UNAIDS: Mythmakers or Liars?

We have spent the last few days in Bukoba, talking to people about their memories and perceptions of HIV. Unfortunately, after decades of being told that HIV is primarily spread sexually, most people firmly believe that this is the case. They believe that HIV came from ‘somewhere else’ (Uganda, America, Europe, truck drivers, sex workers, men who have sex with men, etc), a widespread belief. In Bukoba, they believe (mostly) that it came from Uganda and this may be true. Alternatively, HIV may have spread from Tanzania to Uganda at the same time as it was spreading from Uganda to Tanzania. It seems likely that HIV spread in waves at various different times and its impact in a particular place depended on many of the conditions extant in that place at the time.

The problem with ignoring non-sexual transmission of HIV, through unsafe medical practices or through cosmetic or other practices where blood or bodily fluids may be involved, is that people end up not looking out for such risks. Even where they recognise their existence, they don't know how to protect themselves. For instance, people know that hairdressers should sterilize their equipment between clients but their neither the hairdressers nor the clients know what is required for equipment to be properly sterilized.

Contrary to widespread belief, HIV does not die after seconds or minutes of being separated from the host. It can live for hours or even days on instruments that dry out. And it can live for weeks if it remains wet. If a hair trimmer is used on a person with a disease that is transmissible through blood contact, it needs to be boiled. Just cleaning it in water is not enough, nor is wiping it with methylated spirits or bleach. Yet, people are convinced that this is enough. They even admit that they don't know one way or another what is done with the instruments. Manicurists just turn up with a bucket of instruments and do their work before going on to another client. They don't have the equipment necessary to sterilize their tools, nor do their clients seem to be aware that this is very dangerous.

One person we talked to said that she uses a hair relaxant that burns the skin and makes it liable to break. Hair relaxants are popular here, to produce straight hair. So combs and anything else used would need to be carefully sterilized, but the facilities for doing this are often not available. As a hairdresser, she was unaware that it is not just blood that can transmit infection. Pus is even more dangerous. She was under the impression that if people had sores on their head, this was not risky unless there was also blood. Decades of warnings about the risk of HIV infection have concentrated almost exclusively on sexual behaviour and sexual risk. So people are not adequately prepared for non-sexual risks.

Similarly, risks from unsafe medical procedures could be much more of a threat than sexual risks. People's perception of medical risks is that they will be taken care of by health professionals. This may be true in some cases, but not all medical procedures are carried out by health professionals or in ideal conditions. You can get injections, and possibly other services, from people who run 'pharmacies', often just stalls that have a few medicines. Needles may well be changed between patients. One certainly hopes so. But are syringes always changed? Many people say they don't know and they don't feel they are in a position to question doctors and other health professionals. And many injectible products are sold in multi-dose vials. But it has long been known that vials can become contaminated. This can easily lead to HIV and other diseases being transmitted to many people.

People may face threats that they don't even realise are there. And they may face threats that they have never been told how to deal with. There are ways to take precautions against non-sexual transmission of HIV (and other blood borne diseases) but HIV education campaigns concentrate almost exclusively on sexual risk. Although some people can trot out a list of other HIV threats, including shared razors, toothbrushes, cosmetic equipment and medical equipment, these are considered to be relatively unimportant compared to the risk of sexually transmitted HIV.

UNAIDS publishes a list of recent HIV related publications, along with the abstracts and some editorial comments. This list very rarely includes papers that discuss non-sexual HIV transmission, concentrating instead on the many articles that look at sexual risk or what is perceived as sexual risk. So, for example, there's an article about sex work and the 2010 World Cup in South Africa. There are warnings about the risk of becoming infected with HIV and other sexually transmitted infections, but none about the risk people may face if they have to go to a medical facility for treatment or if they visit a tattoo parlour or if they get their hair cut. And South Africa is a country with very high HIV prevalence.

Another article that UNAIDS highlights is about sexual behaviour trends in France from 1970 to 2006. Sexual behaviour became more 'risky', especially for women, during the period. The same trends in a high HIV prevalence country would have been blamed for high levels of HIV transmission. But because this is a low HIV prevalence country and European, no such pronouncements are made. Non-penetrative sex also appeared to become more often practiced, which, of course, is less of a risk when it comes to HIV or sexually transmitted infection risk. But in some African countries, sexual risk behaviours are low but HIV prevalence is high.

When the survey takes place in a country like France, people's responses tend to be believed. Similar surveys in African countries can elicit similar results, but the responses tend not to be believed if they don't correspond with the data collected on HIV. When, as is often the case, people in African countries say they have not had sex, they have not had risky sex or that they took precautions against risk, and they turn out to be HIV positive, it is assumed that they are lying, mistaken or forgetful. Yet, many of them are likely to be telling the truth but they were infected by some non-sexual route, medical, cosmetic or the like.

Similarly, women have often been infected with HIV while they are pregnant. They are tested early on in their pregnancy and initially found to be negative. But they are subsequently found to be positive when they are retested later. The earliest period of HIV infection is the most virulent. If a woman becomes infected while she is pregnant, the chances of HIV being transmitted to the infant is far higher than if she seroconverted some time before becoming pregnant. The conclusion of this paper is that couple counselling may reduce unprotected sex during pregnancy. But have the authors considered the possibility that some of the women were infected non-sexually? Did they even test the husbands to see if they were also HIV positive? Of course, if the husbands were HIV negative, the belief that HIV is usually transmitted sexually leads to the conclusion that the woman must have had sex with someone other than her husband. This is one of the reasons HIV has become so stigmatized. Husbands often accept the received view about HIV being mainly sexually transmitted. They believe the ‘experts’, not their wives.

There are many hints that a good deal of HIV is not sexually transmitted in African countries. So it's surprising that UNAIDS, WHO and others still hold on to the view that non-sexual transmission accounts for a very small proportion of all incidence. In most African countries, various prevention programmes have been run, some for many years. But these programmes are almost all aimed at influencing sexual behaviour. Very few are aimed at medical transmission and even fewer at cosmetic transmission. And these programmes have been quite unsuccessful. A number of papers have asked questions about which prevention interventions work and, on finding that none of them make much difference to HIV transmission, they keep looking for new ways of preventing sexual transmission. They don't seem to consider the possibility that at least some transmission is not sexual, though they admit that conditions in medical facilities are too dangerous to allow UN employees to risk using them! These papers are right to conclude that gender, poverty and alcohol consumption are important when it comes to sexual transmission of HIV but they are probably not so relevant when it comes to non-sexual transmission. Or, at least, they would be relevant for quite different reasons.

Similarly, a lot of research has shown that behavioural differences don't explain variations in HIV prevalence among young people in African countries. High levels of sexual risk behaviour can be found in places with low HIV prevalence and low levels of sexual risk behaviour can be found in places with high HIV prevalence.

How much evidence does it take for the 'experts' at UNAIDS to conclude that their long held view is wrong, that most HIV is not transmitted by heterosexual sex? How much evidence do they need to find it worth their effort to investigate places where many young children are found to be HIV positive when their mothers are not? If UNAIDS recognises the dangers of allowing its own employees to use medical facilities in African countries, when will they admit that Africans living in those countries also face risks?


It’s very disturbing to hear people saying that they think HIV was created in a laboratory in America and spread deliberately, for whatever reason this might have been done. But it’s hard to shake people’s beliefs in conspiracies when they are constantly being told things that don’t make sense. Many people here know that Africans are not so different from people in other countries that their sexual habits could be almost wholly responsible for the very high rates of HIV transmission you see in some countries. But those who feel they know most about the disease assure them that this is, indeed, the case.

Those who feel they are HIV experts continue to assert the racist view that some Africans have so much more risky sex than people in other countries, it’s no wonder that HIV prevalence is very high in some places. Africans are being lied to, just not in the ways they think. The people who are tasked with eradicating HIV know that the risk of non-sexual transmission of HIV is so high that they need to protect their own employees. They just don’t tell Africans that. As a result, Africans continue to take risks that they could and should avoid. When people know about the risks they face and they know how to take steps to avoid them, HIV transmission rates will go down. But as long as the sexual behaviour paradigm clouds all HIV prevention activities, several more people will be infected with HIV for every one who receives treatment.

Health Minister Takes Aim at Own Foot

In addition to proposing a draconian law to make certain sex related crimes capital offences, the Ugandan government is also considering a law to criminalize ‘deliberate’ transmission of HIV. The ‘State Minister for Health in charge of General Duties’ (is that the same as ‘Minister of Health’?), Richard Nduhura says he is now behind the law, having previously had some reservations. President Museveni also supports the law, which never bodes well.

Naturally, human rights activists and people who have some feelings of humanity are opposed to these laws. Some of them have spent three decades trying to reduce stigma against HIV positive people, whereas laws like these will increase it. People will think twice before having a HIV test, or even going to hospital, if they think they may be HIV positive. Uganda needs more people to test for HIV, not fewer. With these laws, anyone who is at risk of being HIV positive, or even anyone who may be suspected of being at risk, also risks discrimination by neighbours, police and other professionals.

This is particularly serious in a country like Uganda because UNAIDS maintains the contested claim that most HIV is transmitted by heterosexual sex. That means that all pregnant women, their partners and those suspected of having had sex in the past could be HIV positive. After all, the majority of new infections are occurring inside marriages and steady relationships. Therefore, these are the people, along with men who have sex with men, intravenous drug users and commercial sex workers (or anyone believed to belong to these groups) who are most likely to become infected and to be spreading HIV.

But there is a rather more troubling aspect to making ‘deliberate’ transmission an offence. The law is clearly aimed at people who are already discriminated against, along with a lot of other people who will soon be discriminated against. But will it also apply to providers working in medical facilities and those working places where people receive cosmetic treatment? It has long been established that medical and cosmetic transmission of HIV is far more common than the mainstream HIV industry people will admit. But if it ever gets out that people working in these sectors are ‘deliberately’ transmitting HIV, they too will become victims of the law.
What about the esteemed State Minister for Health in charge of General Duties, himself? Healthcare personnel, I am sure, are not ‘deliberately’ infecting people. But what about the ones who reuse a needle or a syringe or fail to sterilize equipment properly? They would be well aware that this carries a big risk of transmitting HIV and other diseases. Perhaps there is a shortage of equipment, perhaps people haven’t received adequate training or perhaps someone is making money on the side by selling reused medical equipment or stealing it and selling it on the black market (I’m not necessarily talking about frontline healthcare personnel, by the way). Isn’t the State Minister for Health in charge of General Duties responsible for the conditions of medical facilities currently extant in Uganda?

Ok, the word ‘deliberately’ is in inverted commas for a reason. How can you tell that transmission is deliberate? I think the answer is simple enough: in many cases, you can’t. Some people may transmit HIV because they didn’t take adequate precautions, others may just be unlucky. Others still may not know they are HIV positive. But this applies to non-sexual transmission as much as it applies to sexual transmission. Healthcare personnel and people providing cosmetic services may not know that the last person on which a piece of equipment was used was HIV positive, before going on to use it on someone else without ensuring that it is properly sterilized.

Will people who use razors and other sharp instruments for hairdressing or other cosmetic treatments be liable for ‘deliberate’ transmission of HIV, if they and their clients happen to be so unlucky? Right now, the word on the street about HIV is that medical transmission is so low as to be almost irrelevant and cosmetic transmission is pretty much irrelevant. But once the hunt is on for people to blame, there will surely be questions about the most efficient means of transmitting HIV, that is, through blood contact.

The aim of HIV prevention policies should be to identify the people who are at risk and to deal with the sources of risk. The aim should not be to group people according to how likely they are to transmit HIV or to be infected with HIV and then to create a law which will end up discriminating against them. But by threatening to punish all ‘deliberate’ transmission of HIV, this law could also punish those who are not currently thought of as transmitting the disease at all, health professionals and those in other service sectors where blood transmission may occur.

In a country where most health spending comes out of the pockets of poor Ugandans and from donors, and very little comes from the government, things are not as neat and tidy as this proposed law may assume. If the aim is to identify all the ways in which people are becoming infected and prevent further infections and also to treat those who are already infected, the health minister and his colleagues are going the wrong way about it. They have, rather predictably, failed to control people’s behaviour as a means of reducing transmission of HIV. They will also fail to reduce transmission by threatening people in ways that result in them being very unlikely to get tested or to declare their status if they are HIV positive. The last thing Uganda needs now is more failure.

HIV Stigma and Institutional Racism

The received view about HIV these days is that unless you are a gay man, a sex worker or an injecting drug user, you are unlikely to be infected. At least, that’s the received view in rich countries. In fact, in their 2009 Aids Epidemic Update, UNAIDS don’t even mention sex workers for North America and Western and Central Europe. They say “[i]n North America and in Western and Central Europe, national epidemics are concentrated among key populations at higher risk, especially men who have sex with men, injecting drug users and immigrants”. Despite this though, heterosexual sex appears to account for about 30% of transmission.

But in poorer countries, especially in Africa, the received view is somewhat different. Here, it is claimed that the most common way of spreading HIV is through heterosexual (vaginal) sex. UNAIDS say “[h]eterosexual intercourse remains the primary mode of HIV transmission in sub-Saharan Africa, with extensive ongoing transmission to newborns and breastfed babies.” They even claim that 94% of transmission is by heterosexual sex in Swaziland.

But the report goes on to suggest, effectively, that low risk sex is high risk sex in Lesotho and Kenya because it accounts for most transmission. “In Lesotho, between 35% and 62% of incident HIV infections in 2008 occurred among people who had a single sexual partner. Heterosexual sex within a union or regular partnership accounted for an estimated 44% of incident HIV infections in Kenya in 2006, while casual heterosexual sex accounted for an additional 20% of new infections”. However, if low risk sex is high risk, this just begs the question of how sexual behaviour could account for so much transmission in some countries but not others. Most people in every country have low risk sex but most countries don't have high HIV prevalence. UNAIDS accept that gay men and drug users are also at high risk, but that they contribute far less to the epidemic.

According to this received view, sex workers in African countries would be particularly at risk, along with their clients and their clients’ other sexual partners. So it’s easy to see how stigma creeps in. If you become infected with HIV, you are probably a prostitute, someone who frequents prostitutes or, even worse, a gay man or an injecting drug user. Because of the stigma attaching to HIV, people are often less quick to see that there are many who could have been infected unwittingly. And the issue of infants being infected by their mother can also be an inconvenience when painting a picture of rampant illicit sex and drug taking.

A former UNAIDS employee, Elizabeth Pisani, says “HIV is mostly about people doing stupid things in the pursuit of pleasure or money”. She also says “In Africa, people are contracting the virus through heterosexual, non-commercial sex”. Pisani is someone who certainly knows how to reinforce stigmatizing views. I’m surprised she ever left UNAIDS.

Of course, heterosexual sex would account for a substantial proportion of HIV transmission. But how substantial is anyone’s guess. Because, holders of the received view claim that HIV infection through accidental blood exposure in poor countries is low or negligible. Back to UNAIDS again: “A small percentage of prevalent HIV infections in sub-Saharan Africa is estimated to stem from unsafe injections in medical settings.” Also: “In an analysis of data from Kenya, medical injections were estimated to be the source of 0.6% of all HIV infections”. Though strangely enough, they admit that medical transmission is far more significant in Uganda.

They even find that in Eastern Europe and Central Asia “[i]n addition to new infections associated with injecting drug use and unprotected sex, key informants and scattered media reports suggest that a notable number of new infections may be occurring as a result of unsafe injections in health-care settings.” However, what they mean by ‘key informants’ etc., actually refers to a whole body of evidence about unsafe injections that UNAIDS are unwilling to countenance, so they ignore it.

In hospitals and clinics in developing countries, instruments that are contaminated with blood and various blood-borne diseases may be reused or inadequately sterilized. Health services are underfunded, understaffed and short of resources. There is no lack of evidence that they are risky places. So how can UNAIDS come up with these figures for medical transmission of HIV? Well, by being selective about what evidence they cite and by ignoring anything they don’t like the look of. High rates of medical transmission, and consequently, lower rates of sexual transmission, doesn’t fit with the view that, in Africa, people have a lot of unsafe sex. And institutions, politicians, churches and funders are interested in supporting sexual behaviour change programmes.

These same people are probably not interested in accepting that some of the problem may arise from unhygienic practices in the very health facilities where they are urging people to go for testing and treatment. The mainstream doesn’t want to see itself as being a significant part of the problem. So UN and WHO personnel, diplomats and other high ranking officers are issued with their own needles and syringes when they are visiting African countries. They are also given instructions to avoid treatment if at all possible.

But Africans themselves are supposed to visit whatever health facility is available to them without even a warning about the risks they face or the precautions they can take. And if they are infected with HIV, they will probably unknowingly go on to infect others.

It seems to me that racist attitudes allow members of institutions such as UNAIDS to assume that Africans have lots of unsafe sex, but that most non-Africans don’t. And racist attitudes allow these institutions to recommend that their employees avoid medical facilities in developing countries, without doing the same for people who have to live in those countries.

In Western countries, people travelling to African countries are likely to be made aware of some of the potential risks of visiting medical facilities there. They can buy information about medical safety and even kits containing syringes, needles and the like, so they can reduce the risks they face further. If it is so important for Westerners visiting African countries to take care when visiting medical facilities, or even to avoid visiting them altogether, why is it not equally important to protect Africans from being infected in these facilities?

Human Rights Are Not Just for the Rich World

According to Dr Marcos Espinal of the Stop TB Partnership, "TB is not a medical problem. It is a development issue. It is an economic problem. It's a human rights situation." And I applaud him for saying this. If developing countries are not allowed to develop (and I would argue that developed countries are doing all in their power to stop them from developing), diseases like TB will not successfully be treated by drugs alone. People in developing countries are poor, they suffer bad health, they receive little or no education, they live in terrible conditions and their human rights are being denied. It is no wonder that TB and many other diseases are rife and increasing.

I would add that HIV, also, is not just a medical problem, nor is it just a matter of sexual behaviour. Parallel arguments could be used to show that, so far, both HIV and TB programmes have failed to prevent the spread of the diseases and will continue to do so. If you don't deal with the conditions that result in diseases spreading, all diseases, you will not eradicate the diseases. After using little more than expensive pharmaceutical products to treat TB for many years, an estimated 440,000 people are now resistant to commonly used TB drugs. I have not been able to find estimates for the number of people with HIV strains that are resistant to first line drugs commonly used in developing countries, but resistance is a very serious threat.

There's an interesting article on the website of the United Nations Development Programme (UNDP). They have been publishing the Human Development Report for many years now and they are about to reveal some of the main trends over the past four decades. The Human Development Report measures development by criteria other than just economic, such as health, gender, education and other things. This article notes that there has been significant progress in development, but this has come from improvements in education and health, not economics.

It also notes that these improvements have little or nothing to do with globalization. Rather, they have been achieved by expansion of "educational and health systems, coupled by initiatives of the international community to enable access to vaccines and antibiotics." In other words, state intervention.

The research finds that there is no correlation between economic growth and changes in non-income components of human development. It concludes that "the oft-repeated dictum that growth is a necessary condition for increasing human development is simply not true."

So the approach to development and human rights related problem, such as HIV or TB, is to improve education, health, economic circumstances, gender imbalances, employment, infrastructure and many other things. The approach should not be to set up well financed vertical programmes that target single diseases or narrow issues at the expense of other, broader issues.

Throwing eye watering sums of money at a problem, such as HIV or TB, will not even solve the problems of HIV or TB. Especially if most of the money is spent on technologies that are produced in rich countries. That's just taking money out of one pocket and slipping most of it into another. It's time for new thinking on development. Development is not just one thing, it's many things. And if you don't know enough about any of them, just read the Universal Declaration of Human Rights and consider how many of those rights people in developing countries are currently being denied.

Behaviour Change for Journalists

The BBC can be funny sometimes, though not very funny. The title of one of their articles runs "Is Zuma's sex life a private matter?" and they promptly answer it in the negative by writing about it. Perhaps the author would have been wiser to ask about the president's attitude towards women and equality, since they have taken the liberty of asking about his sex life. But even an organisation as well (publicly) funded as the BBC often can't resist asking the same questions as almost every other journalist in the mainstream media.

The media needs to get past the connection between HIV and sex. True, HIV is mainly transmitted sexually. But rates of HIV transmission depend on many other things, such as the relative economic circumstances of the people involved, their relative levels of power in relationships (whether ephemeral or otherwise), their levels of education and access to information, their levels of health and nutrition and the like. Indeed, the nature and accuracy of the information to which people have access may also be significant; exalted claims about the role of the media in HIV publicity campaigns certainly suggest this.

Studies have shown that there is no strong correlation between rates of HIV in different countries and levels of what is considered to be unsafe sexual behaviour, for example, multiple concurrent partnerships. In other words, some places where rates of multiple concurrent partnerships are low, HIV rates are high and vice versa. High rates of HIV transmission in South Africa are, to the extent that they are well understood, explained by many things other than sexual behaviour.

If the BBC is really concerned about HIV transmission, it shouldn't be beyond the capacity of the corporation to research the subject a bit better than the average tabloid newspaper. They could even have discussed the fact that Zuma didn't use a condom during his extra-marital relationship and is well known for being against the use of condoms. Sadly, there is very little to HIV prevention in South Africa, or any other developing country, aside from condoms.

It may never become a popular view that HIV has numerous transmission routes and that many of the circumstances in which people live and work determine whether they will be infected with HIV and whether they will go on to infect others. HIV will probably always be viewed as such an extraordinary disease that it is transmitted in isolation from people's overall health and welfare, and that issues such as gender, power and politics are completely irrelevant. But it seems unlikely that the BBC will stick its neck out and adopt an unpopular view.

Religion and Health: Interference or Complementarity

Following my speculations about why some people seem to imagine that they can be made very rich by a miracle, a friend sent me an article entitled Religion, Spirituality, and Medicine. This article is a "comprehensive, though not systematic, review of the empirical evidence and ethical issues" and concludes that "the evidence of an association between religion, spirituality, and health is weak and inconsistent".

Perhaps more importantly, the authors question the ethics of mixing religion and medicine, a question that would still arise even if there was stronger evidence of an association between religion and health. One could ask, which religion would a doctor recommend or agree to discuss? What would they do with someone who didn't believe in any religion? Would each medical professional require special training and what kind of special training? (The authors of the paper did not raise all these questions, but they arise from considering the problems of combining medicine with religion).

Even if people go to a doctor without any expectation that the doctor is, to a large extent, a scientist, that doctor is obliged to do things that are supported by scientific evidence and avoid things that are not so supported. The fields of science and religion are completely different and the practitioners of each field work in different ways. Is it even feasible for doctors to also become experts in religion (as if religion were just one thing!)?

If I was renting a damp room that affected my health badly, should my doctor write a letter to my landlord and ask for my conditions to be improved? Medical advice could be brought to bear on an employer who was exposing me to health risks, but this is a matter for employment laws. The doctor doesn't intervene directly. Yet we know that environmental conditions are closely connected with people's health. We know that economic circumstances are closely connected with people's health but we don't expect our doctor to recommend a pay rise. Even government health advice about healthy eating is considered to be taking things too far by some.

I accept that certain beliefs can be comforting and I certainly wouldn't suggest that people should be told what to believe and what not to believe or how to express their beliefs. If they see praying as part of their recovery from illness or as helpful in bearing an illness from which they will not recover, no one has the right to interfere. But when it comes to prescribing medication, the doctor is the expert, not the religious leader. And when it comes to praying and giving religious advice, the religious leader is the expert.

In fact, I find it exasperating that there are many churches in developing countries who don't seem to be able to make that distinction. They feel they are experts in marriage, reproduction, sexual behaviour and protecting against sexually transmitted infections (STI). They are not experts, generally they know even less than lay people and should certainly have less experience. If you can't persuade someone to give up having sex or sex outside marriage, the least you can do is tell them how to avoid becoming infected with an STI, infecting someone else with one or giving rise to an unplanned pregnancy. Otherwise, these leaders are failing to do what they can to prevent serious consequences.

If religious leaders wish to give medical advice, they had better know what they are talking about. As for advice about sexual behaviour, contraception and reducing the spread of STIs and unwanted pregnancies, many don't seem to have had a lot of success and should leave the job to someone who has the appropriate knowledge and training. In the same token, doctors should discuss religious matters with patients if they feel able to do so and if they are requested to do so but it should never be seen as a type of medical care or treatment.

If someone has a particular set of religious beliefs, presumably they hold those beliefs regardless of their health or lack of health. It seems unlikely that they just 'adopt' those beliefs in the hope that they will get well. Whether someone is religious or not, some will suffer illnesses and injuries and all will die eventually. If the 'belief' is purely conditional on their health, the person's piety would be quite questionable. So I don't see why a religious person would be interested in whether religion is in any way connected with health outcomes in the first place.

Celebrate World Aids Day By Dismantling UNAIDS

UNAIDS has never been shy about producing long and colourful documents about HIV/Aids and in the last couple of days they have released two; the Outlook Report 2010 takes a look back and compares the HIV pandemic of today with that of the mid 1990s; the second document is the yearly AIDS Epidemic Update, which I haven't had the strength to read yet.

The Outlook Report, like many of the various articles commenting on one or other of the reports, sometimes takes a rosy view of how the international community and the AIDS community have dealt with the pandemic. In the sense that things have moved on, and finding that you are HIV positive no longer has the significance it once had, they are right. We have come a long way in treating what was once an untreatable illness that would lead to a certain and very unpleasant death.

But the worrying thing is how the Outlook Report, like many UNAIDS and other reports in the past, talk about the importance of HIV prevention. It has been obvious that HIV prevention is so important that the amount of HIV money spent on it needs to be increased considerably. But the amount has gone down and the prevention programmes that get most of the money have little or no effect and have never had much effect.

Defenders of the disproportionate amount spent on treatment and care of HIV positive people are fond of pointing out that this shouldn't be an either/or debate. True, it shouldn't, both treatment and care on the one hand and prevention on the other should receive more funding than they presently receive and the funding should be more equitably divided. Treatment and care contribute a certain amount to HIV prevention but they are not the same as prevention and they will never contribute more than a certain amount. That's why there are five new infections for every two people put on antiretroviral treatment.

The report goes on to allude to the work that has been done to show that prevention programmes, such as they are, fail to target those most at risk in populations. Most of the money is spent on populations as a whole and very little on, for example, men who have sex with men, commercial sex workers, intravenous drug users, prison populations, fishing communities around Lake Victoria, mining communities and various others, who are very often at risk because of their occupation or lifestyle.

The report seems aware that HIV transmission is not primarily about individual behaviour and that there are different kinds of HIV epidemic in different countries and that some people are more at risk than others. It even seems cognizant of the fact that it is the circumstances in which people live that makes them more or less likely to become infected with HIV. But it hasn't made the leap to realizing that in some countries, especially developing countries, most people live in such circumstances. Not everyone is at equal risk of becoming infected but most people live in conditions that mean they are already at high risk of becoming infected or that they will one day be at high risk of becoming infected.

That makes it sound like HIV prevention is unlikely to ever have much success, but the opposite is true. Treatment and care have been to a large extent dominated by commercial interests. Products, processes and services have been developed, many by those who are in a position to profit from them. But prevention has been dominated by the party-political and pseudo-moral debates of political and religious leaders. Their aim is to further their own agenda, which are far from being concerned about millions of people becoming sick and dying.

Raising awareness about HIV, sexually transmitted infections, sexual health, reproductive health and anything else is good and will go a long way towards protecting people from a number of dangers. But good overall health, healthcare, nutrition, food security, education, infrastructure and many other benefits would give people the maximum protection, not just from HIV, but from other illnesses and ills.

And this brings us to another often repeated pronouncement made by various senior HIV/Aids experts. They like to deny that HIV funding has distorted health and development funding and disrupted more general programmes that aimed to benefit societies as a whole. HIV/Aids funding is not too high, it needs to be higher. But there needs to be a similar move to spend the money more equitably. HIV will not be eradicated without health services, education and other social services, no matter how much money is thrown at it.

So, spending money on all other areas of development will also contribute to the fight against HIV/Aids. But continuing to spend disproportionate amounts on HIV/Aids will not benefit the many other development issues that have been hijacked by numerous commercial and political interests. HIV treatment and care is just one of many health issues that the world faces but HIV prevention is about health, not disease. Therefore it has far broader significance and affects far more people than one single disease. In fact, it affects everyone.

Ultimately a self-serving and very expensive organisation, UNAIDS needs to be reabsorbed back into the overall agenda of public health, or some agenda that encompasses the health of everyone, not the sickness of a few. This is not to say that HIV positive people should not be entitled to treatment or care. Rather, they and all other sick people should be entitled to treatment and care. But people who are not sick should be enabled to stay that way. UNAIDS is good at diverting a lot of money for people once they are HIV positive but this is denying the right of HIV negative people to stay that way.

Targeting Sickness Versus Promoting Health

Questions of whether HIV has or hasn’t been exceptionalised and whether this is a good or a bad thing are often raised. Discussion sometimes involves the issue of horizontal health care, which deals with the overall health of a population as opposed to vertical health, which deals with particular diseases, such as polio, intestinal parasites or HIV.

I am of the opinion that HIV has been exceptionalised and that this is a bad thing. I also believe that health care should aim to be more horizontal. Vertical approaches to individual diseases have sometimes been successful, at least up to a point, but they leave out too many vital areas of health. There is little to be gained by protecting a whole population from a handful of diseases when so many of them will be wiped out by diseases that have been ignored.

Indeed, many people do die from easy to prevent and easy to treat illnesses, such as acute respiratory infections and diarrhoea. The biggest threats to health, especially among infants and children, are things like water and sanitation, poor living conditions and nutrition. These are important for adults, too, as are basic health and medical services.

Big eradication campaigns tend to ignore the most basic health needs of populations. They concentrate on a single or a small number of diseases, they tend not to develop broader health infrastructures or deal with determinants of health and they cost a lot. Often, money could be better spent on ensuring the determinants of healthy populations, but it tends not to be.

The World Health Organisation (WHO) is presently promoting a vaccine that prevents diarrhoea that is caused by the rotavirus, estimated to kill half a million children a year. It is recommended that this vaccine be included in national immunisation programmes. Rotavirus is often fatal to children in developing countries because of lack of access to clean water, sanitation and basic medical care.

However, the WHO recommends a comprehensive strategy that includes improving water and sanitation and providing some of the healthcare products that are required to deal with diarrhoeal diseases. A comprehensive strategy is crucial. There are many water borne diseases and many diseases that are caused by poor sanitation and lack of hygiene.

But this is just a recommendation from WHO. When it comes to funding programmes like this, pharmaceutical companies are always interested in having huge quantities of their products purchased for ‘aid’ projects. The problem is that you don’t cure diseases by providing countries with huge quantities of pharmaceutical products. Who will meet the logistical costs, the healthcare costs and the costs of improving water and sanitation in developing countries?

Rich institutions like the Bill and Melinda Gates Foundation have shown a lot of interest in financing projects in developing countries but much of this money tends to be spent on the development of products, things that can be sold, especially branded products that cost relatively little to produce and create a high level of dependency. For example, antiretroviral therapy for those infected with HIV, genetically modified organisms for farmers, etc. Whether this foundation or other donors would be interested in financing projects that don’t promise to make a lot of money is an open question.

Similar arguments apply to the approach that many countries take to HIV prevention. Most money that has been spent on HIV has gone towards treating and caring for those who are already infected. In Kenya, less than 25% of HIV spending has gone towards prevention and much of that goes into counselling and testing and prevention of mother to child transmission (PMTCT).

These all deserve funding, of course, it is absolutely necessary to test and treat people and to prevent mother to child transmission. But in the meantime, hundreds of thousands of children come of age every year and become sexually active. Many of them will be infected with HIV before they receive proper sex education (if they ever receive it) or go for a test or are exposed to any kind of HIV prevention activity.

It’s extraordinary that negligible amounts of prevention money go into targeting commercial sex workers, men who have sex with men and intravenous drug users, people who are at particularly high risk. But even others, who are also at risk, are unlikely to receive any more than some sort of behaviour change communication (BCC). BCC may well be wonderful, there are certainly some wild claims about how wonderful, but the fact is that HIV is still spreading. It is spreading in places where it has long been spreading and it is spreading in new places.

The problem with our approach to preventing HIV is not that the disease is exceptionalised or horizontal, the problem is that it is not working. We have known for a long time that, although people’s sexual behaviour may be somewhat influenced by BCC, it is not influenced a great deal. And the claims about changes in behaviour are not translating into lower HIV transmission. HIV prevalence in Kenya and many other developing countries has been fluctuating for many years. Rates in many places are now lower than they once were. But in other places, rates are higher.

Prevention of HIV (and diarrhoeal diseases, acute respiratory infections and any other diseases) requires us to look at people’s health, not their diseases. We need to know what healthy people are like, what their circumstances are, how to ensure that they will stay healthy, what could help them avoid health risks and risks of any other kind. That means looking at their economic circumstances, housing, nutrition, employment, education, access to information, equality and any other areas that may be relevant.

Most children will grow up and will have sexual experiences, sooner or later. Rather than wagging fingers at them and telling them to wait till they are older and possibly telling them how to reduce risks, we need to address the circumstances that make risk harder to avoid. They need more information about sex, contraception, risk, sexuality, etc. Issues of gender inequality in school, in the workplace and in society as a whole, also need to be addressed. Prevention programmes also need to include people who are HIV positive, whether they are on treatment or not.

We seem to be going the wrong way with HIV prevention. There are many things we could be doing and are not doing yet. The HIV agenda seems to be set by commercial and political interests and this can only continue to do harm. Healthy people do not make money for healthcare, nor do they make careers for politicians. But being healthy is a right and this should be acknowledged and addressed by countries and institutions that are pouring money into developing countries. We need to change direction with HIV prevention if we want to reduce transmission and eventually eradicate the disease altogether.