIONS IN AFRICA.


To do so, this note presents four arguments for AIDS activists, both in Africa and elsewhere, to recognize and respond to HIV from skin-piercing procedures in African health care and cosmetic services.


1. DE-STIGMATIZING HIV/AIDS: Programs for HIV prevention in Africa – including especially foreign-funded programs -- focus almost exclusively on sex. With all attention on sex, the emotions, prejudices, and controversies around sex naturally spill over into HIV programs. Thus, it is not only wrong to think that all African HIV comes from sex (see points 3 and 4, below), but also confusing and distracting. Currently, stigma against HIV is so great that most people with unexplained infections keep silent, so as not to be accused of sexual behaviors that some people don’t like. When the public discourse is corrected to recognize blood-borne as well as sexual HIV (see: http://dontgetstuck.wordpress.com), people with HIV from blood risks will be able to speak out without facing stigma compounded by charges they are lying. And they will then be able to contribute to public efforts to make health care and cosmetic services safe.


2. PREVENTING HIV INFECTIONS: Ensuring that medical facilities are safe will not only prevent HIV infection but also the transmission of other blood borne pathogens. Across Africa, HIV prevalence is lower in countries where more people are aware of blood-borne risks for HIV; see: http://dontgetstuck.wordpress.com/africans-aware-of/


3. SEX ALONE CAN’T EXPLAIN AFRICA’s HIV EPIDEMICS: All attempts to explain Africa’s epidemics as exclusively sexual have failed to find anything that is so different about sex in Africa that could account for Africa’s high rates of HIV prevalence. Studies find that Africans have fewer partners and use condoms more than Americans and Europeans.
Circumcision is less common in Europe than Africa. Sex can’t explain how HIV prevalence is lower after long term wars, and among people living further from health clinics. Sex is a risk for HIV because so many Africans are infected – but how are so many infected?


4. EVIDENCE THAT AFRICANS GET HIV FROM SKIN-PIERCING EVENTS: A lot of evidence shows HIV transmission through skin-piercing procedures in Africa. Evidence is both old and new. For example:


(a) In 1985, Project SIDA in Kinshasa, Zaire (now the Democratic Republic of Congo), tested inpatient and outpatient children aged 1-24 months and their mothers for HIV. Seventeen (39%) of 44 HIV-positive children had HIV-negative mothers. Among children with HIV-negative mothers, “medical injections seemed to be the most important risk factor for HIV…” The study team noted, “Injections are often administered in dispensaries which reuse needles and syringes yet may not adequately sterilize them” (Mann et al, Risk factors for human immunodeficiency virus seropositivity among children 1-24 months old in Kinshasa, Zaire. Lancet 1986, ii: 654-7. p. 656.)


(b) Around 1990, WHO’s Global Programme on AIDS coordinated a study in Rwanda, Uganda, Tanzania, and Zambia to test in-patient children 6-59 months old and their mothers for HIV. Sixty-one (1.1%) of 5,593 children were HIV-positive with HIV-negative mothers; only three had been transfused. WHO experts concluded “the risk of non-perinatally acquired HIV and of patient-to-patient transmission of HIV among children in health care settings is low” (Global Programme on AIDS. 1992-1993 Progress Report. Geneva: WHO, 1993). A similar conclusion would be unthinkable if 1% of inpatient children in London, Boston, or Seoul were found with non-vertical HIV infections.


(c) A study among women in Malawi, 2003-05, found that women who had received hormone injections for birth control were 10.4 times more likely than other women to return with incident HIV infections, and 23 of 27 women with incident infections had received such injections; relative risk was adjusted for age, bacterial vaginosis, and number of sexual partners; reported condom use was uncommon for both women who acquired HIV infection (11.5%) as well as for those who remained HIV-negative (15.1%) (Kumwenda et al. Natural history and risk factors associated with early and established HIV type 1 infection among reproductive-age women in Malawi. Clin Infect Dis 2008; 46: 1913-1920).


(d) Many other studies in Africa link incident HIV to injections, report virgins with HIV, and report kids with HIV but HIV-negative mothers (see Chapters 7, 8, and 9 of Points to Consider, available for free download at: http://sites.google.com/site/davidgisselquist/pointstoconsider).


PROPOSAL: Let’s dialogue about this at these websites – http://aidsperspective.net/blog/, http://hivinkenya.blogspot.com/, http://blogs.poz.com/sean/,http://dontgetstuck.wordpress.com/ http://signpostonline.info/ – about the evidence, what to do, anything else relevant to the issue.


Simon Collery, David Gisselquist

RethinkHIV Demonstrates Failure of Vertical Health Interventions

RethinkHIV, in their great wisdom, have ranked 18 types of HIV prevention intervention, or eighteen interventions that have had HIV prevention powers attributed to them. Remember, these are all ranked on their presumed economic costs and benefits, not on any data about how well they might reduce HIV transmission, or any other consideration for that matter.

The top five are vaccines, infant male circumcision, prevention of mother to child transmission, making blood transfusions safe and scaling up antiretroviral treatment. Vaccines don't exist yet. But assuming that when they do they will actually be used where they are most needed, unlike most health resources, they might have some impact.

Infant male circumcision is idiotic as most infants don't have sex and circumcision only protects against sexually transmitted HIV, if it protects at all. The arguments for adult circumcision are dubious enough but those for infant circumcision are entirely without foundation. Whatever your stand on male circumcision, there is no reason for performing the operation 15 or more years before it might have some impact.

Mother to child transmission has been very successful in rich countries but in poor countries, and all high HIV prevalence countries are poor when it comes to health spending and quality, the women who are infected with HIV should never have been  in the first place. Many of them didn't get HIV from their sexual partner and the main risks they face are probably non-sexual, such as unsafe healthcare and cosmetic practices. If HIV infection in mothers was prevented, mother to child prevention would be taken care of.

Mother to child transmission programs often forget the 'mother' element, aiming to improve headlining child related (and Millennium Development Goals related) indicators and giving relatively little attention to the maternal indicators. One of the best ways to improve the health and welfare of a child is to do so for the child's mother first. Indicators are a means to an end, though you wouldn't think that sometimes.

Making blood transfusions safe is the august group's number five, which is good to hear. But most national AIDS strategic plans already claim to have achieved this. They haven't, but cost benefit estimates based on the questionable figures UNAIDS provides for HIV transmission through contaminated blood are not going to be reliable anyway. Similar remarks apply to their number six, making medical injections safe, which is only considered 'good', as opposed to the 'excellent' first five interventions.

But all 18 of the interventions considered, from the most cost effective to the least, suffer from the same problem: they all assume that HIV transmission occurs in a social vacuum. And the academics in question are supposed to be considering HIV as a sexually transmitted infection! No disease is independent of the people it infects, the hosts, no matter how it is transmitted (or even if it is non-transmissible). And no disease is independent of the environment in which it is transmitted.

A recent paper on the failure of 'vertical' approaches to health was discussed on this blog a few days ago. Every intervention examined, admittedly from a purely economic point of view, is of little or no use if there is barely any health infrastructure, low levels of education, high levels of inequality and the like, in the most affected countries. Vertical approaches have been failing for decades. Applying them to HIV has failed. But no one informed the Copenhagen Concensus Center.

The interventions that aim to reduce HIV transmission by making blood transfusions and medical injections safe would have an impact beyond HIV alone. This could also reduce nosocomial transmissions of hepatitis B and C, a large percentage of which is transmitted in hospitals and clinics. These measures could also reduce other nosocomial transmissions, such as bacterial infections.

But otherwise, the entire exercise carried out by Bjorn Lomborg, his Nobel Laureates and some other assorted geniuses seems like an expensive waste of time. Perhaps it's good that the Danish Government is cutting funding to their research. But let's hope they divert the funding to broader health projects, ones that certainly don't target a single disease or type of disease; perhaps they could look at health systems strengthening.

One of the biggest dangers of many of the most popular HIV and other sexual and reproductive health interventions is that they are carried out in badly equipped and funded health facilities, often staffed by badly paid and badly trained personnel. Worse still, many health procedures are carried out in makeshift facilities, by people with no training at all, or even in people's own homes.

Before health programs can be successful, health facilities need to be accessible and safe. There is a need for funding that goes way beyond that of HIV, or sexual and reproductive health more generally. But even HIV and sexual and reproductive health issues can not be addressed until health facilities are vastly improved.

The Deadly Arrogance Behind Trials of HIV Prevention Interventions

In a review of randomized controlled trials for HIV/AIDS prevention interventions in Africa, Dr David Gisselquist finds the HIV community somewhat wanting when it comes to tracing the source of infections, asking questions about non-sexual as well as sexual risks and failing to report findings that don't support the prevailing orthodoxy.

As Gisselquist points out, HIV is transmitted through memorable events, be they sexual or skin-piercing. Despite all the reports of 'African' sexual behavior, most people remember a fair bit about their own sex lives, with whom they had sex, when, how often, what kind of sex, etc. Stigmatizing the whole issue of HIV by branding Africans as sex obsessed doesn't help collect information about sexual behavior, but data could be collected.

The problem is that researchers tend to disbelieve Africans when they list no or very few partners, no or very little sex, relatively low levels of risky sex, little sign of promiscuity, an adult attitude towards sex and reproduction and a humane attitude towards sexual partners, friends, family members and children, especially their own children.

Researchers tend not to ask at all about non-sexual risks, which often carry a far higher probability of transmitting HIV and other blood borne diseases; some of these risks are extremely common. For example, it is rare to find data on shaving other cosmetic practices, dental visits, hospital and clinic visits and various medical procedures that could involve the use of unsterile equipment. Or if they ask, they don't seem to report the responses.

Many HIV positive people would be able to remember most or all the events that could have led to their infection, if only they were asked. Many would be able to cite such events, even if not asked, if only they were taught to watch out for those risks as assiduously as they are taught to watch out for relatively low risk sexual experiences, such as penile-vaginal sex with their only sexual partner.

The review identifies 44 randomized controlled trials, following more than 120,000 adults in Africa which saw over 4,000 infections during the course of the trials. But interventions that assume almost all HIV transmission to be sexual, even where the intervention may reduce transmission, will likely fail to identify the circumstances that give rise to massive rates of transmission only found in some African countries. These interventions all failed in this respect.

In general, where people were said to have been infected sexually, no attempt was made to test their partner or to identify a sexual partner who was also HIV positive. No effort was made to identify non-sexual risks, either. So the UNAIDS advice to "know your epidemic" in order that you may "know your response" can not be followed, even by UNAIDS.

It is not even possible to carry out further analysis of data because it was either not collected or has not been made available by researchers. And the review raises a number of serious ethical issues in the RCTs. Six of the studies did not warn participants that their sexual partners were HIV positive, which meant they could have avoided a serious risk of being infected. It is not known how many people became infected in this way.

The review recommends that African governments should insist on trials being carried out ethically, particularly by following protocols that would be required in the countries funding the research. In addition to being carried out ethically, data that is relevant to risks should be collected and made available to the research community. And all data that is relevant to HIV risk should be collected, not just sexual risk behavior.

The findings of this review are truly shocking. That Western governments can carry out such research, knowing the effect they are having on innocent people, is sickening. The fact that African governments allow these trials to take place under such conditions is also horrifying, though it does not exonerate the Western governments involved.

But the most frightening thing of all is that these trials have taken place with the full participation of some of the most highly educated people, using the latest research and equipment, with some of the biggest health research funds ever awarded, over so many person years....

Far from reducing HIV transmission or finding out why transmission is so extraordinarily high in some countries, these randomised controlled trials appear to have allowed avoidable HIV transmission to occur, perhaps even hastened transmission in some instances. This is arrogance on an appalling scale, the consequences of which are deadly. And all done in the name of HIV prevention.

[Dr Gisselquist's review is available in various formats on the Don't Get Stuck website's download page.]