Millennium Development Goals For All, But At All Costs?

A survey was carried out in one district each in Kenya, Tanzania and Zambia to establish which factors are associated with health facility childbirth (thus shedding light on which factors are associated with the decision to give birth elsewhere, perhaps at home). Health seeking behavior is strongly associated with wealth, education, and urban residence; wealthier, better educated women living in urban areas, in general, are more likely to give birth in a health facility.

These factors are of especial interest because of their association with HIV. Wealthier, employed, better educated, urban dwelling women in African countries are often more, rather than less likely, to be infected with HIV. The tables below are for Kenya, Tanzania and Zambia, but these trends can also be found in other countries. The first table shows HIV prevalence by wealth quintile, with prevalence being lower among poorer people and higher among wealthier people.

The next table shows HIV prevalence in males and females, by employment and by urban/rural residence. Males are far less likely to be infected than females, unemployed people are less likely to be infected than employed people and rural dwelling people are less likely to be infected than urban dwelling people.

The third table shows that HIV prevalence is sometimes lower among those who have less education and higher among those with primary education in Kenya and Tanzania and those with secondary education and beyond in Zambia. (Note, figures for education are for attendance, not attainment, so they don't tell you that much. But MDG 2 is about 'achieving universal primary education', not about academic attainment.)

Receiving antenatal care at a health facility is part of the Millennium Development Goal (MDG) number 5, to improve maternal health. Therefore, it is not surprising that all 14 African countries I have looked at have a very high score for this goal, all ready for 2015. But the goal does not consider matters such as conditions in health facilities, skills of providers, facility practices, equipment, supplies, etc. So the percentage of women delivering in health facilities and the percentage of deliveries attended by a skilled health provider are far lower, being out of the MDG limelight.

For information on health facility conditions, equipment and supplies, there are Service Provision Assessments for each of the three countries, showing that there are many serious lapses. But questions about whether skilled providers are skilled, and of how skilled they are, are less often asked (particularly in relation to the MDGs). Another paper, entitled "Are skilled birth attendants really skilled? A measurement method, some disturbing results and a potential way forward", addresses this issue.

Skill levels overall are not impressive and are low in some areas in the countries involved (Nicaragua, Benin, Ecuador, Jamaica and Rwanda). The researchers note that "knowledge of a procedure is no guarantee that it can be performed correctly", but also that problems are not solely due to a lack of skills or training, that some are due to lack of equipment, supplies and other things.

The first article estimates that skilled birth attendance could substantially reduce maternal deaths "presuming that facilities meet standards of quality care." Quite. But various sources of data show that health facilities often don't meet standards of quality care. The possibility that health facilities may be the source of a considerable proportion of HIV infections in high prevalence countries must be considered urgently if healthcare transmitted HIV, and other diseases, are to be averted.

Reducing maternal deaths is a laudable goal, but it is nothing short of unethical to encourage women to attend health facilities where the conditions are likely to be unsafe. Right now, failing to achieve MDG 5 may even be preferable to achieving it. Of course deaths from hemorrhage, obstructed labor, puerperal sepsis and pre-eclampsia must be reduced, but not at the cost of increasing incidence of HIV, hepatitis and other bloodborne diseases.

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.]

UNAIDS and Uganda: Prejudice Begets Prejudice

Using UNAIDS' inherently flawed Modes of Transmission spreadsheet, the Zambian government have decided that men who have sex with men (along with their assumed female partners) give rise to 1.4% of new HIV cases every year. Not a high percentage. But even African countries which use alternative means of estimating also come up with a relatively low figure.

Despite the fact that the contribution is known to be low, some don't seem to be able to resist the temptation to whip out the homophobia card at every opportunity. The current anti-gay frenzy in Uganda may have been stirred up by various conservative evangelical Christian groups, but it has become a useful political tool; whenever anyone mentions anything political, someone starts spewing out homophobic bilge. What are purely homophobic attacks are then dressed up as part of an anti-HIV strategy.

Spurious figures from UNAIDS for the proportion of HIV transmission said to be a result of some kind of illicit sexual behavior are used to support an assumption that anyone with HIV has engaged in illicit sex. Therefore, even though the contribution of men who have sex with men is not high, it's an easy step to just point the finger at any group you hate, or whose behavior you consider to be wrong (or 'sinful'), and blame them.

But the Ugandan government has tried to claim that its homophobic act (the Anti-Homosexuality act of 2014) does not put healthcare employees in the position where they must choose between running the risk of accusations of 'promoting the act of homosexuality' or 'abetting homosexuality' and the like, which carry a heavy sentence, or breaching their ethical and professional codes of conduct (and international human rights agreements). The government's "Ministerial Directive on Access to Health Services without Discrimination" does not explain how healthcare workers should resolve this dilemma.

The trumped up nonsense about gay people 'recruiting' youth is reminiscent of other rabid conservative fundamentalist claptrap that has fed the media for decades. But the 'blame the victim' mentality and the finger pointing at assumed sexual behavior of African people in the field of HIV comes directly from UNAIDS and the HIV industry. There's a gem of wisdom from their former Chief Scientist on this blog post, but it's pure redneck, so prepare to be offended.

The best way to defuse this obsession with linking HIV to things various atavistic parties consider evil, such as male to male sex, or sex between African people (and between African Americans), is to trace the non-sexual as well as the sexual contacts of people testing positive. It will then become clear that the virus can also be transmitted through unsafe healthcare, cosmetic and traditional practices, and not just through unsafe sexual behavior.

Denial Reigns Supreme in the HIV Industry

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

Just a couple of days ago I mentioned the industry myth that everyone is at risk of being infected with HIV, but I didn't expect to come across this piece of 1980s PR again so soon. Nor did I expect to find it in the New Republic.

Most disturbingly, the article is about "interactive maps depicting where AIDS infections were most prevalent [in the US]". These maps corroborate what statistics have shown for a long time, that the people most likely to be infected live in certain identifiable places, that the epidemic is often associated with poverty, and that black people are far more likely to be infected than white people.

I find this disturbing because, having depicted so clearly that people living in certain parts of the country where the population is either poor, black or both are far more likely to be infected, the lead researcher is quoted as saying that "the fundamental, scientific truth of HIV hasn’t changed. Anybody can still get it."

This is not a 'scientific truth', nor any other kind of truth. It was realized a long time ago that many powerful people would not support a program to address a disease that was said to be prevalent mainly among men who have sex with men and injection drug users. So campaigns were based on spurious 'expert opinions', and data was massaged to suggest that everyone was at risk.

Fair enough, in the US it may have seemed at the time that men who have sex with men and injection drug users were already discriminated against, and this prejudice would need to be addressed before much progress could be made against the recently discovered virus. The campaigns were supposed to take the heat off these (at that time) marginalized groups.

It probably worked in the case of men who have sex with men, although it wasn't so successful for those who inject drugs. But one of the biggest fallouts from the campaign was the effect it had on what became the received view of HIV in African countries, some of which still had very low prevalence at the time, but would eventually suffer the worst epidemics in the world.

The HIV industry was built around the promulgation of the view that if HIV prevalence was highest among people who only engaged in heterosexual sex, as it was found to be in high prevalence African countries, they must have engaged in massive amounts of sex, and it must be very unsafe sex.

But even after the industry abandoned its claim about everyone being at risk, they didn't abandon the myth that most HIV transmission in African countries is a result of unsafe heterosexual sex. As a result, three decades of unsafe healthcare has almost entirely escaped the attention of the industry, along with the billions thrown at the virus.

Some in the industry still pontificate about more women than men being infected in African countries, the fact that babies are still being infected despite scaling up of antiretroviral drugs, high death rates despite the amount of money spent on treatment, etc, but none of them have asked about non sexual risks, through unsafe healthcare, cosmetic and traditional practices.

It was OK to talk about non-sexual transmission in the early days, and it's still OK to talk about it when children are infected (and, on rare occasions, white, middle-class heterosexuals in Western countries, presumably). So why is it difficult to accept that adults in African countries, even adults who are sexually active, can also face non sexual risks?

Groups of people said to be at higher risk of infection in African countries were identified left, right and center, but none of them were identified for their non sexual risks, only for their assumed sexual risks. Almost all women (of course), 'mobile' people (not just transport workers, but also migrant workers, soldiers and many others), those engaged in certain occupations, such as fishing and mining, etc.

But women who are sexually active tend to visit health facilities, sex workers visit sexually transmitted infection clinics, so do soldiers and transport workers (and others), big employers such as mines often provide some kind of rudimentary health services, as do some government departments; healthcare is not as ubiquitous as sex, but it is pretty widespread in certain places.

Those who were not at risk, in contrast, often seemed to be poorer people, uneducated people, rural dwelling people, people who didn't live very close to infrastructure or health services, unemployed people and others, whose low risk is explained away by rubbish about smaller sexual networks and the like.

The myth about everyone being at risk of HIV is dangerous because it is so closely related to the myth that HIV is almost always transmitted sexually in African countries. If people don't know the non sexual risks, they will not know that they need to avoid them, or how to avoid them; if risky practices in health, cosmetic and other facilities are not addressed, they will continue to occur.

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

South Africa: With This Kind of Research, Who Needs Ignorance?

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

Following a recent article about HIV among 'old' people in Tanzania which I discussed a short while back, another article has appeared about an increase in HIV among people over 50, this time from Gauteng, South Africa. Prevalence in Gauteng is high, though it is not the highest in the country. The article concentrates, as is customary for articles about HIV, on sexually transmitted HIV, noting 'unsafe' sexual behavior, in addition to 'caring for infected children'.

However the apparent lack of concern older people are said to feel about being infected, along with their 'ignorance' which the authors note, may stem from the fact that people in this age group do not engage in as much 'unsafe' sex as imagined, that the sex they engage in may not be as 'unsafe' as imagined, and that they may face many non-sexual risks as a result of not being informed about these; constant emphasis of sexual transmission and under-emphasis of non-sexual transmission doesn't help either.

Are the researchers even aware that every skin piercing procedure could be a risk, not just reused injecting and other equipment, but also reused cosmetic instruments (tattooing, piercing, shaving) and reused instruments in traditional practices (traditional medicine, scarification, circumcision)? If older people do not, as the authors suggest, see themselves as being at risk of being infected with HIV, perhaps this is because the non-sexual risks they face through caring for HIV positive people, and risks they face themselves in healthcare, cosmetic and other facilities, have rarely been addressed by HIV intervention programs.

The most worrying aspect of this paper is that it is assumed that sex is the only, or the biggest risk, for HIV. This means that non-sexual risks, which may increase in older people who may have greater healthcare needs, are given so little attention that people do things which they don't even realize are a risk. Worse still, those providing healthcare, cosmetic and traditional procedures may not realize the risks, or they may be a lot less vigilant in their day to day activities.

Despite the emphasis the authors put on sexual transmission, "using the same needles or sharp objects" was mentioned by at least one of the interviewees. Also, two traditional healers were among those interviewed and seemed aware of their risk to themselves, but not the risk that their clients face, which may be a lot higher. But the use of 'protective clothing' by those caring for HIV positive people is far too vague to be of any practical value. What about mentioning skin piercing procedures, needlestick injuries, reuse of needles, syringes, razors and other skin piercing instruments?

This seems to be another missed opportunity to address the substantial non-sexual risks people face from infection with HIV and other bloodborne diseases through skin piercing procedures, whether carried out for medical, cosmetic or traditional reasons. Older people, the subject of this paper, and others around them, may face increased risks from skin piercing procedures, especially those found in health facilities. Instead, the authors obsess about the purported sexual behavior of South African people and fail to make any recommendations about reducing non-sexual HIV transmission.

[For more about non-sexually transmitted HIV through unsafe healthcare, cosmetic and traditional practices and how to protect yourself, visit the Don't Get Stuck With HIV site.]

Data Trumped by Idle Speculation and Pig-Headedness, as Usual

For many years, UNAIDS and the rest of the HIV industry have been sending out the message that everyone is at risk of being infected with HIV. However, it has never been true that everyone is at risk and there was never any reason for claiming this. The fact that HIV tended to cluster in urban areas, among wealthier, more mobile and better educated populations has been clear for a long time.

One of the latest papers to include detailed spacial data which demonstrates this clustering effect is entitled 'Localized spatial clustering of HIV infections in a widely disseminated rural South African epidemic', by Frank Tanser and colleagues. The data they produce is very interesting, but the same can certainly not be said of the conclusions they draw.

Unsurprisingly, they assume throughout that HIV is almost always transmitted through heterosexual sex in African countries, the so called 'behavioral paradigm'. And the study is in South Africa, the country with the largest number of people living with HIV in the world. As usual, the assumption is unexamined and unsupported in any way.

The study finds that high HIV prevalence clusters close to the National Road and that it is far lower in inaccessible rural areas. 40% of infected people live within 1km of the National Road. Also the "estimated density of HIV-infected individuals (total HIV cases per square kilometre) living within 1km of the road is 15.7 times higher than the mean density of infected individuals across the remainder of the study area."

Those infected are also better educated, wealthier and far more likely to be employed. No surprises there. And they are also less likely to be migrants. Migrants, especially internal migrants, are one of the groups often said to be at high risk of being infected and of infecting others. But the HIV industry has always been bad at identifying risk groups or, I should say, good at ignoring any evidence that may help identify them.

Whatever theories the paper's authors may have, indeed, whatever prejudices, all this data supports the view that HIV is not entirely spread sexually. The populations in this and other studies also have something else in common: they all live close to or have easy access to health facilities. Wealthy, well educated, mobile people with jobs tend to go to health facilities.

On the other hand, rural people tend to go to health facilities far less often, for various reasons, including poverty, lack of mobility, lack of health related education and the sheer lack of decent, affordable, accessible health facilities. Do these features of serious underdevelopment give people protection from HIV infection? Well, that's a hard question to answer if researchers like Tanser and colleagues don't even raise it.

The authors speculate about why the factors that may have been significant in HIV transmission during an early phase of the epidemic appear to be significant still and why this apparently heterosexually transmitted virus has not been more evenly spread among the population. Just how many warning signs do they need that their overall hypothesis about the virus being spread almost entirely through heterosexual sex is wrong and is little more than an anti-African prejudice?

As if things are not bad enough, this sort of idle speculation and pig-headed refusal to consider some fairly obvious alternatives to the behavioral paradigm is going to encourage those baying for 'treatment as prevention' and pre-exposure prophylaxis (essentially, means of substantially increasing the tonnage of drugs being thrown at the epidemic) to be rolled out in high prevalence countries.

The Sound of a One Legged Argument Kicking Itself

As I mentioned in yesterday's blog, a recent article finds evidence for the concurrency hypothesis 'compelling', despite liberal use of words that suggests a lot of doubt. The hypothesis is that lots of unsafe sex alone, involving numerous partners, low condom use, etc, does not account for high HIV prevalence; but if sexual relationships overlap with each other, HIV transmission will be very high.

A lot of work has been done to show that the concurrency hypothesis is entirely unsupported by evidence, particularly work by Eileen Stillwaggon and Larry Sawers. But in the article mentioned yesterday, Mah and Shelton dismiss anything challenging the hypothesis rather than addressing the failure of all the arguments that claim to support it.

Well, an article just published by Frank Tanser and colleagues finds that there is "no evidence to suggest that concurrent partnerships are an important driver of HIV incidence in [a] typical high-prevalence rural African population." But instead they argue that multiple partnerships are an important driver of incidence.

While Mah and Shelton denied that non-sexually transmitted HIV plays an important role in hyperendemic scenarios, without arguing the case, Tanser and colleagues don't even mention the possibility of non-sexual transmission. While obligingly neutralizing an argument that should never have been given much credence, and one that has been convincingly refuted by others, they seem to be taking a step backwards.

We have been hearing the oversexed African hypothesis for several decades now, it even predates the identification of HIV. So all Tanser has done is revived that tired old reflex as an explanation of massive rates of HIV transmission. But what is it about Africans that results in a virus that is difficult to transmit sexually spreading so fast in a population in which sexual behavior is little different from that found in many other low HIV prevalence populations?

Rates of new infections per year for both males and females in the study population are shockingly high But the researchers don't appear to have established how HIV was being transmitted. They have just assumed that transmission is all through heterosexual sex and then attempted to work out how risky heterosexual sex is among participants. But why is heterosexual sex so risky there? We are not told.

The authors find that "More than 24% of the adult population are infected with HIV and infection peaks at more than 50% in women aged 25–29 years and 44% in men aged 30–34 years." Given the fairly low probability of sexual transmission of HIV, 80 or 90% of women must be exposed to HIV if such high percentages end up infected.

The fact that male prevalence peaks in an older age group than female prevalence is sometimes explained by the 'fact' that older men have younger partners. But only some men have younger partners. Some have partners the same age as themselves. Like a lot of HIV related data, you could be forgiven for thinking that HIV in males is a different virus from HIV in females.

Despite flogging the dead horse of concurrency, which is worthwhile when you consider how much credence it still seems to have in the HIV industry, the authors remark that concurrency may have played a big part in earlier stages in high prevalence epidemics. But earlier treatment of the concurrency hypothesis suggest otherwise, so this concession doesn't exactly strengthen their argument for a return to the promiscuity theory of HIV.

And when it comes to their recommendations for HIV prevention strategy they really seem to weaken. They argue that 'messages' shouldn't be 'diluted'. Pumping out a fairly undiluted though highly stigmatizing message about HIV for many years has not resulted in UNAIDS having much success in reducing transmission, despite spending billions. In fact, the pharmaceutical lobby trying to increase drug use in the pretence that it will reduce transmission even refers to the institution's prevention work as a failure.

Telling people the truth about HIV transmission is not 'diluting' anything. If people are at risk they need to know about the risks and how to avoid them. UNAIDS have used the issue of 'dilution' as a reason for denying non-sexual risks, with the result that most people don't know that such risks exist, and therefore cannot avoid them. HIV prevention is not just an advertising campaign, even if it's never looked much different from one.

Concurrency Regurgitated: Dubious Evidence Found Increasingly Credible by Experts

For unbridled spite and anti-African prejudice, packed up in some academic sounding writing, it would be hard to beat Timothy Mah and James Shelton's 'Concurrency revisited: increasing and compelling epidemiological evidence'. Don't worry, it's not in the least bit compelling.

One of the main claims of the article is that the person engaging in concurrent relationships doesn't face as high a risk as all their partners. And this is supposed to explain why another study showed that, although men were five times more likely to report having concurrent relationships than women, women are far more likely to be HIV positive.

The gist of the pro-concurrency argument is that while multiple partnerships alone, even the sort of multiples estimated by those with similar prejudices to Mah and Shelton, do not explain extraordinarily high rates of transmission found in many epidemics, concurrency does explain them.

Concurrency is roughly defined as "overlapping sexual partnerships in which sexual intercourse with one partner occurs between two acts of intercourse with another partner". But because there is little useful evidence about rates of such behavior, in African countries or anywhere else, researchers usually resort to data which bears little application to that (or any other) definition of the word.

Authors promoting the concept as an explanation of high HIV prevalence claim that it is the only possible explanation. However it is not an explanation at all, even if you insist, as the HIV industry does, that HIV is almost always transmitted through heterosexual sex in African countries. It has never been demonstrated that concurrency levels are high where HIV transmission is high or that high levels of concurrency even result in high rates of transmission.

Mah and Shelton proceed to list various pieces of research that show that HIV is probably frequently transmitted non sexually; they just don't see the research as showing this. Earlier researchers 'presumed' that HIV transmission where only one partner in a relationship is infected occurred through extra-marital sex. They generally didn't check and when they did, they chose not to believe anything that didn't fit their prejudices.

People like Mah and Shelton could do with a bit of instruction in basic logic. If you assume the truth of your conclusion and use that as your premise, you will end up with a fallacy. Some of the researchers are even frank enough to use words like 'presume' and 'probably' in their cited remarks. But Mah and Shelton feign complete confidence in their conclusions, despite the high incidence of words like 'appear', 'suggest', 'likely', 'may', etc, throughout their paper.

A recent paper which shows prominent clusters of HIV prevalence around roads does not, as Mah and Shelton wish to suggest, support the concurrency hypothesis. But it is consistent with the hypothesis that infections cluster around health facilities and routes to and from health facilities. However, even after exposure to the many articles they cite in their bibliography, they still adhere to their half baked ideas, finding them "reasonable and salient".

Given their insistence that HIV is almost always transmitted through heterosexual sex in high prevalence countries (though nowhere else), the authors plump for male circumcision as the reason why HIV transmission rates in West Africa have always been far lower than in East and South African countries. This especially weak version of the highly questionable mass male circumcision drive taking place in East and South Africa is said to be 'plausible', which probably shows more about the minds (and scruples) of the proponents than anything else.

Just when you might have thought those tired old arguments had been put out to grass, along come Mah and Shelton to compound them with some even more clapped out considerations. In my next post I'll cover an article which shows that concurrency is not a significant driver of HIV transmission but that multiple partnerships are. And that old chestnut dates back to the days when even experts agreed that HIV wasn't always sexually transmitted. But that's how AIDS billions get spent.

Presentation at Kilimanjaro Clinical Research Institute

Hordes of articles are appearing right now about some promising results from the use of antiretroviral drugs (ARV) to prevent HIV, as opposed to treating it. This is called pre-exposure prophylaxis or PrEP. But the question is, who will benefit from this use of ARVs, which has mainly been tested on Africans?

ARVs are expensive, despite all the posturing about agreements and deals brokered by Bill Clinton and other notable self-publicists. They are so expensive that few countries with serious HIV epidemics and large scale treatment programs have ever been able to cover more than half of the HIV positive population, at most. Usually coverage is a lot less than half.

The biggest programs in East Africa only include a few hundred thousand people, out of millions infected. But HIV negative populations are many times larger than HIV positive populations. Over 90% of the populations in all the East African countries are HIV negative. How will people be selected for PrEP programs? According to the HIV industry most sexually active Africans are at risk of being infected.

Yesterday I had the pleasure of making a brief presentation about sexual and non-sexual HIV transmission to a group of people who work or study at the Kilimanjaro Clinical Research Institute, part of the Kilimanjaro Christian Medical Center (a powerpoint of the presentation slides is available on the KCRI site). The talk was about my usual concern, the 'behavioral paradigm'. This is the view that HIV is almost always transmitted through heterosexual sex in high prevalence African countries.

This 'paradigm' is not based on evidence. In fact, it is frequently contradicted, especially by UNAIDS's own data. But as the flagship of the AIDS industry, this means that resulting UN policy is almost entirely based on what amounts to an extremely racist view. How will that racism, which so far has resulted in a lot of money being spent on large-scale finger-wagging exercises, affect the rollout of PrEP?

One of the slides I used at the presentation was a screenshot of the mathematical model used to back up the industry's claim that most Africans are at risk of being infected with this difficult to transmit virus. The 'Modes of Transmission Survey' for Kenya, for example, suggests that 44% of the 1.5 million HIV positive people were infected by ordinary heterosexual sex. And members of other groups that would be considered to be at low risk in non-African countries are also mysteriously infected in huge numbers.

UNAIDS' argument for this is somewhat circular because the claim that members of the largest group of HIV positive people are infected by their regular partner is supported by the idea that most regular partners have, or at one time had, 'unsafe sex'. But these are just more assumptions based on the behavioral paradigm, not pieces of data that might support it.

It's hard to know whether this adherence to the behavioral paradigm is going to blow up in the industry's face, or whether it will just feed their ongoing demand for profits at any cost. If virtually every sexually active person in a population is at risk, will they all be offered PrEP? Or are UNAIDS going to claim that PrEP is not appropriate for groups that have been considered to be at high risk up to now?

There is also a problem right now about funding ARVs for people who would die without them. Who will stump up tens of times more funding for drugs for people who will not die without them, probably won't benefit from them at all and may even be harmed by them? If saving the lives of some HIV positive people is not considered worth the effort, is it worth the cost and effort to play around with the lives of huge numbers of people just so pharmaceutical companies can become even richer than they already are.

My worry is not just about the use of drugs to reduce HIV transmission. My worry is about the serious lack of clarity about why certain people, mostly Africans, are so susceptible to a virus that is difficult to transmit sexually, yet so many are infected. Simply throwing a lot of drugs at the problem is unlikely to make it go away. This problem needs to be explained without the use of the thoroughly discredited behavioral paradigm.

[For more about pre-exposure prophylaxis, see my other blog.]

By Following UNAIDS' Advice, Angola's HIV Epidemic Should Rocket

Following a recent posting about the risk of HIV and other blood borne diseases being spread in beauty salons and barber shops in the country of Georgia, here's another one about the same issue in Angola.

Even in Angolas capital, Luanda, many establishments lack sterilizing equipment. Beauty and hairdressing processes sometimes carry the risk of breaking the skin, especially where an area of skin is already damaged. If an infected area is involved, the risk of transmitting HIV is particularly high. Pus is a lot more risky than blood.

The articles don't mention additional risks from things like body piercing and tattooing, though these involve, by definition, breaking the skin. The Angola Aids Institute has pointed out that it is the establishment owners' responsibility to provide equipment and other materials. But it is the employees who need the training.

Anyhow, it's good to have the issue aired. Here in East Africa, a lot of hairdressing, cosmetic treatment, manicure and pedicure takes place on the street and in people's homes, often carried out by ill-equipped and untrained people. And people appear to be entirely unaware of the risks. They point to the small bottle of surgical spirit and cotton wool which they use, to a greater or lesser extent.

If those providing the treatment are unaware of the risks, their customers are even less aware. Worse still, official warnings from UNAIDS and the like about HIV are almost entirely about sexual risks, with non-sexual risks either diminshed, ignored or denied.

Angola borders some of the highest prevalence countries in the world but HIV prevalence there is not even as high as it is in East African countries. This is, even by UNAIDS, accepted as relating to the long civil war there. War is said to keep many parts of a country isolated.

What UNAIDS don't say is that war can also reduce the use of beauty and hairdressing establishments, even the provision of such services. And the august and over-financed institution is even less likely to point out that during long civil wars, over 25 years in Angola's case, health services tend to break down. These factors might significantly reduce the risk of non-sexual HIV transmission.

'Unsafe' sexual behavior was likely to have been far more common during the civil war than since. At least, it's unlikely to have been less common. It is only now that the civil war has ended that people, especially children, are receiving information about sex and HIV. Yet, ironically, it is now that the war has ended that HIV prevalence is rocketing.

Unfortunately, the usual suspects, political, religious, scientific, etc, are rushing to Angola to wag their collective fingers about safe sex. These groups are unlikely to have any impact on HIV transmission. So it's reassuring to hear news from Angola about non-sexual transmission. Let's hope they include unsafe medical practices in their warnings.

Almost all HIV transmission in Angola could have been prevented. There were people warning about non-sexual transmission in the early 2000s, even in the 1990s. But the HIV agenda has long been hijacked by those obsessed by sex, especially sex in Africa. If Angolans don't see the error of global HIV policy and go their own way, they will end up like all the other countries 'guided' by UNAIDS and their ilk.

HIV Transmission Takes Many Forms, So Let's Not Concentrate on Just One

In the US and many other Western countries the number one way of becoming infected with HIV is through anal sex, usually men having sex with men (MSM). The number two way is intravenous drug use. Other modes of transmission are in need of elucidation but we are told they include penile-vaginal heterosexual sex.

Many people, when asked to guess, think that penile-vaginal heterosexual transmission is very common. They are not aware that it is an inefficient mode of transmission, especially compared to anal sex (between men or between men and women) and intravenous drug use.

In some African countries, HIV transmission is said to be predominantly through penile-vaginal heterosexual sex. Intravenous drug use may well be low in a lot of high prevalence African countries. Exactly why male/male or male/female anal sex should be relatively rare or should rarely transmit HIV in African countries has never been made clear by the HIV industry.

But because of the insistance on harping on about penile-vaginal (usually just by implication) heterosexual sex, very little attention is given to any other modes of transmission. And non-sexual modes of transmission, such as unsafe healthcare, unsafe cosmetic practices or anything else, are barely mentioned and are claimed to be almost non-existent if mentioned at all.

So it's not surprising that there is a lot of misunderstanding about anal sex (as well as HIV and sexual transmission in general). People in African countries in particular are usually unaware that anal sex carries a risk of transmitting HIV, or even sexually transmitted infections, let alone the fact that it carries a far higher risk than other forms of sexual intercourse.

The risk may be as much as 18 times higher. That makes it very risky indeed. But, for some reason, the HIV industry has pinned their hopes on targeting penile-vaginal heterosexual sex, almost exclusively. And it's not working. Whether the industry lies or simply doesn't bother to tell the true story, many people are taking risks, getting infected, suffering and dying, completely unnecessarily.

What is so difficult, or even wrong, with telling people the full story? HIV is transmitted in many different ways. Some of those modes of transmission are efficient, such as anal sex, intravenous drug use, unsafe medical and cosmetic practices; and some are not efficient, such as penile-vaginal heterosexual sex. Even sex work is not particularly risky in Western countries, only in African countries, it seems.

To tell people only the bit you want them to hear, for example, about penile-vaginal heterosexual sex alone, is to fail to educate them. They do not get an understanding about how HIV is transmitted. Therefore they remain in the dark about how to protect themselves. The behavioral paradigm, the view that HIV is almost always transmitted through penile-vaginal sex in African countries is a fallacy. And it's killing people.

Sometimes Targets of Prejudice Embrace that Very Prejudice Themselves

It's odd sometimes how the targets of a prejudice embrace that very prejudice themselves. UNAIDS' prejudice about HIV almost always being transmitted sexually in African countries is a case in point. Academic articles and press coverage alike, explicitly or tacitly, assume the truth of the prejudice. And people here say 'we' or 'Kenyans' or 'Africans' like sex, have a lot of sex or prefer 'unsafe' sex.

In an article about adult male circumcision in Uganda, carried out with the aim of reducing HIV transmission (from females to males), Robert Kalumba warns that many people, male and female, seem convinced that the operation protects everyone from both infection and transmission. This is not the case, although the warning is nothing new.

But he also claims that "Ugandans love sex a lot" and it's hard to know what that means, aside from being an echo of the oft expressed prejudice. HIV prevalence is low in some parts of Uganda, high in others, low in some demographic groups and high in others. Do all Ugandans love sex? More than non-Ugandans? What about in places where HIV prevalence is low? What about non-Ugandans among whom HIV prevalence is far higher than it is in Uganda, such as Swaziland?

Kalumba also embraces the reflex about HIV being related to 'ignorance', just as others say that HIV is 'driven' by poverty. Neither of these reflexes are borne out by the evidence. HIV rates in high (and medium) prevalence countries are, in general, higher among those who have a higher level of education and are wealthier. And the effect is usually stronger among women than men.

Of course, lack of education and poverty are undesirable. The continued appalling educational, health and economic circumstances in developing countries is repugnant; but not because of their relation or lack of relation to HIV prevalence. Rather, HIV is repugnant because it is a virulent disease, one that spreads most readily among people who already face many other problems, such as low levels of access to adequate health facilities.

What Kalumba should be asking about mass male circumcision campaigns is why so much money and attention is going towards an operation which will only benefit some people, all men, when so many others are in even greater need, more often women than men. In fact, any effect in the field may prove small or even negative.

The United Nations General Assembly Special Sitting (UNGASS) report for Uganda in 2009 also makes one wonder to what extent HIV is sexually transmitted. A quick look at their graphs for HIV on the one hand and other recognized sexually transmitted diseases on the other shows that infection patterns are completely different.

Many would suspect that HIV is only partly sexually transmitted. And if they do, they will recognize that circumcision and other measures that assume the truth of the above mentioned prejudice will never be enough on their own.

While he is at it, Kalumba and others could take a look at various data from the Ugandan Demographic and Health Survey, which show that the highest figures for 'unsafe' sexual behavior are those for men, whereas the highest figures for HIV are for women. If he looks at the Aids Indicator Survey, he will notice many other anomalies, such as the number of people who are infected with HIV when they have never had sex, rarely had sex, only had sex with their partner or rarely had 'unsafe' sex.

The fact that some of the richest and most powerful HIV related institutions agree that HIV is almost always sexually transmitted in Africans does not make it so. And people like Kalumba need to be able to spot a prejudice for what it is. Because if Africans don't reject the prejudice, policy for HIV 'prevention' in Africa will continue to fail. You can't eliminate non-sexual transmission of HIV by targeting people's sexual behavior, especially among those who are not even sexually active.

HIV Can Be Spread in Beauty Salons, Despite UNAIDS Denial

An article about beauty salons in Georgia (the country, not the US state) makes it clear that HIV, hepatitis B and C and other serious viruses can be spread when good hygiene measures are not observed. Many salons, we are told, do not meet adequate standards. Customers are more interested in getting a good price than in avoiding health risks.

Perhaps people are not even aware of the risks, though. The article didn't manage to find any cases where serious infection had been confirmed to have come from a beauty salon. But if few people know about the risks, they are not likely to connect their infection with a visit to a beauty salon, which may have taken place years, or even decades before.

Even health professionals are unlikely to make the connection. When a HIV positive patient visits a health facility in most countries (I don't know if it's the same with Georgia), they are far more likely to be asked about their sexual history, with other risks given less attention, if any.

Adequate sterilization of instruments that may break the skin requires expensive equipment and good training and management. These may be absent in some salons. And all sorts of treatment can carry risks, not just manicure and pedicure but also male and female hairdressing, shaving and body piercing.

With a population of 10 times that of Georgia and a GDP per capita of less than one tenth, Tanzania must be in a far more dangerous position. There are many salons here, but price is even more important than it would be in a relatively rich and far more developed country.

In fact, the majority of poorer people in Tanzania do not go to salons for a lot of cosmetic work. The needs of many are attended to by friends and family with little or no training and even less access to sterilization equipment. Others go to the ubiquitous street cosmeticians, who will do your hands and feet out in the open as you wait for your bus or your friends or whatever.

UNAIDS doesn't even consider non-sexual transmission to be an issue when it comes to HIV in high prevalence countries. They insist that only around 2-2.5% of transmission occurs in health facilities. No mention at all is made of cosmetic or other non-sexual risks in the Modes of Transmission Surveys that I have seen for African countries.

It would be odd indeed if a country like Georgia were to be a risky place for such non-sexual transmission and a country like Tanzania (or Kenya, Uganda, South Africa, Swaziland and other high prevalence countries) were to be risk free. If people face sexual risks, they probably also face non-sexual risks. And that means they need to be made aware of these risks.

Non-sexual risks are recognised in some countries. A recent paper on the subject of hepatitis B in Pakistan notes "Lack of awareness, socioecomic conditions, sexual activities and sharing of razor blades, syringes and tattooing needles" as risk factors. And there, 21% of the population are infected with hepatitis B. Therefore, non-sexual risks in high prevalence countries need to be given as much attention as sexual risks.

[I should have mentioned that the Pakistan study is about Internally Displaced Persons (IDP), a group that is not representative of the population as a whole. National hepatitis B prevalence is estimated at about 67.5%, far higher than in the study population. In African refugee and IDP camps, HIV prevalence is usually significantly lower than in the population as a whole. Risks are clearly lower, although these camps are said to involve many hazards.]

Any exposure to blood, pus and other bodily fluids could carry the risk of serious disease transmission, especially where viruses like HIV and hepatitis are endemic. Teaching people only about sexual risks when serious non-sexual risks are being faced by everyone in a population, sexually active and non-sexually active people alike, is allowing some of the most easily prevented instances to continue, uninvestigated and unhindered.

UNAIDS have a standard excuse when non-sexual transmission is mentioned. They feel that it could deflect attention from sexual transmission. But if people face both sexual and non-sexual risks, UNAIDS are failing in their duty to give people accurate information that could protect them and their children. We will not protect people from HIV by lying to them about the risks they face.

Reducing Maternal HIV: the Only Acceptable Way of Reducing Pediatric HIV

The received view of HIV in high prevalence countries, especially African countries, is that roughly 80% is transmitted through heterosexual sex and most of the remaining 20% is transmitted from mother to child. So it's not surprising that the HIV hierarchy should target mother to child transmission, or at least talk about doing so. Even if the 80% estimate is way out, a very large number of children are infected during pregnancy, delivery or shortly after birth.

While no one could object to aiming to eliminate mother to child transmission, some might wonder if any effort will be made to prevent HIV in pregnant women. That might seem stupidly obvious but I don't see attempts being made to establish why so many pregnant women become infected with HIV, especially late in their pregnancy, or even shortly after birth.

Of course, transmission of sexually transmitted infections (STI) occur as a result of unprotected sex, as does pregnancy. But many of the women infected with HIV are not also, or not as much infected with more common and easier to transmit STIs. http://www.plusnews.org/report.aspx?ReportID=92664 Perhaps more strikingly, many women who are infected with HIV don't have HIV positive partners. And in a lot of cases, there is no routine follow up and testing of partners in African countries, so we can't always even be sure.

Although there is always the assumption that women who are infected shortly before, during or after their pregnancy are infected by their partner as a result of unprotected sex, there is a good chance that many women are not being infected by their partner, nor even through unprotected sex. UNAIDS' insistance that 80% of transmission in African countries is through heterosexual sex is, after all, not based on evidence. It is, on the whole, an unsupported assumption.

Something even better than preventing mother to child transmission, then, is preventing HIV in mothers. And where sexual partners are not even HIV positive, there is good reason to establish just how women are infected, and then use the resulting data to adjust the 80% figure. HIV transmission through some unknown route is very unlikely to be prevented. And that makes prevention of mother to child transmission a lot more difficult to effect.

In countries such as Libya and Romania, where massive rates of HIV transmission were recognized (and acknowledged) to have occurred through unsafe medical practices, many of the children infected went on to infect their mothers through breastfeeding, as opposed to the other way around. But such modes of transmission need to be recognized (and adknowledged) before they will be investigated, let alone prevented.

Recognizing non-sexual transmission would have another benefit: it would reduce stigma. If HIV positive Africans are told that it is almost certain that they were infected sexually, they will be stigmatized. Especially if it turns out that their partner is not infected. Allowing the possibility that HIV can be transmitted in other ways, which it most certainly can, could save a lot of marriages and lives, even the lives of children at risk of becoming infected.

There is some recognition that the state of public health facilities has direct consequences for the health of the people using those facilities. A lack of drugs, equipment and trained personnel has a negative impact on goals such as reducing child and maternal mortality, HIV transmission, malaria and other diseases.

Apparently, drugs and equipment can be stolen or may never reach health facilities. Sometimes patients have to bring the latex gloves and other equipment that will be used for their care. Perhaps sometimes equipment in short supply is reused, even without proper sterilization. But accepting that it can happen is not enough. It also needs to be established if this is contributing to transmission of diseases, such as HIV, and if so, how big this contribution is.

It's all very well to talk/write about destigmatization. But many of those doing the talking/writing are also doing the stigmatizing. There is plenty of evidence that HIV is not always transmitted sexually in Africa and there is evidence that possible cases of non-sexual transmission need to be investigated. Admitting this would go a long way towards reducing transmission, and also reducing stigmatization.

You will no more reduce stigmatization by saying 'stigma is bad' than you will influence sexual behavior by saying 'unprotected sex is risky'. We have learned that through many years of failing to have much impact on HIV transmission. The issue of stigma is very much in the hands of the people who warn us about how damaging it is, the UN, UNAIDS, WHO, CDC, the World Bank, etc.

The best way to reduce HIV transmission is to be clear about how the virus is being transmitted and not to depend on out of date and inappropriate figures. The best way to reduce mother to child transmission is to reduce the number of mothers being infected. And the best way to reduce stigma is to be honest about HIV transmission: we know that it is not always transmitted sexually and we don't even know how much is transmitted sexually.

Are UNAIDS Getting Off On Their Own Sexual Fantasies?

If paying for sex commoditizes it, does paying people not to have sex also commoditize it? Would anyone bribe their daughter with money to wait till they are married before they have sex? Or would they bribe them with money not to have sex for money? Somehow, I can't imagine parents thinking this way.

I don't know if paying girls not to have sex commoditizes it but I know it's one of the stories that does the rounds because it seems to appeal to journalists. And I know that UNAIDS sees it as worth a try in South Africa. I just can't see them trying it out in Washington DC (which might have the highest HIV rates in the Western world).

The article informs us that young South African girls are "one of the highest risk groups, because poverty drives them to have sex in exchange for gifts." What, all young girls? Or is it just all 'poor' young girls? "Researchers now want to see whether using cash payments as a reward for getting good grades and having annual HIV tests could curb the girls' risky sexual behaviour." So if the grades are not good and/or they don't have annual tests for some reason, no money for them?

Maybe things have changed radically in SA but only a few years ago "Startling new evidence from a three-year survey [showed] that HIV is now growing fastest among those who are wealthier and educated." This phenomenon is quite familiar in Kenya and even more so in Tanzania. In fact, the phenomenon is most marked among female Tanzanians: HIV rates are higher among well educated, well off Tanzanian women.

The Nature article is not too clear but I think it is saying that money is being given to boys and girls. Apparently boys are being involved because "Men are driving the epidemic — through their sexual behaviours, drug-taking, risk-taking and the fact that they often hold the balance of power in decision-making in intimate relationships."

Maybe the epidemic is being driven by men, but people could be forgiven for not being entirely convinced of that. HIV prevalence among females at age 15-19 is 6.7% and among males it is only 2.5%. We are informed, frequently, that young women sleep with older men. But how much older? And do all young women sleep with older men? Because in the 20-24 age group, female prevalence is 21.1% and male only 5.1.

Some estimates suggest that some (but by no means all) females sleep with men who are between five and ten years older than them. So if 15-19 year old females were sleeping with 20-24 year old men, it looks like a lot of the males are actually being infected by females, not the other way around. 6.7% of 15-19 year old females are infected, compared to 5.1% of 20-24 year old males. Sorry for being repetitive but these figures don't suggest that HIV transmission is being 'driven by men'.

Even if some young women have sex with much older men, there is no evidence that they all do. And while female prevalence peaks at 32.7% in the 25-29 year age group, it peaks at only 25.8% among 30-34 year old males, never reaching female prevalence rates in any age group. The figures could even suggest that the number of promiscuous females, if you go for the promiscuity theory of HIV transmission, radically outnumbers that of promiscuous males.

This doesn't really give credence to the idea that the epidemic is being driven by men. In fact, it might make you question the assumption that the epidemic is entirely driven by sex. You have huge numbers of females being infected at a very young age and far smaller numbers of men who could be infecting them. The whole principle behind making money from sex is that there are relatively few women being paid by a relatively large number of men.

If the number of women selling sex outnumbers the men buying it, the bottom falls out of the market. But, interestingly, if fewer women are willing to sell sex, the value will go up. If lots of these young females, said to be selling sex because they are so impoverished, suddenly disappear off the market, those left selling sex will be able to command a far higher price. The scheme may have some benefit, but probably not the one intended by UNAIDS!

But the two main claims in the article about paying young women not to have sex are that HIV is driven by large numbers of poor young women having sex for money and that HIV transmission is driven by (smaller numbers of) promiscuous men. Neither of these claims seems very plausible. What is plausible is that small numbers of poor young women have sex for money and that small numbers of promiscuous men pay for sex.

And this still doesn't explain extraordinarily high HIV prevalence figures found in South Africa, therefore it can not justify paying young girls (or boys) to not have sex. HIV prevention interventions need to be based on reality, rather than on the fantasies of a bunch of bureaucrats desperate to have something to show for the billions that have been poured into their institution.

Enabling girls to stay in school has been shown to reduce 'unsafe' sex, unplanned pregnancies and possibly sexually transmitted infections and HIV. But if HIV prevalence is usually higher among better educated girls, perhaps this needs to be investigated before spending money and precious time with interventions that may not work and that may make things worse. There is no substitute for establishing exactly how HIV is being transmitted in high prevalence contexts. Because we clearly don't know that yet.

HIV Treatment Has Come a Long Way, Prevention Has a Long Way to Go

South Africa, apparently, has a plan to "eliminate HIV in the next 30 years". The plan is based on a mathematical model, which assumes very high HIV prevalence and a population that will be tested once a year. Those found positive will be given antiretroviral drugs immediately, to take for the rest of their lives. The model says that this will eliminate the epidemic.

It would be interesting to know what figures they used in their model. South Africa has indeed tested many millions of people in the last twelve months, perhaps 12 million or more. But it has been estimated that people might need to be tested more frequently than once a year, perhaps twice or even four times a year. Will once a year be feasible, even if it turns out to be enough?

Sure, plenty of research has shown that a lot of people responding to antiretroviral treatment have a very low viral load and are unlikely to transmit the virus to their sexual partners. But that doesn't mean that 'test and treat', as it's called, will eradicate transmission altogether.

Recent research which gave rise to a lot of the hype about test and treat involved discordant couples. These are couples where only one person, the 'index case', is infected. It is believed that the index case will, sooner or later, infect their partner if they continue to have unprotected sex. The rate of transmission in discordant relationships is, indeed, very high. Putting the infected partners on drugs, assuming that they are found to be HIV positive early enough, could significantly reduce the risk to the HIV negative partner.

But that doesn't answer the question of how the index partner was infected. They would probably not have been protected by a test and treat policy, unless that policy was able to ensure that a huge percentage of new infections were discovered and treated very early on. But, while you can see the motivation for putting the HIV positive partner on drugs to protect the negative partner in discordant couples, in a couple where neither is positive there is no such motivation.

The South African plan doesn't deal with the issue of whether all HIV positive people will agree to or adhere to treatment. It doesn't even ask if putting people on treatment immediately is the best thing for those people's health. Leaving treatment till too late is clearly bad for people's health. But treating them too early, as well as being expensive and more likely to result in non-adherence and consequent resistance, may not be ethical.

It certainly won't be ethical if people are compelled to take the drugs, regardless of whether they need them or not. But there's also the question of whether people should take drugs for the benefit of others, or for the benefit of public health. [There's an interesting discussion of patient autonomy by Dr Joseph Sonnabend on his POZ blog.]

Treating more people, if and when they need treatment, is a good thing. Testing more people and testing them regularly is also good, especially if the results of such widespread testing are used to figure out why so many people become infected in South Africa. But test and treat alone is very unlikely to eliminate any epidemic in any country in 30 years, or even in 100 years.

No matter what any model (or 'expert') tells you, treating as many HIV positive people as possible is not the same as developing strategies to ensure that people don't become infected in the first place. Public health is a lot more complicated than any mathetical model can show. That's why so few diseases have ever been eradicated.

Diseases that have been virtually eradicated in some countries were not eradicated merely because of some powerful technology, either. They were eradicated because the conditions under which the disease is transmitted were also addressed. Water, sanitation and hygiene in the case of many diseases, air quality and habitation in the case of others, food and nutrition, living conditions, working conditions, etc. Test and treat remains relatively blind to the conditions under which HIV is transmitted (as has the HIV industry).

Alarmingly, research has shown that test and treat alone will not even come close to eradicating HIV in the US, where transmission is many times lower than in South Africa and the amount per head spent on healthcare is the highest in the world. And this is not because the universal testing part of the strategy is not in operation but because only 1 in 5 people on treatment have the undetectable viral load requried to ensure that they don't infect their partner through unprotected sex.

Test and treat is neither a miracle nor something that is impossible to effect. But it will not eradicate HIV epidemics, ever, anywhere. And public health experts should know that there is no such precedent for eradicating a disease that is transmitted in a number of ways (some of which are adequately acknowledged and some of which are not). It is wholly irresponsible to make the implicit promises that one hears constantly about test and treat.

There is a lot we don't yet know about HIV transmission and, apparently, a lot we are not very anxious to discuss. So let's not get distracted from HIV prevention by what is just one in a long line of hyped technical fixes. Test and treat, treatment as prevention, whatever you want to call it, will only ever be part of an effective strategy to eradicate HIV.