One of the results of the exceptionalization of HIV is that other health conditions end up being ignored, including sexually transmitted infections (STI). Given the HIV industry's obsession with sexually transmitted HIV, it might be expected that STIs such as syphilis might get a bit of attention.
However, many women can be tested and treated for HIV, and receive prevention of mother to child transmission (PMTCT), without being tested for syphilis and other STIs. These preventable and treatable STIs can be passed on to children, despite most women attending antenatal care facilities at least once during their pregnancy.
WHO estimates that two million pregnant women are infected with syphilis every year and about 1.2 million of them will transmit the infection to their child. Far fewer children are infected with HIV. And the number of deaths from syphilis during pregnancy is higher than the number of infants infected with HIV.
At one time, a lot of attention was given to treating STIs as a means of reducing HIV tranmsission. Trials showed that this had very little impact on HIV transmission and a recent Cochrane Review makes it clear that STI control is not an effective HIV prevention strategy.
But, importantly, the review concluded that there are "other compelling reasons why STI treatment services should be strengthened, and the available evidence suggests that when an intervention is accepted it can substantially improve quality of services provided."
Syphilis and many other STIs are preventable and treatable, yet they often seem to be ignored. And it sounds as if they have only received much recent attention because of the possibility that they may reduce HIV transmission.
Surely STIs should be prevented and treated where possible because they are diseases, not just because this might have an impact on HIV transmission? HIV is debilitating and incurable, but other STIs are debilitating and curable.
Whether STI treatment has an impact on HIV transmission or not, people should not have to suffer from them or risk passing them on to their partners and their children, especially when this is entirely avoidable. They have a right to prevention and treatment for all diseases, not just HIV.
Showing posts with label exceptionalism. Show all posts
Showing posts with label exceptionalism. Show all posts
Monday, May 2, 2011
Thursday, March 24, 2011
'We Haven't a Clue, But We're Doing a Great Job', Say Academics
With a population of only about 800 million, sub-Saharan Africa (SSA) has 22.5 million HIV positive people. The rest of the world, with a population of about 6 billion, has 10.8 million HIV positive people. While 2.81% of SSA is infected, only 0.18% of the rest of the world is. In that sense, SSA's epidemic is 15.5 times worse and that of the rest of the world and Lesotho's (an exceptionally high prevalence country) is 75 times worse.
So how do we interpret these enormous differences? If we accept UNAIDS' and the HIV industry's claim that about 80% of HIV is transmitted heterosexually in African countries, does this mean that people there have more sex than non-Africans? And how much more? Ten times more? Fifty times more? Or is it more dangerous? Ten times more dangerous? Fifty times more dangerous?
In a kind of a sort of a way, they do mean this, or something like this. But they don't mean anything very specific. So if most sexually active people had sex four times a month, perhaps Africans have the time, energy and inclination to have sex at least once a day, every day, and often more than once. Actually, they would need to have a lot more sex with this, or it would need to be unbelieveably dangerous, to account for some of the very high prevalence figures found in SSA.
But the industry clings to its behavioral paradigm, the belief that HIV is mostly transmitted sexually in African countries. Some representatives of the industry recently published a paper wondering what kinds of sexual behavior change resulted in substantial declines in Malawi in recent years. The concluded that it may have been a reduction in the number of sexual partners among (heterosexual) men. They weren't sure about this, though, nor are they sure what could give rise to such a reduction.
I'd like to know what caused sexual behavior in Malawi and other SSA countries to increase to non-humanly possible levels in the first place. And why is it that it's always men who engage in the highest levels of 'unsafe' sexual behavior, but always women who outnumber men, often vastly, in numbers infected? And if it wasn't quantities of sexual behavior, but rather increased risks, why did these increase and then decline?
The authors note the lack of success so far for most interventions. They even cast doubt on the potential effectiveness of mass male circumcision, pre-exposure prophylaxis (PrEP) and immediate initiation of antiretroviral therapy for all HIV positive people, without these being accompanied by substantial changes in behavior. This is almost anti-establishment.
Perhaps they would like to reconsider their adherence to the behavioral paradigm? Because in the case of Malawi, it is possible that more than 50% of HIV infection comes, not from heterosexual sex, but from unsafe healthcare. With the appalling health facilities found in many SSA countries, it is plain arrogance to insist that 80% of HIV transmission is heterosexual and that most of the other 20% is a result of mother to child transmission.
In fact, if nearly 20% of infections are said to be from mother to child, it is very likely that many of these are, in reality, also a result of unsafe healthcare. And far from all these infants being infected by their mother, some mothers may be infected by their infants during breastfeeding.
The authors of the paper conclude, as they did in a recent paper on Zimbabwe, that there was the 'funeral factor', the fear of contracting, suffering from and dying from HIV/AIDS that may have given rise to changes in male sexual behavior. It's always good to have something to attract journalists, but this doesn't explain why so many more women are infected than men. If HIV is not all being transmitted through heterosexual sex, then some interventions that address non-sexual transmission are urgently needed.
The HIV industry has been kicking around the oversexed African theory of HIV transmission for almost thirty years. In addition to being insulting to Africans, especially African women, it does not stand up to scrutiny. This paper is just one more in a long line of travesties. These researchers claim that behavior change has averted tens of thousands of deaths. On the contrary, the number of infections and deaths that have resulted from the failure of HIV research is incalculable.
So how do we interpret these enormous differences? If we accept UNAIDS' and the HIV industry's claim that about 80% of HIV is transmitted heterosexually in African countries, does this mean that people there have more sex than non-Africans? And how much more? Ten times more? Fifty times more? Or is it more dangerous? Ten times more dangerous? Fifty times more dangerous?
In a kind of a sort of a way, they do mean this, or something like this. But they don't mean anything very specific. So if most sexually active people had sex four times a month, perhaps Africans have the time, energy and inclination to have sex at least once a day, every day, and often more than once. Actually, they would need to have a lot more sex with this, or it would need to be unbelieveably dangerous, to account for some of the very high prevalence figures found in SSA.
But the industry clings to its behavioral paradigm, the belief that HIV is mostly transmitted sexually in African countries. Some representatives of the industry recently published a paper wondering what kinds of sexual behavior change resulted in substantial declines in Malawi in recent years. The concluded that it may have been a reduction in the number of sexual partners among (heterosexual) men. They weren't sure about this, though, nor are they sure what could give rise to such a reduction.
I'd like to know what caused sexual behavior in Malawi and other SSA countries to increase to non-humanly possible levels in the first place. And why is it that it's always men who engage in the highest levels of 'unsafe' sexual behavior, but always women who outnumber men, often vastly, in numbers infected? And if it wasn't quantities of sexual behavior, but rather increased risks, why did these increase and then decline?
The authors note the lack of success so far for most interventions. They even cast doubt on the potential effectiveness of mass male circumcision, pre-exposure prophylaxis (PrEP) and immediate initiation of antiretroviral therapy for all HIV positive people, without these being accompanied by substantial changes in behavior. This is almost anti-establishment.
Perhaps they would like to reconsider their adherence to the behavioral paradigm? Because in the case of Malawi, it is possible that more than 50% of HIV infection comes, not from heterosexual sex, but from unsafe healthcare. With the appalling health facilities found in many SSA countries, it is plain arrogance to insist that 80% of HIV transmission is heterosexual and that most of the other 20% is a result of mother to child transmission.
In fact, if nearly 20% of infections are said to be from mother to child, it is very likely that many of these are, in reality, also a result of unsafe healthcare. And far from all these infants being infected by their mother, some mothers may be infected by their infants during breastfeeding.
The authors of the paper conclude, as they did in a recent paper on Zimbabwe, that there was the 'funeral factor', the fear of contracting, suffering from and dying from HIV/AIDS that may have given rise to changes in male sexual behavior. It's always good to have something to attract journalists, but this doesn't explain why so many more women are infected than men. If HIV is not all being transmitted through heterosexual sex, then some interventions that address non-sexual transmission are urgently needed.
The HIV industry has been kicking around the oversexed African theory of HIV transmission for almost thirty years. In addition to being insulting to Africans, especially African women, it does not stand up to scrutiny. This paper is just one more in a long line of travesties. These researchers claim that behavior change has averted tens of thousands of deaths. On the contrary, the number of infections and deaths that have resulted from the failure of HIV research is incalculable.
Wednesday, March 23, 2011
Will Reduced Funding for UNAIDS Mean Less Prejudice?
My first experience of a HIV voluntary counselling and testing (VCT) clinic in Kenya was memorable for the fact that, among the bustle of people coming and going from the public hospital, those wanting anything to do with HIV turned left before the hospital gates. The would sit outside the standalone clinic, in full view of passers by.
This phenomenon, which is still the norm, is just one aspect of HIV exceptionalism and it clearly puts people off going to VCT clinics. It compounds the stigma that surrounds HIV, the fact that anyone who sees you at the clinic will know that you may be HIV positive. Those who are HIV positive face the even greater stigma of having to go to a Comprehensive Care Clinic, dedicated to those with HIV.
Now a pilot program in Western Kenya is trying out the idea of integrated care, where people turn up to see a health professional without being segregated into HIV and non-HIV groups. And aside from reducing the fear people had of being sneered at by other patients and even by health professionals, some are saying that it also frees up scarce resources.
It is good to hear that efforts are being made to see HIV as just one of many illnesses, because people also suffer from and die from so many diseases, often preventable and/or curable conditions. Those who defended the exceptionalization of HIV claimed otherwise, but it is widely felt that resources, including personnel, tended to be deflected away from less prominent conditions.
In fact, one of the groups most vulnerable to HIV, young women of child-bearing age, were unlikely to get much care aside from HIV related care. If they turned out to be HIV positive, they might get just enough care to ensure than their baby was not infected. But then they would be left to their own resources, ignoring the fact that the best way to ensure the health of an infant is to ensure the health of their mother.
Those who turned out to be HIV negative were even less likely to get the care they needed. But recently, there has been talk about putting a greater emphasis on maternal health. Some have even talked about strengthening health systems and improving health facilities, without reference to one, or a handful, of diseases. This may just be a way of reducing funding, but it may also be a genuine attempt to right the balence. I'm accepting that the two could be compatible.
Another of the effects of the exceptionalism of HIV was the way it was never really seen as the business of national governments in high prevalence countries. It was always something that donors controlled. The only interest that health (and other) departments would take seemed to be in the vast sums of money that HIV seemed to attract.
If it is true, as defenders of exceptionalism like to claim, that much of the HIV money was additional, on top of health funding, that's great. And if it is true, as they also claim, that HIV money has also helped strengthen health systems, that's great too. Though I have to say, I don't believe those claims for one moment. But all the better for health systems if they are right, because it's very likely that they will have to get by on a lot less if the pilot is scaled up across the country.
My worry is not that less money will be spent on HIV prevention. Very little is spent on prevention now and most of it is being spent on useless exercises. But if health facilities do not give some attention to levels of infection control, there is a danger that they will continue to expose patients to diseases such as HIV itself, as well as many others.
Conditions in Kenya's hospitals are appalling. Nurses in Pumwani, one of Kenya's busiest state run maternity hospitals, have gone on strike to complain about conditions, extreme shortages of personnel, equipment and medicines. Maternal, infant and under five mortality rates in Kenya are among the highest in the world as a result of these conditions. And yet UNAIDS still claim that HIV is almost never transmitted in health facilities. This is an area of HIV prevention that is in urgent need of attention.
Treatment and care for HIV positive people may suffer if funding for this is reduced. After all, though this amounts to little more than funding for drugs, they are inordinately expensive. But a reduction in donor money for HIV drugs may result in a reduction in the sort of prices that the market has never been able to sustain. And many HIV positive people don't even die of AIDS. They, in common with those suffering from AIDS, often die of preventable and/or curable conditions, despite levels of donor funding for AIDS drugs.
If HIV becomes less exceptionalized, perhaps it will also start to be looked at more realistically. The experience in Kakamega and other districts is, apparently, quite encouraging, especially in the way it has reduced stigma. If HIV is seen as just one of many diseases, it may also be recognised that it can be spread in health facilities, just like hepatitis, MRSA and lots of other diseases. And this would represent a paradigm shift in HIV prevention.
This phenomenon, which is still the norm, is just one aspect of HIV exceptionalism and it clearly puts people off going to VCT clinics. It compounds the stigma that surrounds HIV, the fact that anyone who sees you at the clinic will know that you may be HIV positive. Those who are HIV positive face the even greater stigma of having to go to a Comprehensive Care Clinic, dedicated to those with HIV.
Now a pilot program in Western Kenya is trying out the idea of integrated care, where people turn up to see a health professional without being segregated into HIV and non-HIV groups. And aside from reducing the fear people had of being sneered at by other patients and even by health professionals, some are saying that it also frees up scarce resources.
It is good to hear that efforts are being made to see HIV as just one of many illnesses, because people also suffer from and die from so many diseases, often preventable and/or curable conditions. Those who defended the exceptionalization of HIV claimed otherwise, but it is widely felt that resources, including personnel, tended to be deflected away from less prominent conditions.
In fact, one of the groups most vulnerable to HIV, young women of child-bearing age, were unlikely to get much care aside from HIV related care. If they turned out to be HIV positive, they might get just enough care to ensure than their baby was not infected. But then they would be left to their own resources, ignoring the fact that the best way to ensure the health of an infant is to ensure the health of their mother.
Those who turned out to be HIV negative were even less likely to get the care they needed. But recently, there has been talk about putting a greater emphasis on maternal health. Some have even talked about strengthening health systems and improving health facilities, without reference to one, or a handful, of diseases. This may just be a way of reducing funding, but it may also be a genuine attempt to right the balence. I'm accepting that the two could be compatible.
Another of the effects of the exceptionalism of HIV was the way it was never really seen as the business of national governments in high prevalence countries. It was always something that donors controlled. The only interest that health (and other) departments would take seemed to be in the vast sums of money that HIV seemed to attract.
If it is true, as defenders of exceptionalism like to claim, that much of the HIV money was additional, on top of health funding, that's great. And if it is true, as they also claim, that HIV money has also helped strengthen health systems, that's great too. Though I have to say, I don't believe those claims for one moment. But all the better for health systems if they are right, because it's very likely that they will have to get by on a lot less if the pilot is scaled up across the country.
My worry is not that less money will be spent on HIV prevention. Very little is spent on prevention now and most of it is being spent on useless exercises. But if health facilities do not give some attention to levels of infection control, there is a danger that they will continue to expose patients to diseases such as HIV itself, as well as many others.
Conditions in Kenya's hospitals are appalling. Nurses in Pumwani, one of Kenya's busiest state run maternity hospitals, have gone on strike to complain about conditions, extreme shortages of personnel, equipment and medicines. Maternal, infant and under five mortality rates in Kenya are among the highest in the world as a result of these conditions. And yet UNAIDS still claim that HIV is almost never transmitted in health facilities. This is an area of HIV prevention that is in urgent need of attention.
Treatment and care for HIV positive people may suffer if funding for this is reduced. After all, though this amounts to little more than funding for drugs, they are inordinately expensive. But a reduction in donor money for HIV drugs may result in a reduction in the sort of prices that the market has never been able to sustain. And many HIV positive people don't even die of AIDS. They, in common with those suffering from AIDS, often die of preventable and/or curable conditions, despite levels of donor funding for AIDS drugs.
If HIV becomes less exceptionalized, perhaps it will also start to be looked at more realistically. The experience in Kakamega and other districts is, apparently, quite encouraging, especially in the way it has reduced stigma. If HIV is seen as just one of many diseases, it may also be recognised that it can be spread in health facilities, just like hepatitis, MRSA and lots of other diseases. And this would represent a paradigm shift in HIV prevention.
Wednesday, July 22, 2009
AIDS Exceptionalism has Defenders
Stephen Lewis, the former UN Special Envoy on AIDS in Africa, says that "AIDS exceptionalism is a defensible concept". I have to disagree.
I think HIV is an extremely serious issue and the disease has horrifying consequences. However, I think exceptionalising it has the effect of distracting attention from the very conditions that allowed HIV to spread as widely as it has done.
Health services, education, social services, infrastructure, governance, inequalities and attitudes towards sex and sexuality are some of determinants of HIV transmission. But improvements in all these areas are necessary, regardless of whether HIV is high, low, increasing or decreasing. In Kenya, from the eighties onwards, these issues have all been ignored. The arrival of HIV as a serious epidemic didn't cause them to be ignored but it certainly provided an excuse for putting them all on the back boiler.
People need to know about safe sex, people need reproductive services and education, inequalities and prejudices need to be dealt with, but not just because of HIV. HIV is just one more sexually transmitted disease, it is just one more hazard arising from low levels of sexual health and sexual awareness.
I don't think the money going into HIV related programmes is wasted and if more money is needed, more money should be made available. But much of the money is being spent on goods and services from rich countries, very little is being spent in 'recipient' countries. These goods and services are being purchased regardless of whether that is the best strategy for HIV prevention and care programmes.
And very little is being spent on preventing new infections. Pharmaceutical and other countries are very keen to sell their overpriced products when it comes to treatment but not so keen about prevention. Yet unless the number of people becoming infected goes down, treatment will never be sustainable in the long run. Universal treatment is probably not even sustainable in the short run, for that matter.
With all due respect to Stephen Lewis, I think treating AIDS as exceptional has the effect of divorcing it from its context of serious and long term underdevelopment.
I can't comment on Lewis's accusations about other people in the AIDS field acting from motives of resentment and professional envy. I can understand if he is worried about levels of funding and how they may be affected by the current obsession with the global financial crisis. But I don't think it's justifiable to spend large amounts of money on pills for people who have no food or clean water. And I think that ridiculous situation arises in part from AIDS exceptionalism.
Communicable diseases (some of them, anyhow) get a lot more attention than other health issues but mortality from communicable diseases is only 25% of total mortality. A lot more people are dying of non-communicable conditions. More infants are dying now, more under fives are dying and more mothers are dying now, mostly from non-communicable conditions, than in the 1980s.
If Lewis believes that development funding is too low, I can agree with that. And certainly, HIV related funding has never been high enough. But there are many other diseases, communicable and non-communicable, that receive far less funding, if any. Worse still, people are dying from preventable and treatable conditions.
I don't think less money should be spent on AIDS; but I think greater amounts of money should be spent on programmes that improve people's lives more broadly rather than on programmes that concentrate narrowly on HIV, especially on sexually transmitted HIV. People's lives need to be transformed in every way and, for many, HIV is the least immediate of their problems.
When people have enough food and clean water for themselves and their dependents, when they have access to proper health services, when they receive adequate levels of education, when governance and laws actually protect people rather than increase their vulnerability, HIV treatment and care programmes may have some chance of being effective. Then also, people may be interested in protecting themselves and others against HIV.
There is a hierarchy of needs in developing countries and HIV is not at the top right now. Exceptionalising it won’t put it at the top but dealing with people's most urgent needs could raise its perceived importance.
I think HIV is an extremely serious issue and the disease has horrifying consequences. However, I think exceptionalising it has the effect of distracting attention from the very conditions that allowed HIV to spread as widely as it has done.
Health services, education, social services, infrastructure, governance, inequalities and attitudes towards sex and sexuality are some of determinants of HIV transmission. But improvements in all these areas are necessary, regardless of whether HIV is high, low, increasing or decreasing. In Kenya, from the eighties onwards, these issues have all been ignored. The arrival of HIV as a serious epidemic didn't cause them to be ignored but it certainly provided an excuse for putting them all on the back boiler.
People need to know about safe sex, people need reproductive services and education, inequalities and prejudices need to be dealt with, but not just because of HIV. HIV is just one more sexually transmitted disease, it is just one more hazard arising from low levels of sexual health and sexual awareness.
I don't think the money going into HIV related programmes is wasted and if more money is needed, more money should be made available. But much of the money is being spent on goods and services from rich countries, very little is being spent in 'recipient' countries. These goods and services are being purchased regardless of whether that is the best strategy for HIV prevention and care programmes.
And very little is being spent on preventing new infections. Pharmaceutical and other countries are very keen to sell their overpriced products when it comes to treatment but not so keen about prevention. Yet unless the number of people becoming infected goes down, treatment will never be sustainable in the long run. Universal treatment is probably not even sustainable in the short run, for that matter.
With all due respect to Stephen Lewis, I think treating AIDS as exceptional has the effect of divorcing it from its context of serious and long term underdevelopment.
I can't comment on Lewis's accusations about other people in the AIDS field acting from motives of resentment and professional envy. I can understand if he is worried about levels of funding and how they may be affected by the current obsession with the global financial crisis. But I don't think it's justifiable to spend large amounts of money on pills for people who have no food or clean water. And I think that ridiculous situation arises in part from AIDS exceptionalism.
Communicable diseases (some of them, anyhow) get a lot more attention than other health issues but mortality from communicable diseases is only 25% of total mortality. A lot more people are dying of non-communicable conditions. More infants are dying now, more under fives are dying and more mothers are dying now, mostly from non-communicable conditions, than in the 1980s.
If Lewis believes that development funding is too low, I can agree with that. And certainly, HIV related funding has never been high enough. But there are many other diseases, communicable and non-communicable, that receive far less funding, if any. Worse still, people are dying from preventable and treatable conditions.
I don't think less money should be spent on AIDS; but I think greater amounts of money should be spent on programmes that improve people's lives more broadly rather than on programmes that concentrate narrowly on HIV, especially on sexually transmitted HIV. People's lives need to be transformed in every way and, for many, HIV is the least immediate of their problems.
When people have enough food and clean water for themselves and their dependents, when they have access to proper health services, when they receive adequate levels of education, when governance and laws actually protect people rather than increase their vulnerability, HIV treatment and care programmes may have some chance of being effective. Then also, people may be interested in protecting themselves and others against HIV.
There is a hierarchy of needs in developing countries and HIV is not at the top right now. Exceptionalising it won’t put it at the top but dealing with people's most urgent needs could raise its perceived importance.
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