We do them in Black for 14.99

I was recently sent an article which stated that “Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.”

The operation is provided free of charge. But this ‘intervention’ randomized participants into three groups, the first receiving about $2.50 in food vouchers, the second receiving about $8.75 and the third about $15, conditional on getting circumcised within two months. There was also a control group of men who received no compensation.

You may wonder why an operation said to be so highly beneficial requires a financial incentive; your wonder may (or may not) be assuaged by the assurance that some men face certain “economic barriers to VMMC and behavioral factors such as present-biased decision making”.

‘Present-biased’ suggesting that people will not spend money now on something that promises a future benefit only. However, perhaps these men don’t see any benefit; perhaps they use condoms, have only one, HIV negative, sexual partner, don’t have sex at all, live in a place where HIV prevalence is extremely low (there are many in Africa, far more than places where prevalence is high), etc. It’s also unclear what proportion of HIV is transmitted through heterosexual sex, which is the only mode of transmission circumcision enthusiasts even claim to reduce.

So those providing the operation propose ‘compensating’ each man for some of the costs involved in having the operation, possibly including the opportunity costs of missing work for a few days. You could argue that there will be no net financial benefit, and that this is nothing like bribing people to conform to a practice that some western donors from rich countries see as beneficial, but that the majority of people, even in rich countries, consider useless, perhaps even harmful.

The claimed future ‘benefit’ comes to this: one person out of every one hundred or more men who are circumcised (we don’t know the number because mass male circumcision trials have been biased towards showing the effectiveness of the operation) may be ‘protected’ from infection with HIV; ‘protected’ if it really is the circumcision that protects the man; no causal protective mechanism has ever been convincingly demonstrated.

The upshot of the trial will not surprise anyone. Hardly any of those in the control group went on to avail of their free circumcision. Slightly more of the men receiving $2.50 did so. The same goes for those receiving $8.50 and those receiving $15. But the overall impact was “a modest increase in the prevalence of circumcision after 2 months”.

The several hundred thousand Kenyans claimed to have already agreed to be circumcised under these mass male circumcision programs (many of whom would have been circumcised anyway in accordance with tribal practice), and the millions claimed to have been circumcised under similar programs in other African countries, may be disappointed that they will not receive anything at all to reflect “a portion of transportation costs and lost wages associated with getting circumcised”.

Depending on whose figures you use, circumcisions in African countries are claimed to cost as little as $60. Other figures suggest that the cost is at least twice that, and NGOs profiting from these programs would have an interest in claiming costs as high as possible. All the figures are puny compared to what the operation would cost in a rich country. But with an estimated 22 million men said to be currently eligible in Africa, and several tens of millions more boys not counted in the original estimate, just how much money is available?

Much of the literature about mass male circumcision is about notional economic benefits and quite superficial issues, such as assumed cleanliness and hygiene (for which there is no evidence), aesthetic aspects, improved sexual experience, and the like. Very little is about ethics, politics or, god forbid, human rights.

The ‘benefits’ of circumcision are easy enough to exaggerate and any disbenefits can be discounted because the ‘beneficiaries’ are male Africans, whose ‘unsafe’ sexual behavior is said to be responsible for the bulk of HIV transmissions.

To those promoting mass male circumcision, the useless piece of flesh on the end of a penis is a man, an African man, at that. Whereas the foreskin represents a vast funding opportunity and permits unbridled expression of a pathological belief in the multiple virtues of genital mutilation. The right to bodily integrity has, apparently, been suspended.

Uganda’s HIV Prevention and Control Act May Fall Foul of Itself

The Ugandan HIV and AIDS Prevention and Control Act, 2014, has been rightly criticized for potentially criminalizing certain kinds of HIV transmission and for compelling pregnant women (and their partners) to be tested for HIV.

It is felt that the law will result in people avoiding testing in order that they cannot be accused of attempted or intentional transmission of the virus. However, pregnant women who are not tested are unlikely to receive prevention of mother to transmission treatment or treatment for their own infection.

But there are other flaws in the act, which appears to have been put together in a hurry and without any proof reading. For a start, it seems to be assumed that HIV is almost always transmitted through sexual intercourse, aside from transmission from mother to child.

In Uganda, this is ridiculous. Children with HIV negative mothers were found to be HIV positive in three separate published studies, in the 80s, the 90s and the 2000s. More recently, several men taking part in the Rakai circumcision trial were infected even though they did not have sexual intercourse, and several more were infected despite always using condoms. (There are links to all the studies on the Don't Get Stuck With HIV site.)

The act makes no explicit mention of non-sexual transmission through cosmetic and/or traditional skin-piercing practices, though tattooing and a handful of other practices are mentioned. But there is no mention of circumcision (or genital mutilation), male or female, whether carried out in medical or traditional settings.

The above incidents raise questions about the act's definition of 'informed consent', which requires that people be given "adequate information including risks and benefits of and alternatives to the proposed intervention". Were mothers informed about all of  the risks that their infants faced? Were they even made aware of risks to themselves, through unsafe healthcare?

Were the men in the Rakai trial informed about unsafe healthcare risks? Trials should not endanger the health of those taking part, and participants should be adequately informed about the risks. But where people appear to have been infected with HIV as a result of taking part in the trials, this possibility has not even been investigated.

The act does not include transmission as a result of infection control procedures not being followed (or not being implemented). Nor does it include careless transmission, as a result of not following (or implementing) procedures, not training personnel adequately, not providing health facilities with the equipment and supplies needed, etc. The Ugandan state itself has an obligation to prevent and control HIV transmission, according to the act.

Curiously, the act states that there will be no conviction if transmission is through sexual intercourse but protective measures were used (also if the victim knew the accused was infected and accepted the risk). Protective measures probably include condoms, but do they also include antiretroviral treatment? Vast claims are made about reductions in HIV transmission when the infected party is on treatment. Yet people have been convicted of intentional transmission in countries other than Uganda; being in antiretroviral treatment didn't always protect them from conviction.

Part one of section 45 reads: "All statements or information regarding the cure, prevention and control of HIV infection shall be subjected to scientific verification"; part three reads: "A person who makes, causes to be made or publishes any misleading statements or information regarding cure, prevention or control of HIV contrary to this section commits an offence and shall be liable on conviction...".

So it’s not just pregnant mothers and other parties who may fall foul of the HIV Prevention Act. Those who wrote the act may have contravened it themselves in a number of ways. Even those running drug and other health related trials, health practitioners and traditional and cosmetic practitioners may also risk contravening the act.

South Africa: Don't Panic About Ebola, We Have Extremely Effective Surveillance Systems

Some may beg to differ with the health minister. While TB is very different from ebola, South Africans will (I hope) recall hearing about an epidemic of multidrug-resistant (MDR) and extensively drug resistant (XDR) TB being transmitted in health facilities in South Africa and surrounding countries, perhaps since the early 2000s. Scaremongering about infectious disease outbreaks doesn't do anyone any good, but nor does underestimating the ease with which diseases can spread, within a country and internationally.

A three decade HIV pandemic has shown us that surveillance systems on their own are not enough. The XDR/MDR epidemic is very closely connected with the HIV epidemic in South Africa and has been attributed to poor infection control. Countries that wish to control disease spread need strong health systems. However, the reaction to HIV has not been a sustained strengthening of health systems as a whole, but rather a vertical, cherry-picking approach. The result is that most countries in sub-Saharan Africa now have crumbling health systems, massive shortages in skilled health personnel, inadequate equipment and unreliable vital supplies.

Conditions are so dangerous that UNAIDS advises UN personnel not to use health facilities in developing countries, although the institution seems to believe that the same facilities are fine for Africans. Guinea, Liberia and Sierra Leone have relatively low HIV prevalence, whereas the number of HIV positive people in Nigeria could be the second highest in the world; South Africa is home to the highest population of HIV positive people. This has only weakened health systems further.

Nor is there any need to single out South Africa, Nigeria or the three countries that have the worst ebola outbreaks so far. There are Service Provision Assessments and other reports for many African countries showing that basic supplies such as gloves, soap and water, drugs, even injecting and other equipment, are frequently lacking. There are also scores of articles alluding to dangerous conditions, some published many years ago.

The South African health minister, and health ministers in all African countries, would be better off using outbreaks of ebola, MDR and XDR TB, hepatitis and HIV as arguments for investing in health systems that can provide safe health services for everyone, rather than for the rich alone, or for those suffering from headline grabbing diseases. Nosocomial TB in South Africa is thought to have started more than ten years ago, and affects many health facilities, in several countries. Therefore, there have been numerous outbreaks over that period, not just a few isolated instances.

Many of the people who have died of ebola are health professionals and others who are probably more aware of the risks they face than their patients are. Claiming that health systems are fine and that they are able to cope is a betrayal of the work their health professionals are doing. Minister Dr Aaron Motsoaledi should tell the WHO and other international institutions something that is an open secret about healthcare safety in African countries - it is in very urgent need of attention.

Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics

An article in a Nigerian newspaper highlights the very serious hepatitis epidemic there, with an estimated 20 million people, about 12% of the population, infected with either hepatitis B (HBV) or C (HCV). Although one of the ways HBV can be transmitted, and the way HCV is usually transmitted, is through blood, it is less common to find explanations of why or how people come into contact with someone else's blood, or how to avoid this.

The Don't Get Stuck With HIV site gives details of numerous ways you can come into contact with someone else's blood through healthcare, cosmetic and traditional practices. Healthcare practices include antenatal care, birth control injections and implants, transfusions, child delivery, dental care, donating blood, injections for curative and preventive reasons, catheters, male circumcision and others.

Cosmetic practices include manicures and pedicures, shaving, tattooing, body piercing, use of Botox and other products, performance enhancing drugs and perhaps colonic irrigation. Traditional practices include male and female genital cutting (FGM and MGM), traditional medicine, scarification and various other skin-piercing practices.

The Don't Get Stuck with HIV site also lists some of the steps you can take to protect yourself from exposure to HIV, HBV, HCV or other bloodborne pathogens, even ebola. The site also links to articles and sources of data about unsafe healthcare, unexplained HIV infections and other indications that risks for bloodborne transmission of various viruses are not always so widely recognized.

As a result, people often don't know there is a risk and they don't know how to protect themselves. This is as true of HIV in high prevalence countries with inadequate health services, HBV and HCV in countries where those viruses are common, and even ebola or other haemorrhagic viruses, when such an outbreak occurs. Indeed, ebola epidemics have only occurred in countries where healthcare is known to be unsafe, such as Democratic Republic of Congo, Sudan, Uganda, Guinea, Sierra Leone, Liberia and most recently Nigeria.

Two lengthy reports on healthcare safety in Nigeria have been published in the last few years. The second was a survey using the WHO's 'Tool C', also used for the survey from Philippines mentioned in a recent blog. Bearing in mind the warnings we are currently hearing about ebola, and the warnings we should have been hearing about HIV and hepatitis:

"Of the health facilities observed, only 23 (28.8 percent) had soap and running water for cleansing hands, and no facility had alcohol-based hand rub available.

Overall, fewer than half of all injections observed were prepared on a clean surface...

They found that injection providers only washed their hands in 13 percent of cases; none used an alcohol-based hand rub...

Fewer than half of the providers were seen to use water or a clean wet swab to clean the skin before vaccination, therapeutic, and family planning injections...

For vaccination, in 79.7 percent of cases, auto-disable syringes were used.

However, for dental procedures, there were two observations where providers used sterilizable syringes, and of these two, one of them also used a sterilizable needle...

18.7 percent had a needle left in the diaphragm of a multi-dose vial.

When glass ampoules were used during vaccination, the providers used a clean barrier in 1 of the 11 vaccination injections observed. Providers used a clean barrier in the only such dental injection observed, 3 of 11 family planning injections, and 4 of 43 therapeutic injections observed (9.3 percent).

Providers generally used standard disposable needles and syringes (70 percent) for phlebotomy procedures, and lancets for procedures requiring lancing (78.6 percent). Providers were rarely seen to use safety devices such as auto-disable and retractable syringes...

62.6 percent of procedures were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs was unlikely (in 42 out of 67 hospitals and 20 out of 32 lower-level facilities).

[for blood draws and intravenous procedures] Overall, providers washed their hands with soap and running water in only 2 of the 99 observations.

Data collectors observed that patients shared a bed or stretcher with another patient in 17.6 percent of IV infusions. This was also the case for 4.5 percent of IV injection patients.

Data collectors observed that in 69.3 percent of cases, the provider used a clean gauze pad and gently applied pressure to the puncture site to stop bleeding after the procedure.

Only 10.5 percent of providers cleaned their hands with soap and water or an alcohol-based hand rub following the observed procedures. In the 35 cases in which there was blood or body fluid contamination in the work area, the area was cleaned with disinfectant in 20 percent of observations (see Table 14).

During interviews, five percent of providers (11 out of 217) reported that they used sterilizable needles in injections, phlebotomies, IV injections, or infusions. Of the 5 out of 187 supervisors who reported use of sterilizable syringes and needles, three said that fuel was always available to run the sterilizer, while the remaining two reported that fuel had been unavailable for less than one month at some point.

Half of the 80 health facilities had infectious waste (non-sharps) outside of an appropriate container."

This list includes only some of the risks to patients. There is also a section on risks to the provider, risks to other health staff, such as waste handlers, and risks to the community. Nigeria is unlikely to have the worst health facility conditions in Africa and there are many areas of healthcare safety requiring urgent attention.

When news reports about ebola constantly emphasize things like eating bushmeat and 'traditional' practices at funerals, think of the kind of conditions that can be found in Nigerian hospitals even when healthcare personnel are aware that an inspection is taking place. When reports about hepatitis concentrate on intravenous drug use and other illicit practices, and when reports about HIV seem to be almost entirely about sexual behavior, conditions in health and cosmetic facilities and contexts where traditional practices take place must also be relevant.

Seek and you shall Find: Evidence in Support of HIV Drug Sustainability

A recent piece of research claims to find that mass male circumcision programs do not result in 'risk compensation', the idea that some HIV interventions can result in an increase in 'risky' behavior, such as sex without condoms. Happily for those aggressively promoting mass male circumcision, they say they found no evidence of risk behavior. Whether they found evidence that it doesn't occur, rather than failing to find evidence that it does occur, is another matter.

Similar research into the use of pre-exposure prophylaxis (PrEP), the use of HIV drugs before some kind of exposure to HIV, such as through sexual intercourse with a HIV positive person, also found no evidence of 'risk compensation', although this research was carried out in the US; PrEP is more of a rich person's intervention at the moment.

And a meta-analysis of "every study that has looked at the sexual behaviour of people after starting HIV treatment" has found no evidence of 'risk compensation'. Most of the studies took place in African countries. These results must have found a welcoming audience at the HIV industry's annual back-slapping event that has just finished in Melbourne.

But these findings may suggest something very significant that the researchers have not mentioned: perhaps HIV positive people are nowhere near as promiscuous, careless and uncaring as they are depicted as being by the HIV industry thus far.

It is not known what proportion of HIV transmission is a result of sexual intercourse and what proportion is a result of other modes of transmission, such as exposure to contaminated medical instruments, unsafe cosmetic or traditional practices.

The assumption that most transmission is a result of sex is a prejudice, rather than an empirical finding. The assumption that transmission through various non-sexual routes is low is a result of not looking for evidence that would demonstrate such transmission and ignoring any evidence that comes to light, which it usually does inadvertently.

Those promoting mass male circumcision and other revenue streams do seem to be inordinately blessed when it comes to finding 'evidence' that the intervention is safe, acceptable, effective and worthy of the hundreds of millions that has been spent, and the billions that has been earmarked for moving from adult and child circumcision to include infant circumcision, the latter being a far more sustainable proposition.

Now that so much money can be made from various mass HIV drug administration strategies, such as pre-exposure prophylaxis, early treatment, treatment as prevention, treating HIV positive pregnant women for life (as opposed to a shorter course of treatment), etc, it seems unlikely that any of the big funders will wish to put much money into finding out how people in high prevalence countries are infected in the first place, and aiming to prevent such infections from occurring.

Of course, like infant circumcision, allowing a substantial number of people to continue to be infected with HIV is far more sustainable than aiming for the industry's claimed goal of virtually eliminating HIV by 2030. A steady stream of new infections from the worst epidemics should keep the industry afloat for at least a few more decades, and perhaps even ensure their survival for the rest of the century.

Kenya's HIV Prevention Revolution: Beating Swords into...Condoms

Kenya's recently published 'HIV Prevention Revolution Road Map - Count Down to 2030' presents various HIV data for each of the 47 counties, based on their new constitution. National prevalence is estimated at 6%, 1.6 million people (compared to 5% in the latest Aids Indicator Survey). But instead of getting rough data for each of the 8 provinces, it is now possible to see just how heterogeneous the country's epidemic is.

Prevalence ranges from a very low .2% in Wajir to a massive 25.7% in Homa Bay, 128.5 times higher. The estimated number of people living with HIV in Wajir is 500, compared to 140,600 in Homa Bay, 281 times higher. Of course, people can work that out for themselves. But try working out how the situation in these counties can be so different if you also believe that HIV is almost always transmitted through sex.

Because that is the conclusion of the experts who put together this research. The contribution made by Homa Bay alone is said to be roughly the same as the contribution of sex workers plus their clients in the country. Over 60% of new infections are said to be a result of the sexual behavior of the populations of 9 counties, making up less than a quarter of the population. In contrast, the 10 lowest incidence counties are said to contribute 1% of all infections, through their sexual behavior, of course.

It is now claimed that 93.7% of all new cases of HIV are sexually transmitted. Only 20% of the hundreds of millions of dollars being pumped into the epidemic is to be spent on prevention, and most of that will be spent on condoms, finger wagging and a lot of other rubbish that has failed to have any influence on the epidemic so far. And yet it is expected to reduce transmission to about 1000 cases by 2030.

One of the most disturbing aspects of the report is a photograph that sums up the attitude of UNAIDS and other big players in the HIV industry (a lot of drugs are being sold through reports like this) towards Kenyans and other Africans. It depicts a crowned 'King of Condoms', with a paper crown on his head, demonstrating to the country's first lady how to put a condom on a wooden dildo, while others look on.

Or perhaps others don't see that as an instance of crass infantilization? Perhaps they don't find anything questionable about the idea that HIV is transmitted almost entirely through sexual behavior in African countries? But the assumption is based on an entirely flawed 'Modes of Transmission' spreadsheet, rather than on research. Thirty years into the epidemic, with next to nothing to show for the billions that have been spent on prevention, shouldn't we start collecting empirical data to guide future efforts?

Why 'Reducing HIV Transmission' Must Never be an Excuse for Genital Mutilation

The English Guardian has put together figures for female genital mutilation (FGM) and the top ten are Somalia, Guinea, Djibouti, Egypt, Sierra Leone, Mali, Sudan, Eritrea, Gambia and Burkina Faso. But the top ten for HIV that I have been looking at recently are Swaziland, Botswana, Lesotho, South Africa, Zimbabwe, Zambia, Namibia, Mozambique, Malawi and Uganda. The table below shows just how dramatic the non-correlation is.

The English Guardian is calling for an end to FGM, of course. But a far less dramatic non-correlation has been used to justify three randomized controlled trials of mass male circumcision in African countries. The results of these trials are have been used to justify a continuation of mass male circumcision, involving tens, even hundreds of millions of men, boys and infants and several billions of dollars. While HIV prevalence is lower among uncircumcised men than circumcised men in some countries, it is lower among uncircumcised men in others, while in several more countries circumcision status makes no difference. The correlation coefficient is roughly zero.

Results of further research into mass male circumcision is being presented to 16,000 attendees at the Melbourne HIV conference this week, research carried out on people who are not aware that they are guinea pigs for the current obsession with the operation. Because, as the figures show, we have no idea why circumcision sometimes appears to 'protect' against HIV and why it sometimes appears not to. Nor do we have any idea what proportion of HIV is transmitted through sexual contact and what proportion is transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

Similarly, we have no idea why HIV prevalence is so high in some African countries but so low in others. The fact that HIV prevalence is very low in countries that practice FGM is not seen as justification for carrying out trials of the operation on millions of people and presenting the results at an international HIV conference (such trials would probably be carried in secret). In fact, it is assumed that FGM status is seen as irrelevant to HIV transmission, and that, even if it is somehow relevant, carrying out trials into the operation as a HIV intervention would be entirely unethical.

International health and development institutions, the UN, the mainstream media, political and religious leaders all around the world, and many others, condemn FGM and would not consider it as a means of reducing HIV transmission. They would not even condone carrying out field trials into any kind of FGM, not even the less damaging kinds, not even the kind that leaves no permanent damage, because it is not ethically justifiable to carry out such an operation for no medical reason, on infants, children, or even unconsenting adults. Quite right, too.

But the research carried out by the people slapping each other on the back in Melbourne, presumably at some considerable cost, were financed by the likes of the Gates Foundation (which also funds the English Guardian's Development section, where the FGM article appears), FHI 360, Engender-Health and University of Illinois at Chicago. Several (if not all) of these institutions have their origins in a 'population control' theory of development, the belief that the population of developing countries is too high, and lowering birth rates will increase development and reduce poverty; less polite people would call this 'eugenics'.

I wonder if these parties have some information about, or beliefs about, mass male circumcision having some negative influence on fertility. Because, if they were to believe the same thing about FGM, would they also promote it with the same energy and persistence (and funding, and institutional backing)? What about other means of reducing fertility, such as Depo Provera, which has been associated with higher rates of HIV transmission? Gates and other 'population control' organizations certainly do promote that.

So promoting your favorite 'public health' intervention as a means of reducing HIV when the evidence is slim is bad enough. But this intervention involves something that is ethically unjustifiable unless it is carried out for medical reasons. So these various parties went a step further: they carried out, and continue to carry out, 'trials' of this operation on millions of people. The excuse is that it 'reduces HIV transmission'. But using that kind of evidence, so does FGM.

Genital mutilation without consent is not ethically justifiable; the fact that HIV prevalence is lower in countries where genital mutilation is common does not justify mass male circumcision programs, where millions of people are unwitting guinea pigs to this neo-eugenicist experiment. Those promoting mass male circumcision programs, funding them or working on them are involved in a crime of inestimable proportions, and must be stopped.

Kenya: Needle Exchange Programs Could Save Lives

[Cross posted from the Don't Get Stuck With HIV blog.]

Despite the success of needle exchange and other harm reduction programs around the world, there people and institutions who still reject them. Even though injection drug use is said to contribute a relatively small proportion of HIV infections in Kenya, apparently some community and religious groups don't always wish to support them. Perhaps they do not understand harm reduction?

Canada has been particularly open to needle exchange and other programs, and the view that "Drug users shouldn’t be given clean needles...it only encourages them" is a minority view now, thankfully. If needle exchange reduces transmission of HIV and hepatitis, it must be encouraged. While it may not cut injection drug use directly, it provides a means of reaching out to users in a meaningful way.

Persecuting durg users and suspected drug users, searching and questioning them, using possession of syringes as a reason for arresting them and confiscating their injecting equipment, do not ultimately result in a reduction in injecting drug use. Worse still, these actions result in users facing potentially more dangerous conditions, as well as increasing syringes and needle reuse.

Community and religious groups may be influenced by a hangover from the Bush era. Bush had a sort of 'victorian' influence; if he believed something, no matter how stupid, his supporters (sort of hard to believe he had them, but he must have) would believe the same thing. This is especially true of his supporters who were in receipt of US funding for their activities.

The contribution of prison populations to the HIV epidemic in Kenya is also said to be high. Even Canada, the US and Australia don't have a needle exchange program in prisons, but it would be wise for Kenya to establish where infections are coming from among prisoners.

Aside from the copious innuendo about what men do in prisons, male to male sex is likely to be an issue in a country where it can land you in prison. Prisoners must face other risks, too. Injection drug use is one possibility, but also perhaps tattoos, body percing, blood oaths, traditional practices occur in prisons? Even sharing razors and other sharp objects carries some risk.

Kenya's Modes of Transmission Survey is not a reliable means of estimating the combined contribution of several groups, such as injection drug users and prison populations. People who fall into these groups may face a high risk of being infected, yet few intervention programs are currently aimed at them.

Needle exchange programs would be a good start and may help to launch other programs, such as opioid replacement therapy, in the long run. But other programs addressing prisoners, men who have sex with men, sex workers and others could address between 20 and 30% of HIV transmission, which is a very substantial figure.

Too many African countries have been swayed by Western prudishness about sexual behavior in their approach to HIV. They have adopted some of the homophobia, xenophobia and other prejudices on which various wars on 'terror', 'drugs' and the like have been based. This has not led to rapid reductions in HIV transmission; so it's time for a change.

[For more about HIV transmission through unsafe healthcare and cosmetic practices, visit the Don't Get Stuck With HIV site.]

The Only Certainty About Unsafe Healthcare and HIV is Ignorance About It

[Cross posted from the Don't Get Stuck With HIV blog.]

An article by Ndebele, Ruzario and Gutsire-Zinyama, who work for the Medical Research Council of Zimbabwe, claims to dismiss the 'wait and wipe' finding, which came from circumcision studies carried out in Africa. This refers to the finding that men who waited at least 10 minutes after coitus and used a dry cloth to wipe their genitals were far less likely to be infected with HIV than both circumcised and uncircumcised men who did not follow this procedure.

What is most extraordinary about this finding is that it has been feebly denied by some, but ignored by far more; in contrast, the findings about a rather weak association between circumcision and HIV transmission was used to push an extremely aggressive, well funded and loudly publicized program to circumcise as many African males, both teenagers and children, as possible.

One should no longer be surprised when researchers embrace the results they expected, while at the same time distancing themselves from those they don't expect, and certainly don't want. The 'wait and wipe' finding was presented at a conference some time back and was covered by US media. But it never received the attention, or subsequent funding, that mass male circumcision programs received.

So, seven years after those hyped mass male circumcision programs started, and a claimed several million men and boys circumcised under the programs, no further research appears to have been done into this interesting finding. Ndebele et al, who don't seem aware that HIV prevalence in Zimbabwe is higher among circumcised men, rebuke several commentators, including myself, for suggesting that 'wait and wipe' could become an alternative strategy to circumcision.

What I said was that appropriate penile hygiene is a lot simpler, cheaper, safer and less invasive than mass male circumcision. The circumcision enthusiasts have encouraged people to associate circumcision with hygiene, but they have never shown that HIV transmission has anything to do with penile (or vaginal) hygiene. It simply suits their purposes that people seem ready to believe in such a connection.

So how can Ndebele et al question the findings about penile hygiene without also questioning those about mass male circumcision? And how can they not call for further research to be carried out? They accuse myself and other commentators of engaging in 'pure speculation', which we do engage in. But we are not the ones who collected the original data, some of which we now wish to selectively dismiss, and the rest of which we wish to use to aggressively promote circumcision programs.

So they proceed to engage in pure speculation of their own, and they seem to believe they are 'dismissing' arguments about the possible role of unsafe healthcare with a rhetorical question: they ask "With all the campaigns on safe needles that have been going on, where on earth can one still find health professionals using unsafe needles?" The answer is that syringe reuse is likely to occur in every high HIV prevalence African country.

Merely running a campaign about unsafe healthcare and syringe reuse does not reveal the extent of HIV transmission through these routes. Nor does running a campaign ensure that unsafe healthcare simply ceases to be an issue after a few years. No number of strategies, position papers, frameworks, roadmaps, multi-page reports, toolboxes or other pen-pushing exercises so beloved by the HIV industry will tell us the extent of non-sexual transmission of HIV through unsafe healthcare.

Nor will 'putting unsafe healthcare on the agenda' (no matter for how long) ensure that any meaningful changes will come about. Most people know little about non-sexually transmitted HIV and are constantly told that 80% of transmission or higher in Africa is a result of unsafe sex. Researchers rarely even mention HIV transmitted through unsafe healthcare, except to dismiss it, without evidence.

The authors argue that the results they wish to embrace are correct and that the results they wish to deny are merely a "coincidental finding", and conclude that "there is no need to conduct further research" into the 'wait and wipe' finding.

This just about sums up the HIV industry's approach to mass male circumcision. This has been a process of scrabbling about for data, any data which appears to support the program, and denying or ignoring any data which shows the program to be a hoax; all cobbled together by greedy (and probably somewhat pathological) 'experts', who will do anything to promote circumcision, ably supported by an institutionally racist HIV industry.

[For more about HIV transmission through unsafe healthcare, cosmetic and traditional practices, see the Don't Get Stuck With HIV website.]

It's not Condoms that are Failing to Protect Against HIV, it's UNAIDS

[Cross posted from the Don't Get Stuck With HIV blog.]

At the beginning of this month, David Gisselquist took a careful look at UNAIDS' 'Modes of Transmission' model and found it seriously lacking, grossly overestimating HIV transmission among couples in long term relationships in Malawi. As a result of this flaw, the model gives results which appear to support the extremely racist view that most Africans in high HIV prevalence countries, male and female, engage in a lot of unsafe sex, and mainly sex with people other than their partners.

David shows how the Modes of Transmission model currently estimates that 81% of Malawi's 95,000 new HIV infections were accounted for by spousal transmission. If you remove the flaw, the percentage goes down to 20%, leaving 60% of all infections unaccounted for by the model (non-sexual transmissions from mother to child make up much of the remainder). How were all those other people infected, including the women who are said to have infected their babies?

It is very likely that a substantial number of HIV infections in Malawi and other high prevalence countries are a result of non-sexual transmission, such as through unsafe healthcare, cosmetic procedures and traditional practices. The much lauded 'ABC' (Abstain, Be faithful, use Condoms) approach to HIV prevention does not work, not because many Africans actually live up to the stereotypical 'all men are bastards, all women are hapless victims', but because HIV is not always transmitted through heterosexual sex.

Consider condoms, which are a great technology for reducing unplanned pregnancies, many sexually transmitted infections and sexually transmitted HIV, through anal and vaginal intercourse. But a number of surveys have found that HIV prevalence is very high among those who use condoms. Indeed, prevalence is often higher among those who at least sometimes use condoms than among those who never use them. The following chart is from the relevant Demographic and Health Survey for four countries.

In some cases, HIV prevalence is 50% higher among those who sometimes use condoms than among those who never use them, sometimes 100%. Shocking? Only if you think HIV transmission in high prevalence African countries is all about sex. Consider another set of figures, this time for condom use at last sexual intercourse in past 12 months. The figures for those who have not had sex in the past 12 months also raise questions (data from DHS surveys). You could suggest that people are not honest, or that people who are infected are 'abstaining', but it is far more vital to figure out exactly how people are being infected in order to prevent further infections.

Why are HIV prevalence figures so much higher among people who say they sometimes use condoms? I can only tell you what I think; condom use is completely irrelevant to non-sexually transmitted HIV. That sounds obvious, but UNAIDS insist that almost all transmission is through heterosexual sex, yet they stand by figures like these. It is not possible for HIV prevalence to be so much lower among those who never use condoms if almost all HIV transmission is sexual. But there may be an explanation for why those who sometimes use condoms seem so much more likely to be infected.

HIV prevalence is often highest among wealthier, urban dwelling, employed, female, better educated people who live in wealthier countries that have reasonable access to reproductive healthcare services, a relatively low population density and sometimes a higher urban population (but not always). People who answer that description, people who can tick at least some of those boxes (some of the factors are interdependent), it seems, are also more likely to use condoms.

So it is not a case of people with the above characteristics using condoms, yet still being more likely to be infected with HIV, but rather a case of those same people being more likely to be infected with HIV through unsafe healthcare or some other non-sexual route. Once you challenge the sexual behavior paradigm the rest is clear: condoms are irrelevant to non-sexual HIV transmission. It only sounds unintuitive if you keep clinging to the sexist, racist and extremely dangerous reflex about sexual behavior, so beloved by UNAIDS, WHO, CDC, PEPFAR, the Gates Foundation and various universities that have been prominent in the HIV industry.

Given what we so often hear about HIV being inextricably linked with poverty, unemployment, lack of education, isolation, poor access to health services, etc, it is worth emphasizing that the virus may often be more closely linked to the opposite of these factors. Of course, all of these factors are abhorrent and it should be the aim of every wealthy country to ensure that such conditions are alleviated. But if HIV is being transmitted through unsafe healthcare and other routes, all healthcare development must be SAFE healthcare, all HIV education must include information about non-sexual transmission, all employment 

and environments must exclude risks of bloodborne transmission of HIV, as much as possible.

So first we need to recognize that HIV is not solely transmitted through 'unsafe' sex and that it can be transmitted, perhaps far more easily, through unsafe healthcare, cosmetic procedures and traditional practices. ABC 'strategies' do not work because HIV transmission is not all about sex, not because Africans are too careless, promiscuous or ignorant (or even 'disempowered') to follow its patronizing advice. Safe sex has its place, but safe healthcare is a far more urgent issue in high HIV prevalence African countries right now. It's not condoms that are failing to protect people against HIV, but the intransigence of UNAIDS and the rest of the HIV industry.

WHO Supports Circumcision Despite What They Know About Injection Safety in Africa?

[Cross posted from the Don't Get Stuck With HIV site]

The World Health Organization's (WHO) mass male circumcision page states that the operation reduces risk of HIV transmission from females to males (etc), and that they and UNAIDS recommend circumcision as a strategy for HIV prevention, "particularly in settings with high HIV prevalence and low levels of male circumcision". The claimed maximization of "public health benefit" raises many questions, about compatibility with their current victim blaming and individual responsibility strategy, and also about what can be done in areas with high rates of circumcision and high rates of HIV prevalence (or do they have a policy on foreskin reconstruction?).

But the question I'd like to concentrate on is what WHO means by 'settings'. If it refers to high HIV prevalence countries, then they must be aware that most HIV epidemics do not follow national or other geographical or political boundaries. Malawi, as mentioned in a previous blog, can be divided into three clusters, two clusters of low HIV prevalence and one of high prevalence. Only the high prevalence cluster has high rates of circumcision. Rwanda, similarly, has three clusters, two of low prevalence and one of high prevalence. Burundi has only one cluster, and that's the capital city, where most of the country's HIV positive people reside.

Indeed, high HIV prevalence tends to cluster in cities in most African countries, yet the vast majority of people in most high prevalence countries live in rural areas, where prevalence is often low, sometimes very low. So WHO aims to target up to 80% of males, when most of them can not be said in any useful sense to live in 'high HIV prevalence settings'. Although HIV epidemics are heterogenous, within as well as between countries, if high prevalence settings refer to anything at all they refer to areas where access to healthcare facilities is high and levels of safety in healthcare facilities are low (for example).

It gets worse because if you look at Burundi and Rwanda's Demographic and Health surveys (just two examples out of many) you will see that HIV prevalence is higher among Muslim men (mostly circumcised) than men of some of the other (often non-circumcising) denominations; prevalence is lower even among uncircumcised Muslims than circumcised Muslims. Other Demographic and Health Surveys show that HIV prevalence is far higher among Muslim women than among women of other denominations, not just higher than among Muslim men. So, not only does circumcision not always protect men from HIV, it may well have something to do with higher rates of transmission from men to women; this at least merits a bit of investigation, doesn't it?

What does this have to do with WHO's (somewhat vague) data on injection safety and healthcare safety, more broadly? Well, in a document on injection safety success stories, the WHO notes that an estimated 25 billion injections are administered annually and that an estimated 70% of them are unnecessary. The report states that "Unsafe practices and the overuse of injections can cause an estimated 32% of Hepatitis B virus, 40% of Hepatitis C virus and 5% of all new HIV (human immunodeficiency virus) infections every single year." "At least 50% of injections were unsafe in 14 of 19 countries...for which data were available" according to another WHO report.

We don't know what levels of injection safety are like in WHO 'priority' countries for mass male circumcision programs (Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe). But we may assume, in the absence of data, that high HIV prevalence countries also tend to have higher rates of HIV transmission through unsafe injections. So what is the range of ates? 10%? 20%? The rate would be very low in many Western countries, so it must be fairly high in at least some high HIV prevalence countries to average at 5%. But if we are not told how high rates are, and for which countries, how can 'priority' countries even weigh the benefits against the risks? How can WHO, for that matter (yet they do claim benefits, up to "3.4 million new HIV infections" to be averted by 2025, not forgetting savings of US$16.5 billion)?

The 20 million figure that WHO recommends to be circumcised only refers to medical circumcisions (and it doesn't include children or infants, not yet anyhow), not to all those non-medical circumcisions carried out in unsterile conditions. The number of non-medical circumcisions would be many tens of millions, perhaps even over one hundred million over the course of these mass male circumcision programs (another 11 years to go). What if even just 5% of them were to be infected with HIV through unsafe practices? They won't be receiving injections, presumably, but one would like to think that WHO approved programs would have higher standards of safety than circumcisions performed in unsterile conditions by non-medically qualified people. Alas, it is difficult to estimate rates of HIV infections through unsafe medical and traditional practices because so little effort has ever been made to collect such data.

WHO and UNAIDS are obsessed with sexual behavior, but reluctant to assess non-sexually transmitted HIV, especially via unsafe injections and unsafe healthcare in general. Yet they are willing to promote mass male circumcision programs to reduce HIV transmission when their own figures suggest that the number of people who risk being infected with HIV through these programs is likely to be far higher than even the most outlandish estimates of infections 'averted'. Far from being a 'distraction' from effective HIV prevention, as some have called it, mass male circumcision programs are likely to transmit several times more infections than they could ever hope to avert.

UNAIDS' Dubious Claims about HIV/AIDS 2013

[Cross-posted from the Don't Get Stuck With HIV site.]

UNAIDS risk missing their target of reducing "sexual transmission of HIV by 50% by 2015". But there is a way of meeting that target, and they could meet it by tomorrow. If they belatedly admit that HIV is far more easily transmitted through unsafe healthcare, they could begin to estimate the contribution of things like reuse of needles, syringes and other equipment that comes into contact with blood and other bodily fluids.

This would also greatly assist their progress towards their 'ZeroDiscrimination' target too, because even though they can't reverse the damage they have done by insisting that Africans are irremediably promiscuous, the status of this claim as institutionalized racism will eventually become clear, at least to those who are prepared to think the issue through a little (a surprisingly small number of people so far).

After all, reducing 'sexual transmission' is one of their stated goals, whereas UNAIDS has barely breathed a word about transmission through unsafe healthcare in their 20 year, multibillion dollar, celebrity studded reign. They could just quietly (imperceptibly, even) reveal some changes in the way figures are collected and next December 1, a re-estimation of non-sexual transmission of HIV could be the subject most deserving of their customary (spontaneous) standing ovation module.

UNAIDS are uncharacteristically frank about mass male circumcision, which is something of an embarrassing fiasco: "As of December 2012, 3.2 million African men had been circumcised [...]. The cumulative number of men circumcised almost doubled in 2012, rising from 1.5 million as of December 2011. Still, it is clear that reaching the estimated target number of 20 million in 2015 will require a dramatic acceleration." (They don't say how many of the 3.2 million circumcised over quite a few years would have been circumcised anyway but took advantage of the free (anesthetized) operation.) Might this spell an unobtrusive retreat from this dangerous imperialist program?

But one of the heftiest pieces of bullshit in the 'report' (and there is stiff competition) is about "the goal of providing antiretroviral therapy to 15 million people by 2015". They say that "As of December 2012, an estimated 9.7 million people in low- and middle-income countries were receiving antiretroviral therapy, an increase of 1.6 million over 2011. That brings the world nearly two-thirds of the way towards the 2015 target of 15 million people accessing antiretroviral treatment."

The difference between UNAIDS' claim and the truth is expressed in a few words, such as 'were receiving' therapy. If they said that 9.7 million people had been recruited on to a therapy program, that might have been true (or somewhat closer to the truth). But 9.7 million is, at best, the number of people who have at one time been put on a program. Neither UNAIDS, WHO, PEPFAR, CDC nor anyone else knows how many of those 9.7 million ever took the drugs, or for how long, how many dropped out of the program, how many were recruited on to two or more programs or simply died, etc.

No one knows, and no one really cares because 9.7 million is an impressive figure, and it sounds like a good attempt at the 15 million target. There is not much incentive to estimate how many people are alive and on antiretroviral treatment, indeed, such an estimate could prove fatal to several substantial institutions (not just UNAIDS, which seems to thrive on failure to achieve anything at all, aside from spending money and institutionalizing bigotry). Is the true figure 8 million people, 7 million, or some far lower number? Billions of dollars say that no one is going to ask this impertinent question (unless they are not in receipt of any of those billions, and never will be).

Unsafe healthcare does exist in extremely poor, high HIV prevalence countries, surprising as that may seem to those who are used to the mainstream view that HIV is hardly ever transmitted through heterosexual sex in every country in the world, but almost always transmitted through heterosexual sex in a handful of African countries. What contribution does unsafe healthcare make to the worst HIV epidemics in the world, all in sub-Saharan Africa? Would it be the one or two percent UNAIDS grudgingly suggests, or something far higher? We don't know yet. No billions have been offered for the answer to this question.

Using cumulative figures is great, because you get that great 'step' effect when you produce bar graphs, and there is nothing like comforting, progressive steps to convince people that everything is good in UNAIDSland, and in the HIV industry in general. A very achievable 2015 target would be the abolition of UNAIDS and the promotion of safe healthcare. Because unsafe healthcare risks the spread of HIV, something UNAIDS has never got around to accepting. But I suspect that instead, there will be a continuation of the finger-pointing and victim-blaming that has characterized the mainstream approach to HIV in high prevalence countries so far.

Justine Sacco: Dangerous Truths and Dangerous Falsehoods about HIV

[Reposted from the Don't Get Stuck With HIV website.]

An American on her way to South Africa is said to have Tweeted "Going to Africa. Hope I don't get AIDS. Just kidding. I'm white!" This is a heartless and insensitive remark to make. But what makes it most heartless and insensitive for a white American to say it is the fact that it is so true. In the US, African Americans accounted for 44% of all new HIV infections in 2010, despite representing only 12-14% of the population. Also in the US, men who have sex with men are said to represent about 4% of the population, but account for 63% of all new HIV infections in 2010, and a disproportionate number of them are black/African American.

Even in South Africa HIV prevalence among white people is very low. But national prevalence is amongst the highest in the world and there are more HIV positive people in South Africa than in any other country. While America has the worst HIV epidemic in the developed world, with over 1.1 million HIV positive people, the majority of infections arise among men who have sex with men and (to a lesser extent) intravenous drug users. HIV infection among white heterosexuals who have no serious risks, such as receptive anal sex or intravenous drug use, is very low.

The American who tweeted the first stupid, but sadly true, remark offended so many people that she arrived in South Africa to find that a storm had erupted on Twitter and she had lost her job. So, to make matters worse, she made a statement to a South African newspaper which contained a dangerous but often heard falsehood:

"For being insensitive to this crisis -- which does not discriminate by race, gender or sexual orientation, but which terrifies us all uniformly -- and to the millions of people living with the virus, I am ashamed."

This is completely untrue, as the figures for the US show so clearly. About two thirds of people living with HIV globally are black Africans. An estimated 60% of HIV positive people in Africa are female, compared to only 20% of new infections in the US in 2010. Hispanics and Latinos in the US made up 21% of new infections in 2010; the rate of infection was 2.9 times higher in Latinos than it was in white males; it was also 4.2 times higher in Latinas than in white women.

HIV most definitely does discriminate by race, gender and sexual orientation. This is not a new discovery, either. It may be an acceptable thing to say in certain circles, but we should never forget the differences between HIV in Africa, where the majority of HIV positive people live, and HIV in developed countries, where HIV is less prevalent overall, and is rare among heterosexuals who have no serious risk behaviors.

Justine Sacco, who tweeted the remark, is so right to think that she is very unlikely to be infected with HIV; a lot less likely than a black African, and also less likely than a black or Latino/Latina American. It is disturbing to think that so many people continue to believe or say otherwise. Why is HIV prevalence so high among black Africans and black/African Americans, yet comparatively low among white people, especially white men who engage in no serious risk behaviors?

What do Media Censorship and Manipulation, Gates, the BBC and Circumcision Have in Common?

Internews describes itself as an "international non-profit organization whose mission is to empower local media worldwide to give people the news and information they need, the ability to connect and the means to make their voices heard". But one of their much trumpeted programs claims to train journalists about the 'science' behind mass male circumcision programs in Kenya and creating demand for the procedure. There's quite a difference between training journalists on the 'science' of circumcision and creating demand, and the latter generally has little to do with empowerment.

The fact that the BBC's Media Action portal, Creating Demand for Voluntary Male Medical Circumcision, which is backed by the Bill and Melinda Gates Foundation, has named the work of Internews as an example of best practice also says a lot more about the three institutions' shared biases than about empowerment. Even the URL bluntly states the bias.

A press release gushes: "Internews’ training approach illustrates the benefits of training journalists to report accurately and impartially on culturally sensitive topics, such as VMMC. The training resulted in some 100 news stories focused on this high impact HIV prevention procedure that were published or broadcast. What was notable was that the media did not carry any negative news stories about the topic during the period that Kenya was rolling out the medical procedure in Nyanza Province." Oddly, another version of this press release uses the term "falsely negative news stories"; I wonder which is correct? Or is any negative news story 'falsely negative'?

So where is the impartiality in creating demand for mass male circumcision? If people have reservations about circumcision perhaps they have good reasons to. But if the procedure is as wonderful as proponents claim it is, why should such aggressive demand creation be necessary? It is claimed that Internews training "does not prescribe to journalists what to cover" but that their main concern is accuracy. Yet their country director Ida Jooste, perhaps inadvertently, flatly contradicts this claim.

She says that a "critical article was published in Uganda about VMMC quoting a poor-quality study which attacked the credibility" of the often cited Randomised Controlled Trials that took place in Kenya, Uganda and South Africa. Without citing that 'poor-quality' study, she goes on: "Rather than wait for the Kenyan media to pick up and run the story, Internews proactively convened a round-table with journalists and VMMC experts from the National AIDS and STI Control Program, and other organizations to analyze the story and examine its scientific arguments. As a result, not a single media outlet in Kenya chose to pick up or run the sensational story."

I don't think I'd use the word 'impartial' there. Ensuring that only positive coverage is aired and that negative coverage is quashed is media censorship and control, pure and simple. This is all paid for by the US taxpayer, though it seems the UK may now have something to do with it too.

Internews also 'worked with' (should that be 'worked on'?) civil society and health agencies working in the field of mass male circumcision. When they ran a conference focusing on women's 'involvement' in mass male circumcision, "to their delight" this resulted in 25 news and feature stories. This is pure manipulation, but those involved seem to express no shame, apology or even justification for it. Joost is even cited as saying "We believe that the impact of positive media coverage, or at the very least, the absence of negative coverage, complements and reinforces traditional public campaigns aimed at creating demand and behaviour change".

The above illustrates a concerted effort by a donor (Gates), an international media outlet (the BBC, via its corporate social responsibility wing) and a well-funded US non-profit, to control the Kenyan media. These parties then openly report their successful manipulation and censorship of the media, which has resulted in completely biased coverage of a public health program that is opposed by many of those who have taken the time to inform themselves about it.

What kind of foreign donor funded public health program, only carried out on certain African populations, is so important that it is necessary to manipulate the press so that they only report positive stories and that they don't report negative stories about it? If Kenyan people had any objections to this kind of neo-imperialism, would their press even report it? If the US wanted to impose a mass male circumcision program in the UK, would the BBC also collude with Gates, PEPFAR, CDC, UNAIDS and other parties to make sure objections were not heard? This must be what is meant by 'informed consent'.