Idle Arguments Support Blinkered Policy

I'm developing a tendency to write very long blog posts and this means that I'm less likely to pick up errors. My last post contained a serious error in the second paragraph that probably made the following paragraphs difficult to understand. I have inserted a correction and apologise to anyone who may have found my argument hard to follow as a result.

In future I need to remind myself that if I can't form a conclusion in less than 1000 words, I probably need to do more thinking than writing. Perhaps even 1000 words is too long and I should aim for 500-700? Anyhow, I thank people for their patience and especially those who have taken the trouble to let me know when they have spotted an error.

In a nutshell, I don't disagree with Mr April's conclusion, that opt-out testing is superior to opt-in testing. I just think the argument is idle and should be completely unnecessary in the first place.

People originally advocated for opt-in HIV testing because those found positive risked being stigmatized. They risked being stigmatized because of the mistaken belief that HIV positive people are in some way immoral or bad (although these qualities are usually implied rather than stated). Unfortunately, the risk of being stigmatized is still very real, despite the evidence that HIV infection is not mainly, as the HIV orthodox view claims, a result of unsafe sexual practice.

Arguments like those presented by April presuppose the truth of the behavioral paradigm, this view that HIV is mainly transmitted through unsafe sex. Attempts to test as many people as possible for HIV in high prevalence populations have been thwarted by the resulting stigma and discrimination, which arises from the behavioral paradigm, even though this paradigm is completely unsupported by evidence.

It shouldn’t take a philosopher or medical ethicist to spot policy that has been formulated on the basis of naked prejudice. But as long as the offending paradigm is retained in HIV policy making, people will continue to be stigmatized. The stigma is a consequence of the paradigm.

To the extent that philosophers or ethicists fail to take account of how things actually are on the ground, their arguments will be, as Wittgenstein might say, ‘wheels that are turning but are not themselves turning anything’. Perhaps Mr April even thinks that UNAIDS, the WHO, the Harvard Medical School, the CDC or the Johns Hopkins School of Public Health are able to inform him about how things are on the ground. But he is mistaken. All they can offer is their prejudice, which he seems to have accepted.

It could be argued that, because Mr April’s arguments are not based on anything happening in the real world, they have no consequences. But his arguments are developed in places where HIV policy is also developed. Therefore, people in high HIV prevalence countries suffer the consequences of the stigma and prejudice that arises from current policies. In fact, what is happening in the real world, unlike academic arguments in certain institutions, has little noticeable influence on policy. But policy can have a huge and overwhelmingly destructive influence on the real world.

Do We Want to Reduce HIV Transmission or Not?

Considerable resources have gone into HIV 'prevention' programs over the last few decades. Billions of dollars have been spent on labor and materials and millions of people have been involved in one way or another. But most of these programs, when they have been carefully evaluated, have been found wanting in numerous ways. And careful evaluation is itself both expensive and time consuming. After so many years of lack of success, or failure, depending on your perspective, you might expect the less good prevention programs to have been phased out and replaced with more viable ones.

A careful re-evaluation of the MEMA kwa Vijana program in Tanzania by Aoife Doyle, et al, published in June in PLoS Medicine, looks at a school based prevention program that was started in 1999 and subsequently found to give little benefit. It was argued that the original evaluation was too soon after the intervention took place and that, over time, the program would have more benefit. The re-evaluation showed that it was not just a matter or time or volume and that nine years after the program started, it was still not having much impact on either primary (HIV rates, herpes simplex rates and unplanned pregnancies) or secondary outcomes (other sexually transmitted infections).

The study concluded that the "results of this trial show that such skills-based sexual health education interventions and youth friendly health services can make a valuable contribution towards the...goal of increasing young people’s access to the information, skills, and services they need to reduce their vulnerability to HIV. However, these results imply that such interventions, on their own, will not be sufficient to reduce HIV and other STIs among young people in sub-Saharan Africa."

The MEMA kwa Vijana program did show some improvement in knowledge, attitudes and even some change in sexual behaviors among those exposed to the intervention. But the difference between those who had been exposed and those who hadn't been exposed was small, certainly too small to be expected to reduce HIV, herpes simplex or unplanned pregnancies significantly. The results of the many years of trying to reduce HIV transmission could be called good, but they are seriously limited. It is, indeed, a good thing if young people know more about sex, risk and limiting risk. But why years of expensive intervention and research are needed to make clear something that is already widely acknowledged is what makes this approach to HIV so exasperating.

Most HIV prevention interventions carried out in African countries are based on the assumption that HIV is transmitted, almost exclusively, through heterosexual sex. In the words of the Editor's Summary at the end of this paper, "HIV is most often spread through unprotected sex with an infected partner, so individuals can reduce their risk of HIV infection by abstaining from sex, by delaying first sex, by having few partners, and by always using a condom."

This is sometimes called the 'behavioral paradigm' and it leads to the further assumption that in order to reduce HIV transmission, all that is required is to teach people about sexual risks and how to minimize them. Children (and adults) are bombarded with 'information' about HIV, STIs, pregnancy and various 'behaviors' that are risky. They are further bombarded with words such as 'abstinence' and 'being faithful', these being assumed to be ways of minimizing risks. Less frequently, they may hear about or even receive condoms, often after being told that these do not give much protection. But the words 'abstinence' and 'being faithful' have been demonstrated to have little meaning for most people. And they are sometimes bandied about in the absence of the word 'sex' or any discussion of what sex is, safe or otherwise.

Participants in MEMA kwa Vijana may have reduced their numbers of partners, increased their use of condoms and answered various questions they were asked. But if the intervention didn't affect the number of pregnancies or levels of HIV, herpes or other STI transmission, knowing about safe and unsafe sex is not the same as practicing safe and avoiding unsafe sex. Knowledge does not necessarily have much affect on behavior. There's nothing surprising about this, except the apparently long held hope that, one day, 'correct' knowledge and 'appropriate' attitudes will give rise to appropriate behaviour; specifically, later sexual debut, fewer lifetime partners, greater condom use, etc.

Doesn't this and other experiments carried out on relatively deprived, undereducated and unhealthy people indicate that 'unsafe' sexual behavior may not be behind all HIV transmission? And if sexual behavior is the problem, we haven't identified what it is about sexual behavior in some parts of some African countries that gives rise to rates of HIV transmission tens or even hundreds of times higher than in non-African countries with similar sexual behaviors.

The overall results of the program in question were poor. But they were far poorer for females than for males, both in terms of behavior change and outcomes. The re-evaluation finds that those who were exposed to more of the program received greater benefit, which may give some slight comfort. But those likely to have least exposure to a school based program in many high HIV prevalence areas would be females. Girls are often not sent to school for very long and are likely to miss more days and perform less well in exams. Yet, females are more likely to become infected with HIV and other STIs and they are more likely to be infected early on in life.

If HIV transmission is not all about sex then concentrating almost exclusively on prevention of sexual transmission is not likely to have optimum impact on HIV transmission. Male circumcision and microbicides will only reduce sexually transmitted HIV, at best. And these and other programs tend to target those thought to be most vulnerable to sexual risk. Pre-Exposure Prophylaxis, the use of oral antiretroviral drugs to prevent HIV, may also reduce non-sexual HIV transmission. But this also is currently being targeted at groups thought to be at high risk of sexual transmission. Which efforts, then, are going to reduce HIV transmission in the majority, who are at low risk sexually, and therefore unlikely to be targeted?

The report notes that "Qualitative work carried out in the trial communities in 1999–2002 found that many young people were not always in a position to use the knowledge and skills obtained through MEMA kwa Vijana. Peer pressure to be sexually active, and widespread attitudes and practices in the broader community such as negative attitudes to condoms, material exchange for sex, and older male–younger female relationships, may have posed too great a challenge for youth who wanted to reduce their risk behaviours."

So there are two major problems: rates of sexual transmission of HIV are unlikely to be influenced significantly by such programs; but non-sexual transmission of HIV will not be influence at all. It seems that young people are not being told anything about HIV transmission through unsafe medical or cosmetic practices. If they are not told that such a phenomena exist, they are not going to know how to protect themselves. Even if sexual HIV prevention programs don't work very well, for whatever reasons, prevention of non-sexual HIV should not be ignored. Currently, it is being ignored.

Indeed, years of monitoring and collecting data on thousands of young people in programs like this ignore the possibility that some, perhaps many of the people becoming infected, are infected by some mode other than through sex. Many years of intrusive research have been wasted because of the assumption that HIV is mostly transmitted sexually. Research into the MEMA kwa Vijana program may have been carried out with the best intentions. But assuming that the only risks that people face are sexual risks is unwarranted and dangerous. And the assumption is not due to ignorance on the part of those doing the research. Non-sexual risks of HIV transmission have been recognised for almost as long as sexual risks.

Sex education is, undoubtedly, a good thing. Reducing transmission of HIV and other STIs is a good thing, as is reducing unplanned pregnancy and many of the other projecte outcomes of good sex education. But there are educational prerequisites to the success of a sex education program. Children need to have a basic level of education to benefit, for a start. And they need to be attending school frequently enough to gain enough exposure. Teachers and peer educators need to be well trained and committed to the program. Basic school education is not guaranteed for most children in Tanzania, so the potential for a school based sex education program is probably seriously diminished.

It is widely known, even in the HIV industry, that HIV is not exclusively transmitted sexually, not even almost exclusively. Programs assuming the behavioral paradigm have all failed; this one in Tanzania is by no means the only one. These two facts put together should, one would think, lead the learned industry leaders to conclude that the behavioral paradigm should be discarded. They should see the need to modify programs that aim to reduce sexual transmission. And they should give some attention to assessing the non-sexual risks and design programs to reduce these risks and to teach people about them, rather than denying that they exist or that they are relevant.

Those evaluating the MEMA kwa Vijana program don't let on that they are aware that young people may face non-sexual risks or that some of those who became infected may not have been infected through unsafe medical or cosmetic procedures. The program may not have been the unmitigated waste of time that it appears. Some sexual transmission may have been avoided but the numbers infected didn’t reduce because some were infected by other means. But even if the program had better results than first appears, it is just as much of a waste of time because it does not increase awareness of non-sexual risks of HIV transmission.

There is little point in only informing people about one kind of risk, sexual risk, and neglecting all others. It would be of some slight value if sexual transmission had been reduced, but it probably wasn’t. And it is disappointing that this paper just adds to the deep pile of research that has come up with similar findings without coming to the conclusion that the problem is the behavioral paradigm, that HIV is not "most often spread through sex with an infected partner". If both wheels on your bike are punctured, putting extra patches on one wheel and none on the other is pointless, you will still be unable to cycle. For how long are such considerable resources going to be wasted while HIV transmission continues, almost unabated?

Big HIV Funding and Blatant Racism

Many people and organizations in the HIV world, especially those involved in HIV treatment, as opposed to prevention, are worried about the effects of global financial belt tightening on HIV budgets. They are right to worry. A lot of big funders are capping funding or reducing it. And the global financial situation may not be the only reason for this austerity.

For many years, HIV prevention has taken a back seat to HIV treatment. Those in favour of treating as many people as possible and ignoring the fact that more people are becoming infected than going on treatment, assure us that mass roll out of treatment also plays a part in 'health systems strengthening'. This is supposed to make those concerned about a high rate of new infections feel better, as if new infections are being taken care of because those infected for some time are being treated in great numbers.

Indeed, defenders of the status quo that involves treating those who are infected and almost completely ignoring new infections, explicitly argue that HIV treatment also prevents new infections. To an extent that is difficult to quantify, this is true. HIV positive people who are responding to treatment (which means they also need adequate levels of nutrition and general health, etc) tend to have a lower viral load. They are less infectious and, therefore, less likely to infect others.

But this still leaves others vulnerable to infection. If many were not currently vulnerable to infection, the rate of new infections would be negatively correlated with the number of people who are responding to treatment. Those in favour of treatment at the expense of prevention claim to be averting infections, but only by using a circular argument; that the number of new infections must be lower than it would have been if treatment hadn't been rolled out because treatment reduces the incidence of new infections. The fact is, widespread treatment hasn't yet reduced new infections very much.

Well, if these treatment fundamentalists are really concerned about the effect that cuts in funding will have on the lives and health of people in developing countries, there are a number of alternatives they could consider. For a start, they will have to make some effort to reduce new infections at some stage. No person or organization would be wise to keep spending money on outrageously expensive drugs for treatment when the numbers of infections continues to rise, more or less unabated.

So these concerned and worried parties (Michel Kazatchkine, Michel Sidibe and others) can start campaigning for the sole use of generic versions of antireteroviral drugs (ARV), at least in poor countries. At present, expensive, branded versions are used almost universally. There has been a lot of pleading about how much pharmaceutical companies have dropped their prices but these reductions are nothing compared to the savings that use of generics could bring. To argue for more or continued funding for overpriced medicine is stupid and downright deceitful.

With the money saved by switching to generics, some money could be spent on prevention. And I don't mean the ABC (abstain, be faithful, use a condom) rubbish that has been churned out for more than ten years. This 'behaviour change communication' and any prevention programmes based on the idea that Africans have lots more sex than anyone else, has never worked and it never will work. More money has probably gone into publicity to show how successful this disgraceful waste of money has been than into programmes that really do work.

Plenty of research has shown that most of the 'prevention' programmes that have been carried out so far have achieved little, especially as far as reducing HIV transmission is concerned. But there is also research that receives a lot less attention which shows that HIV transmission can be reduced significantly, but also cheaply. Larry Sawers and Eileen Stillwaggon have argued for this in several publications, including in an article entitled 'Understanding the Southern African 'Anomaly'; Poverty, Endemic Disease and HIV'.

In this article, Sawers and Stillwaggon demonstrate that HIV transmission can be influenced by inexpensive measures such as providing people with deworming, sanitation, STI (sexually transmitted infection) treatment, mosquito control and safe water. These, they argue, are all essential in controlling HIV. In addition, these measures all have benefits that go beyond their effects on HIV and will improve the lives and health of tens of millions, perhaps hundreds of millions, of people in developing countries.

There is a lot of good money to be made in the HIV industry, especially where expensive drugs are involved. Attention to these drugs has been far higher than the success of ARV rollout could explain. Yes, many people are alive now who would not be alive without the drugs. But this has been achieved at a cost that is far higher than necessary. And as a result, preventing new infections has been given short shrift, even though this can be effected at relatively low cost. One might almost think that HIV has been seen as an opportunity to sell vast amounts of drugs that have a very small market outside of developing countries.

To make it clear, in case people may think I'm advocating against spending money on drugs for people who are HIV positive: I believe everyone who is in need of HIV drugs should receive them, but I believe they should be purchased at the lowest cost possible. This is not currently the case. Costs are kept artificially high by intellectual property laws (In other words, market protectionism) that favour rich countries and multinationals, by behind the scenes deals, by lobbying and by fancy marketing and publicity. The big HIV funders are being robbed blind, or perhaps they are being robbed and happen to be blind as well. I also believe that HIV positive people should have all their other health needs attended to and that they should have access to an adequate diet without which the drugs and treatment they receive are useless.

Once the cost of treating HIV positive people has been set at a level that poor countries and poor people can afford, there should be a lot more money available for preventing new infections. The approaches mentioned by Sawers and Stillwaggon, above, are all vital. And they are compatible with others, such as identifying instances of HIV being transmitted non-sexually, whether by unsafe medical practices, cosmetic practices, unsafe traditional medical practices or whatever.

As long as the big earners in the HIV industry continue to spend billions on overpriced medicine when cheaper alternatives are available, their wailing about rights and justice are so much hypocrisy. They are long enough in the business now to know what is going on, a lot better than laypeople do. And it must be as clear to them as it is to anyone who bothers to check that HIV prevention has to accompany HIV treatment if the disease is to be eradicated. Equally, these big earners cannot continue to ignore the evidence that they are wrong about sexual behaviour in African countries. Levels of risky sexual behaviour are higher in America and Europe than they are in Africa (and Sawers and Stillwaggon are particularly clear on this point in all their publications). Claiming otherwise is blatant racism.

Fiddling with Technical Fixes While People Continue to Die

Time reports on a study which raises concerns about HIV drug resistance. Most Kenya government documentation about HIV treatment is concerned with getting as many people on treatment as possible, or appearing to do so. Where the aim is to get as many drugs out to as many people as possible, resistance is probably not so visible. After all, you need to monitor people regularly and carefully for signs of resistance and funding doesn't always stretch to that.

It's not really clear how many people in Kenya are currently on HIV treatment. Figures vary a lot and don't always make it clear whether people who were once on treatment but have since died are included. Probably a few hundred thousand are on treatment at the moment, maybe three hundred thousand. But it's even less clear how many are on second line treatment. Second line treatment is given to those who have developed resistance to first line treatment and it's prohibitively expensive.

Most of the hundreds of millions of dollars of HIV money is spent on drugs, either for treatment or prevention. No one would want to deny people who are suffering from HIV/Aids access to necessary drugs, of course, but there must be a limit to how much money can be spent on drugs to the almost total exclusion of other aspects of treatment and prevention. I don't know what that limit is but there are proposals to put even more people on drugs and the sustainability of these proposals is highly questionable.

At present, people whose HIV infection has reached a particular stage are usually put on antiretroviral drugs (ARV). Perhaps about half the HIV positive Kenyans who have reached this stage are currently receiving treatment. Pregnant women who are infected with HIV are put on a short course of ARVs and this results in most babies growing up HIV negative. Less frequently, people who may have been accidentally infected with HIV can be given a short course of ARV treatment called post exposure prophylaxis (PEP).

But there are proposals to roll out ARV drugs to more and more people. For example, it was proposed just over a year ago to test everyone, or as many people as possible, and to put anyone found to be HIV positive on ARVs. If this could be done, the number of people on treatment would go up several hundred percent.

Another proposal is to roll out what is called pre-exposure prophylaxis (PrEP). This would involve putting HIV negative people on ARVs in the hope that this would protect them from becoming infected. The target of this kind of programme would be those seen to be most at risk of contracting HIV. This could involve sex workers, men who have sex with men, prisoners, intravenous drug users and perhaps the clients of sex workers, people who have many parters and people who have concurrent sexual partners, relationships that overlap with other relationships.

The number of people who would be targeted would be hard to estimate. How many men who have sex with men are there in Kenya? Is it five percent of the population or 10 percent (2-4 million)? Men who have sex with men are hardly going to identify themselves in the current homophobic climate anyway. An obvious target of PrEP is people who are HIV negative but are in a relationship of some kind with someone who is HIV positive, called discordant relationships. This could number some 350000 people.

Similarly for sex workers, how many are there? Is it hundreds of thousands and does that include people who occasionally engage in sex work or who don't consider themselves to be sex workers? And what about identifying their clients, how many million would there be? Is it really feasible to identify those most at risk of becoming infected with HIV? The recently published modes of transmission survey shows that, for years, HIV programming has been seriously misdirected and also that those who are most at risk is a very mixed and constantly changing group.

There are questions about the possible effectiveness of PrEP but there must also be questions about the feasibility of identifying all the people who could benefit from it, given the numbers of people who are infected with HIV and the numbers of people who are in danger of becoming infected. If resistance is a problem at current levels of ARV rollout, what kind of problem would it be if ARVs were rolled out to all people at risk or thought to be at risk of contracting or of transmitting HIV?

All the uses of ARV run the risk of resistance. Those who are HIV positive and on ARVs are at risk, but so are the women who receive short courses of ARVs to prevent mother to child transmission, so are those who receive post exposure prophylaxis, so are those who receive pre exposure prophylaxis. With resistance comes increased sickness and death unless second line treatment is rolled out. And second line treatment means increases in cost of several hundred percent. Again, questions about sustainability arise.

The question of whether we can treat our way out of the HIV epidemic is constantly raised but the answer is unclear. I would suggest that the answer is no and that even efforts at preventing the spread of HIV should steer clear as much as possible from technical fixes, such as ARV drugs. Drug treatment of HIV, let alone drug prevention, may not be sustainable and is already seriously affecting the amount of money available for preventing HIV transmission.

Instead of the almost inconceivable amounts of money being proposed to pay for drugs for treatment and prevention, far lower sums of money could be spent on improving the overall health, education and welfare of Kenyans and of those in other high HIV prevalence countries. It is immoral to continue pretending that there is a technical fix just around the corner and that everything will be OK. As long as we continue to look for technical fixes and ignore the lives of people in underdeveloped countries, people will continue to become sick and to die from treatable and/or preventable conditions.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)

Kenya Makes a Start in Addressing the HIV Epidemic

For the first time, I have come across an official Kenyan Government publication relating to HIV that is readable, credible and well thought out. Their survey entitled'HIV Prevention Response and Modes of Transmission Analysis' is available now (despite being dated March 2009). It address many of the worries about Kenya's HIV epidemic that have only been briefly mentioned before, but never adequately dealt with.

For example, it questions the fact that a far larger percentage of HIV spending goes on treatment and care than on reducing transmission; it questions the fact that HIV prevention programmes are top down and the same everywhere, even though the HIV epidemic affects areas very differently; it questions the fact that much of the HIV prevention spending seems to go to those who are not most at risk of being infected with or of transmitting HIV; many of those who are most at risk or in need of specific prevention programming receive little or none.

At last, the fact that there are men who have sex with men in Kenya and that they contribute to the epidemic is admitted and it is concluded that they need to be targetted. A recent report (too recent for this survey) shows that men who have sex with men live in all provinces and in urban and rural areas. It also shows that the clients of male sex workers providing services for other men are predominantly Kenyan. Previously, it was said that men having sex with men was a foreign phenomenon and that it mostly occurred along the coast.

Indeed, HIV transmission by men who have sex with men may be even higher than estimated by the Modes of Transmission Survey. But it's good that the issue is being discussed, rather than denied or ignored. The paper also admits that much of the money that goes into prevention goes towards interventions that have not been shown to have any impact on transmission. It admits that specific interventions may not have had much impact yet, even though some indicators are positive. It acknowledges that programmes and services are concentrated in areas where the need is not greatest.

So, people who are most at risk of becoming infected and of infecting others, such as men who have sex with men, commercial sex workers (and those who engage in any kind of transactional sex), intravenous drug users, long distance drivers, members of the fishing community and others are being acknowledged as being in need of prevention services. Let's hope that will be translated into the provision of these services. This survey is a very important step in Kenya's approach to HIV prevention.

But before some of these groups can be targeted, there are other problems that need to be addressed. It is illegal for men to have sex with men, certain aspects of commercial sex work are illegal and intravenous drug use is illegal. Members of these groups are rightly afraid to identify themselves and to risk being identified because they are the victims of persecution by members of the public, clients, professionals, police and others. But the survey mentions these issues and makes recommendations relating to them.

It remains to be seen whether any of the improvements recommended by this survey are made by the current government. But reading this survey gives me hope because maybe now there are some people in a position to do something who are willing to even discuss phenomena that have so long been ignored.

We Don't Need Evidence that Health, Education and Other Social Services Are Good

You might think that HIV prevention interventions have some bearing on the context in which they are implemented. For example, you might think that interventions to persuade people to have fewer partners are concentrated in areas where it has been shown that people have many sexual partners. Or you might think that about interventions to persuade people to avoid concurrent relationships, sexual relationships with more than one person at a time.

But in fact, interventions are mostly the same wherever you go, whether it's a developed country or an underdeveloped one. The little research that has been done into sexual behaviour suggests that in some places people have far more lifetime sexual partners than in others and even that in some places people have more concurrent sexual relationships. But no research shows that areas where people have more sexual partners or more concurrent sexual relationships actually correspond closely with areas of high HIV prevalence.

It's just an assumption that if HIV prevalence is high, people there much have more sex, more partners and more concurrent relationships. Some of the research that has been done clearly demonstrates that areas with high levels of HIV have lower levels of multiple partnerships and concurrent partnerships. It also demonstrates that areas with high levels of multiple partnerships and concurrent partnerships have lower rates of HIV. Clearly, unsafe sex is unsafe, wherever it occurs and however, but specific prevention programmes would need to be clear about what kind of 'unsafe' sexual behaviour, precisely, is occurring and how to change that.

But HIV prevention interventions are more likely to be dreamed up by those with political, religious or commercial interests, in complete isolation from anything that could be called evidence. And so far, they have almost all worked equally badly, whether it's in South Africa, which has the highest number of people living with HIV in the world or the US, which has the highest HIV prevalence in the developed world. These failures are not because of lack of available evidence about what would work and what would not work, though there is a lack of evidence. The failure is because HIV prevention funding has been seen as a matter of 'morals', petty politics and a good way to make some money.

If these circumstances were to change, what hope would there be that the high rates of HIV transmission in many countries of the world could be reduced? The issue of concurrent partners is hotly debated by the foremost academics in the field. But what these people don't disagree on is whether condoms work. There is no evidence that condoms don't work, though they are not 100% efficient. There is only a prejudice against the use of condoms because people who use condoms are having sex. But if people weren't having sex there would be no HIV pandemic.

I have never heard an academic, or anyone else, arguing that education, health education and sexual health education are bad and producing evidence to support their arguments. I have only heard bigoted politicians and religious leaders who seem to know little and care less about what their country's children know about sex and sexuality. Over and over again, it has been shown that children who know about sex and sexuality are more likely to delay their first sexual experience and to take precautions against unplanned pregnancy, HIV and other sexually transmitted infections.

Research into sexual behaviour is not just scarce, it's hard to do and the results are rightly hotly debated. But we don't need to wait for this difficult and costly research to be completed to aim to cut the transmission of HIV. It would be immoral to wait for this research. We know now that people have sex and they need sex education and contraception. They need health services, especially sexual and reproductive health services. The majority of new cases of HIV transmission in developing countries are still sexually transmitted, so to those who say HIV prevention is difficult or that evidence is lacking: this is not completely true.

Sure, there are controversies and there is research that badly needs to be done. But ignoring the efficacy of condoms, education, health and other social services in cutting the transmission is not only wrong, it is also disingenuous. Access to education, health and other social services are human rights so no 'evidence' is needed for these areas to be funded straight away. And while we're considering these human rights, we could also take a look at gender imbalances of all kinds, but especially relating to employment, family law, inheritance and marital power imbalances.

High HIV prevalence relates to the broad determinants of sexual and other types of behaviour, to the overall conditions in which people live, to their levels of health, education, wealth and many other things. HIV prevention has mainly concentrated on individual sexual behaviour and this is one of the things that makes reducing HIV transmission appear to be so intractable.

As the authors of a paper published in The Lancet over three years ago conclude: "No general approach to sexual-health promotion will work everywhere, and no single-component intervention will work anywhere. We need to know not only whether interventions work, but why and how they do so in particular social contexts. Comprehensive behavioural interventions are needed that take account of the social context, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour."

How Long Can We Continue to Ignore Those Who Are Still HIV Negative?

I was back in Mogotio with Ribbon of Hope today, weeding the watermelon beds in our latest shamba (smallholding). There were eight of us there today, three who were getting paid for the work. Others will get payment in kind. I have to be honest, I managed to do a few hard hours under the hot equatorial sun but I had to give up at lunchtime and I'm now stiff and sore. And there was at least two thirds of the field left to weed when I left!

But it's good to see the project get off the ground because it will provide some casual employment in an area that sees little work and it will provide some good food crops at low prices at a time when food prices are particularly high. In the next few months the shamba will require a lot of looking after, weeding, irrigating and security. There will be plenty of people willing to do some of that work.

Mogotio is only about 30 kilometers out of Nakuru, so it is by no means the most isolated place you'll find. But it feels isolated. There are very few NGOs that ever visit the place and I haven't been able to find out about anything they do. I saw a World Vision four wheel drive but none of the community leaders I asked could say what the organisation does there. UNHCR has been active in the area recently because hundreds were displaced by the heavy El Nino rains. There are over one hundred white UNHCR tents just outside the village, but that's an exception.

The area is almost entirely dominated by the sisal industry. There are a few factories, most of which don't operate very much. There is little money to be made by growing sisal and people who live in these areas don't make much of that money anyway, it's mostly made by the estate owner, who lives in Nairobi and rarely visits the area. Some of the people who work for or have worked for the factories are owed wages going back many years. Every now and again they get some money, but just a fraction of what they are owed.

Like a lot of parts of Kenya, HIV is widespread here but it receives little attention. Most NGOs are based in the cities and bigger towns. They work in or close to wealthy suburbs and rarely leave those areas for long. When they do, it's like a state visit, a convoy of huge, air conditioned, white, oversized vehicles, stirring up the dust and little else. HIV spreads more slowly in rural areas and that may be one of the reasons that less attention is paid to them than to urban areas. However, the majority of Kenyans, over 80%, live in rural areas.

And many more people in rural areas don't go to school or don't go to school very much, many don't have access to mainstream media, they don't have access to health or other social services and they have little or no connection with the benefits of the cities and towns. They are more isolated than their distance can explain. Every now and again something comes their way, probably not much, then the project or organisation leaves and loses touch.

But even some of these isolated areas have access to some HIV testing and counseling facilities and even the HIV drugs that most people are supposed to receive for free. They usually don't have access to any other kind of drugs and they are lucky if they can stay healthy, but it's a start. But treating more and more HIV positive people every year has little impact on reducing HIV transmission. Many more people become infected for every one person who gets treatment.

And HIV prevention really is a strange animal. In all the time HIV has been around, few methods of HIV prevention have been developed. A fraction of the money that goes into HIV goes towards prevention, less than 25% in Kenya. About half of that goes on prevention of mother to child transmission and the 12% that's left is spent on rather dubious projects that are known to be of little or no benefit.

A series of findings were presented at the 2006 Aids Conference that demonstrated that most kinds of HIV prevention programmes have a very small effect, some have a negative effect and the majority don't do anything. Consider the list: Voluntary Counseling and Testing, Condom Social Marketing, Mass Media, Abstinence-Based Interventions, Peer Education, Family Planning Counseling for HIV-Infected Women, Needle Exchange Programs, and the Effect of HIV Treatment on Risk Behavior.

The only one in the above list that has proved itself is needle exchange programmes. These have been known to be effective for a long time but they are strongly disapproved of by many funders, especially US funders, who feel that they increase drug use. They don't increase drug use, they reduce it and they have an impact on HIV transmission. But such programmes are of little relevance in Kenya as a whole and of virtually no relevance in a place like Mogotio.

The majority of HIV infections in Kenya come from heterosexual intercourse. A sizeable percentage comes from male to male intercourse. A debatable, possibly high percentage, comes from medical treatment, such as injections. But in rural areas, like Mogotio, people are in need of good education, health services, ordinary health services, not vertical interventions that treat HIV (or something else) alone, basic social services, infrastructure and things like that. There is no mystery about HIV transmission that makes its reduction intractable. People need a reasonable standard of living, they need security in their lives, especially food security, they need work, for which they get paid; just basic things that people in developed countries take for granted.

Yet more and more money continues to be poured into programmes that are unlikely to work or even ones that have been demonstrated not to work. In the case of Mogotio, of course, they don't even get these programmes most of the time. Money intended for the constituency appears to get stuck elsewhere and people are forced to plod along without even the most basic of their rights being realized. As long as people have so many problems in their lives and so little to aspire to, HIV will continue to be low on their list of priorities. If HIV is low on their list of priorities, even effective prevention programmes, if effective programmes exist, are destined to fail.

Will PEPFAR Become a Fund for Health?

It sounds as if PEPFAR (President's Emergency Fund for Aids Relief) is about to change a bit under the Obama administration. These changes are all long overdue. For a start, Aids is no longer to be seen as an emergency. It wasn't an emergency before PEPFAR started, so this is good to hear.

The 'exceptionalisation' of Aids, treating it as if it is a disease that is separate from health in general, should have its own institutions and funding, is to disappear. Again, this move is long overdue, but still welcome. Hopefully, it will mean that some of the huge sums that have been raised for Aids will be spent on health services. Those who think Aids issues will lose out needn't worry, people with Aids also have general health needs. So everyone will gain.

The head of PEPFAR, Eric Goosby, is at last questioning the sustainability of putting everyone who is HIV positive on drugs that they will need for the rest of their lives. Of course, HIV positive people should be treated, but with far more people becoming newly infected for every one put on treatment, something really has to be done to reduce the number of new infections as well.

So HIV prevention should return to the agenda. The question is, what kind of prevention programmes will be funded by PEPFAR? In the past, prevention has included little but lecturing people on their sexual behaviour. There are few prevention programmes that have had much impact on HIV transmission. Of course, most well funded programmes will tell you that they have been very successful and show evidence that whatever mindless drivel they repeated to all and sundry can be trotted out at the ring of a bell, or whatever.

But rates of HIV transmission remain high in many countries, including the US, despite these questionable programmes. Does PEPFAR have anything new to bring to the table? If they don't, it would be good to hear that they are willing to talk about using condoms and employing other harm reduction approaches to HIV. For example, clean needle and syringe distribution and greater advocacy and support for sex workers, men who have sex with men and other vulnerable populations.

Another change proposed is that PEPFAR funds go to governments rather than, primarily, to NGOs. While it's true that NGOs may not have done very well in many cases, I'm not sure about the wisdom of handing large amounts of money to governments. Kenya has had a particularly bad history when it comes to administrating large amounts of money intended for HIV treatment, care and prevention (or any kind of funding). Time and time again, investigations have found administration of funds wanting, only for the money to flow in again once the row has died down. PEPFAR recently announced a doubling in Aids funding, amounting to 2.7 billion dollars over the next five years.(A Ugandan writer also worries about these changes ito PEPFAR.)

Disbursements of US aid for HIV don't relate to a country's need. The HIV epidemic in Kenya is by no means the worst in Africa, even in Sub-Saharan Africa but they are one of the top recipients of funding. No, disbursements seem to depend more on how cozy a country's relationship is with the US and for Kenya, the relationship has been very cozy since independence. Perhaps questions about how much of that money actually benefits people with HIV are irrelevant to PEPFAR, as long as cozy relationships remain, who knows? But let's hope the changes take place and my fears are not realised.

The One Trick Pony That Can't Defy Gravity

When debates become polarized there can be a danger that neither side can accurately characterize the view of their opponent. Thus, Gregg Gonsalves of the International Treatment Preparedness Coalition characterizes a particular view as the 'Aids backlash' and lumps together a number of views that may not even be held by any particular person or group. He characterizes the backlash thus:

The belief that "the fight against AIDS has misdirected our energies towards broader goals in health and development; the provision of antiretroviral therapy is a folly, it's too expensive and isn't worth the money to continue its expansion; efforts against AIDS are destroying health systems and promoting unnecessary deaths from other simpler-to-treat diseases and conditions such as childhood diarrhea".

Personally I think there is probably not enough money put into the fight against Aids and that much of that money is not being used very well. In particular, I think too little of the money is being spent on prevention and almost all of that is not being used very well. True, it took some time for the international community to face the threat that Aids presented but when they did face it, they came up with a level of funding that has never been matched by campaigns against other diseases or disease groups (such as sexually transmitted infections, water borne diseases, etc).

I don't think the provision of antiretroviral therapy (ART) is a folly and I don't think people who hold the sort of sceptical view I've expressed in the last paragraph necessarily do either. The fact that there are many more people becoming infected than there are being put on ART is not an argument to reduce ART programmes, rather, it is an argument for finding out why HIV prevention is being ignored and rectifying this situation urgently. There is little point in spending nothing on people until they become infected with an incurable illness if something could be done to prevent them from becoming infected.

But also, there is little point in treating people for HIV and leaving them to die of something else. There are many preventable and treatable diseases that are killing people, including people who are HIV positive. I think that this is, in part, because of poor health facilities and services and an acute shortage of personnel. But also, there is a lack of funding that goes back several decades.

I am in complete agreement with Gonsalves when he points out that poor health services are not a result of the Aids pandemic. This is clearly true in Kenya and many other developing countries, where poor health services date back to the early 1980s, when Aids existed but hadn't been identified and certainly hadn't even begun to wreak the havoc that came later. Aids didn't help these ailing health services and certainly decimated the health workforce, as well as the workforce as a whole. But in short, Aids was just another nail in the coffin for public services in general, not just health.

I sympathize with Gonsalves to some extent, but when is money going to be spent on HIV prevention programmes that work, as opposed to programmes that promote purely political (including religious and pseudo-religious) ends? When is money going to be spent on the things that concern the most people, the many diseases and social problems that most people face? I needn't list the diseases or even the problems, Gonsalves would be more aware of them than most.

Some of the people that Gonsalves may gloss over as the 'Aids backlash' wonder how HIV positive people will benefit from a one trick pony health programme that can give them ART but nothing much else, perhaps not even the food they need to be able to take the antiretroviral drugs. They wonder why HIV positive people with certain diseases are more worthy of treatment than those who are dying of the very same easily preventable and treatable diseases. They wonder why those who are at risk of becoming infected with HIV are not entitled to very much, but if they become infected, they may receive a great deal.

But, more importantly, I think: what kind of HIV programmes can be implemented successfully in countries that have inadequate health services, along with poor standards of education, hardly any social services, very little infrastructure, lack of political leadership, governance, legal systems and levels of equality that would be required for these very expensive programmes to work? Even one trick ponies can't work without any solid foundation, as the Aids one trick pony amply demonstrates.

Foundations for HIV Prevention

I rarely come across articles criticizing HIV prevention programmes for their lack of success, but apparently a contributor to the Social Aspects of HIV/AIDS Research Alliance conference this year draws attention to the fact that many 'prevention' interventions were implemented without ever being tried. He may have gone on to say that ones that were tried and found to be useless continue to attract most prevention funding, but I wasn't at the conference.

Professor Geoff Setswe is right that HIV took some time to be recognised and had already infected many people before the most appropriate methods of preventing its spread had been investigated. But more than 25 years later, prevention programmes continue to be rolled out that are untested or that are tested but found to have little or no benefit. But no one is counting bodies when there is money to be made.

It's easy to blame health and other social problems on the global economic crisis now, but that wasn't the problem just over a year ago. In Kenya, since the 1980s, one excuse after another has been blamed on the lack of progress in education, health and other areas. If it wasn't economic, it was oil or food or political or environmental and if it wasn't a crisis it was a disaster. The HIV pandemic itself is just one of those many 'disasters' or 'crises'.

But poor health in Kenya is not a disaster, nor is it a short term crisis. Health services have been reduced in Kenya at least since the early 1980s, when the Moi government depended on loans from international financial institutions to prop up his form of democracy. These institutions funded him in return for his agreement to cut spending on social services and the public sector in general. It seems unlikely he or his colleagues (who overlap considerably with the present administration) were particularly worried about the idea of reducing public spending.

Health service spending in Kenya is now minimal (as are spending on education and other social services). Health infrastructure needs to be built from the ground up, more or less. Most people don't go to hospitals or clinics and many who do fare worse than they would have if they had stayed at home. It's little wonder that HIV was transmitted rapidly in Kenya during the 1980s and continues to spread today, despite the hundreds of millions of dollars spent on the disease. There are still far more people being newly infected than receiving treatment, though a lot more money is spent on treatment.

Fine, Professor Setswe, clinical trials are not always appropriate for testing social and behavioural interventions. But are clinical trials needed to show that starving people need food, that those suffering from malnutrition need proper nourishment, that poor people need support, that sick people, whatever they are suffering from, need medical attention, that those without adequate supplies of water die of thirst or water borne diseases? And the list goes on. Those who pigheadedly continue to talk about how difficult HIV is to prevent seem to be uninterested in what those in high HIV prevalence countries really suffer from.

HIV is a real disease. Those suffering from it need treatment and care. Those who are in danger of becoming infected need to be protected from it or to be enabled to protect themselves from it. But most people will get up in the morning and have food, water, work, school fees, day to day health and many other things on their minds. And in all the time that HIV has been around, these other concerns have been largely deprived of attention and funding.

Finally, mass male circumcision is mentioned as a possible HIV prevention method that is supported by a lot of evidence but has been held up for various reasons. Perhaps one of the reasons that circumcision has been held up is because health services in Kenya and other countries who were tricked by those same international financial institutions have been reduced to the extent that it is not possible to roll out any kind of mass health programme. Some of the HIV programmes that were rolled out failed because infrastructure, education, health and many other areas have been so underfunded for so long.

The same article mentions a Dr Ntanganira, who says that "We know what works". But the article doesn't say what works, unfortunately.

The Aids Industry Sure Knows How to Blow its Own Trumpet

Yesterday was World Aids Day again and in Kenya you couldn't miss the copious amounts of advertising, bunting, leafleting, t-shirts, sun visors and other paraphernalia of the industry. High and not so high officials were out in strength to collect their per diem, without which, presumably, nothing important could happen. There were the mobile testing clinics in areas that already have static testing clinics and millions and millions of condoms distributed.

For all it's faults, the Aids industry has published some figures that certainly look good. Botswana, which has one of the worst HIV epidemics in the world, has the highest percentage in any African country of people on antiretroviral therapy (ART), the highest rates of HIV testing and the highest number of women on ART to prevent mother to child transmission (PMTCT). They also have the third highest percentage of children on ART.

Over several decades, the campaigns to recognise the rights of HIV positive people to receive treatment have been successful in a lot of countries. In many developing countries, a sizable percentage of HIV positive people in need of treatment are on treatment. In the West, very few babies born to HIV positive mothers are themselves HIV positive. Indeed, the percentage of HIV positive babies born to HIV positive mothers is declining in a number of developing countries too and should be relatively low by now in a country like Botswana, where such a high percentage of HIV positive mothers are receiving PMTCT.

But rights seem to be most commonly recognised for those who are already infected with HIV. If you read various developing country HIV strategic plans (which are curiously similar, despite the epidemics being very different in quality), you will notice that the word 'rights' is rarely used except in relation to HIV positive people, mainly in relation to access to treatment. The rights of those who are not yet HIV positive, and that's most people, are rarely mentioned. Yet they have a right to the things that will ensure that they remain HIV negative.

Of course, it is hard to quantify the effects of the various HIV prevention programmes that have been rolled out in Kenya and other African countryies. Most of them were run by wealthy organisations who could afford the 'research' and publicity that would make them look very successful. The reality is that very little is known about preventing HIV and, beneath the hype, few programmes have been truly successful.

I would be the first one to admit that the very idea of cutting HIV transmission is fraught with difficulties. Many things have been tried, some of them perhaps even well thought out. But in the end, there is very little money to be made out of prevention and therefore very little money put into it. Condom distribution is an exception, but where there is little or no health or science education, let alone sexual and reproductive health education, condoms haven't really taken off that well. You may have heard otherwise but there are good commercial reasons for that.

The problem with the majority of the prevention programmes that have received some of the relatively small amount of money that is available for HIV prevention is abstinence. Most programmes relied on the idea that if people would just abstain from sex, they would not be likely to be infected. The more liberal advocated abstinence until marriage, until it was noticed that more and more people are becoming infected by their spouse. But various programmes were cobbled together that, one way or another, advocated abstinence or what amounts to abstinence. People didn't abstain and most of them won't. This is not something peculiar about developing countries. Abstinence campaigns have failed where ever they have been tried.

The reason I mention the rights of people who are HIV negative is that many of them will, sooner or later, become infected with HIV because one or several of their rights are presently being denied. People, whether adults, children, male or female, have a right to health and a right to treatment when they are sick. Yet more people in Kenya and other developing countries are dying of easily treatable and curable diseases than are dying of Aids.

Children have a right to a decent education and part of that should include levels of health and science education that should give them the prerequisites to attain enough understanding of sex, sexuality and reproductive health to avoid becoming infected with HIV or other sexually transmitted diseases and to avoid unplanned pregnancies. In a word, people need education to lead healthy lives.

People have a right to a decent standard of living for themselves and their children, they have a right to adequate food and nutrition, they have a right to good standards of governance and security, water, sanitation, infrastructure and many other things. They have a right to a legal system that protects them from harm and persecution and the like. Women need to be given the same rights as men, in the workplace, in the economy, in education, in health and everywhere else. Men who have sex with men, intravenous drug users and commercial sex workers need their rights protected.

It is the denial of the sorts of rights mentioned above, along with various other rights, that leaves people vulnerable to becoming infected with HIV and suffering many other serious consequences. People in developing countries who are suffering from HIV now, and those who have died of it, were likely denied one or several of their rights. HIV is not transmitted in isolation from people's circumstances, from the conditions in which they live and work.

Those who are HIV positive and those who are HIV negative are equally entitled to their rights, though skewed funding for Aids would suggest that this is not the case. In order to avoid transmitting HIV to others and in order to remain HIV negative, everybody's rights need to be protected. In short, everyone is entitled to these rights and without them, the treatment and care programmes for people who are HIV positive will be, to a large extent, in vain; the half hearted prevention efforts will also be in vain.

Prevention has proved to be a slippery fish. But treatment and care for one disease in isolation from all the other things people can and do suffer from has also been less successful than it should have been. There is little point in treating one incurable disease and ignoring the many others that are more easily treatable and often even curable. But that is what's happening. The Aids industry is just too rich and powerful to allow people to know that.

HIV Treatment is Necessary, But Not Sufficient, For Prevention

Medicins Sans Frontieres (MSF) has published a report on reduced funding for HIV treatment, from the World Bank's Global Fund and the US Government's President's Emergency Fund for Aids Relief (PEPFAR) in particular. MSF have good reason to be worried.

The pharmaceutical industry successfully lobbied governments and international institutions to pay huge amounts of money for antiretroviral (ARV) drugs that most of the people suffering from HIV/Aids would never be able to afford. In fact, the governments of countries with high rates of HIV/Aids would never be able to afford these drugs, either.

Countries like Kenya have the option to produce generic versions of ARV drugs at a fraction of the price that is currently being paid. But most countries, including Kenya, have chosen not to exercise this right, preferring to enact laws that make it unlikely that the country can produce or even purchase such cheap generic versions. Good relations with the pharmaceutical industry seems to be more important to them than saving the lives of their citizens.

MSF are right, huge ARV rollouts cannot now be stopped without endangering the lives of millions of people who are HIV positive and even people who are, as yet, HIV negative. But rather than arguing for the money to keep coming, in fast increasing amounts, they could concentrate on finding ways of reducing the cost of treatment so that it can continue and even expand.

How much of the billions of dollars of aid money have been spent on building factories to produce drugs that people need in Kenya? I haven't heard of any. Most of the money has been spent in ways that don't go on to produce anything or increase the country's sustainability or self reliance. The funds have mostly been spent as if HIV is just an emergency.

Well, it is something of an emergency, but there are underlying factors that are not part of an emergency. The country has a decaying health service, decaying education sector and a small and decaying infrastructure. People are poor, unhealthy, badly educated and unable to access vital services, such as clean water and proper sanitation. These are the things that face the majority of Kenyans every day, whether they are HIV positive or not.

Money spent on drugs, regardless of the overall condition of health systems is, to a large extent, wasted. Many drugs go out of date before being distributed, they get to people unprepared to take them properly, they are taken by people who are dying of other, easily prevented and treated illnesses, etc. My argument is not that ARVs should not be purchased and distributed and prescribed; it is that there needs to be a proper, accessible health service for all this to happen.

There is not a proper health infrastructure in Kenya, there hasn't been for a long time and increased HIV/Aids funding has not brought about a health infrastructure that serves people's needs. True, there are many clinics and institutions that were not here before HIV/Aids and wouldn't have even appeared. But these mostly deal with HIV/Aids, not other, basic health problems that people face.

My argument is also directed at the emphasis on HIV/Aids treatment over prevention. MSF's Goemaere is right to object to the prevention/treatment 'dichotomy'. Of course treatment has a positive effect on prevention efforts. But it is not enough to try to treat our way out of the epidemic. This is clearly not working and much more needs to be done to prevent new infections. Otherwise, the aim to treat everyone who requires treatment becomes even less attainable and less sustainable that it is right now.

People who are HIV positive need more than just drugs, or even treatment. There are a lot of threats to their health and welfare than HIV. They are dying because they are too far from the hospital, because the hospital is not up to the job of caring for them, because they are entitled to benefits they don't know about or that have been stolen by someone else, because they are poor and isolated and not considered important enough. But there just aren't the services needed to support chronically sick people and these will not just appear because the country is swamped by HIV/Aids (treatment) related institutions and programmes.

Those who are HIV negative need to stay that way and this won't happen by rolling out ARVs, alone. They have needs that are far more important and urgent that the possibility that they may become infected by something that won't kill them for many years. Most won't live for very long anyway, for a huge variety of reasons that are not being addressed right now.

Goemaere recognises the false dichotomy of treatment/prevention, but fails to see that increasing treatment while effectively ignoring prevention will not combat HIV/Aids in the long run. Assuming that HIV treatment will also prevent infections is not enough because it doesn't prevent enough infections and it never will. And treatment will never be as efficient as it should be if health, education, infrastructure and other social services continue to be ignored.

Prevention Needs to Consist of More than Good Intentions

To continue a theme that crops up regularly in this blog, an article on AllAfrica.com argues that Kenya needs to invest more in prevention campaigns than curative ones. True enough, but this article is about non-communicable conditions, such as hypertension, diabetes, mental illnesses, asthma and cancer. Health should start with prevention, whether that involves preventing communicable conditions, non-communicable conditions or even accidents such as road traffic accidents, industrial and agricultural accidents or injury and death from criminal acts.

However, realising that prevention is important is one thing, actually doing something about it is another. Take road traffic accidents (RTA), for example. All sorts of shenanigans have been put in place here recently, ostensibly to reduce RTAs. There are police checks and the rest, but what do the police do, exactly? Well, it's no mystery, they take a bribe and wave the driver on. There could be 22 people in a vehicle licensed for 14, bald tires, faulty brakes, out of date insurance or whatever, but as long as the police get their money, no further questions are asked.

In a country where health spending and health infrastructure has been reduced and continues to be reduced since the early 1980s, what exactly are health professionals supposed to do about all these conditions, communicable and non-communicable? The fact that prevention is better and cheaper than cure is irrelevant when there is bugger all money, anyway. But, even where prevention is even felt to be worth the effort, such as with HIV/Aids, are the figures for HIV transmission falling? Certainly not.

There is plenty of talk about preventing HIV but only 30% of HIV funding is allocated to HIV prevention. Most of that (which is probably nowhere near 30% of funding in reality) goes into a lot of mindless bullshit cobbled together by bigoted donors who don't give a damn about whether HIV transmission is really reduced as long as no one offends against their high minded but ultimately self serving interpretations of Christian morality. And it usually is Christian morality.

A report by a Nairobi based institution has come up with some alarming but unsurprising figures on teenagers knowledge of sex and their sexual behaviour. A large percentage of teenagers are having sex but they know little or nothing about safe sex. Unsurprising because they have been taught little or nothing about safe sex. Where has all the tens of millions of dollars intended for HIV prevention gone? It is has gone into not teaching teenagers about safe sex. I don't know how much money can be spent on the non achievement of something; that is in serious need of investigation. But the money is gone and the knowledge is nowhere to be found.

The report goes on to say that 40% of girls and 50% of boys have sex before the are 19, they believe all sorts of rubbish about sex, they fear pregnancy more than HIV, sex education is not taught in most schools, contraception is usually not mentioned (for fear of horrifying donors, politicians and church leaders, who are very sensitive people), half of the girls in a survey had exchanged sex for money, gifts or cash and 47% of the teenagers surveyed either had a child, were pregnant or had undergone an abortion. A separate study finds that 5.5 million girls between 15 and 19 give birth annually in Kenya, that's one eighth of the entire population!

If the calls for investment in preventing disease were to lead to improvements in very basic goods, such as water, sanitation and infrastructure, basic living conditions, primary health, education, gender equality, legal reform and things like that, Kenya would eventually be a lot better off. But it seems more likely that if any money is provided to prevent diseases and improve health, it will be spent on following purely political, commercial and religious agenda. Once those have been attended to, there's rarely any money left for anything else.

Use Condoms and Get Tested, Regularly

Uganda has launched a new HIV/Aids campaign, ‘Stay Negative and Love Condoms’. That’s good to hear because condoms are vital for preventing HIV. There are lots of other things that can be done but a campaign that highlights the use of condoms is certainly preferable to ones where abstinence and faithfulness are stressed and condoms hardly mentioned. It’s also good to hear that some effort is being put into preventing transmission of HIV, rather than concentrating mainly on people who are already infected. The Aids Healthcare Foundation is running the programme so I’ll be watching out for further information on it.

In addition to emphasizing abstinence and faithfulness at the expense of prevention strategies that have any chance of working, the Ugandan government hasn’t been pulling its weight in its HIV prevention efforts. Research shows that people’s sexual behaviour is not very heavily influenced by recent campaigns for safer sex. Perhaps now they will look beyond sex, at people’s livelihoods and circumstances, which determine when, where, how often and with whom people have sex. While they are at it, they could work on their attitude towards men who have sex with men (MSM).

Currently MSMs are pretty much ignored by HIV prevention campaigns and they continue to be the victims of persecution and abuse. They are a very high risk group and this abuse only makes matters worse. They need the protection of the law and access to health services. As do commercial sex workers and intravenous drug users. Criminalization and the continued refusal to engage in meaningful harm-reduction efforts for these groups are senseless and appears to be motivated by political or religious interests (if these are in any way different).

Indeed, many countries are considering some kind of law making it a crime to knowingly transmit HIV. People who are infected with HIV need to be identified by voluntary testing, not hounded and criminalized. In addition to the use of condoms, testing is a vital and effective tool in HIV prevention and care. People need to be encouraged to test, not threatened with a prison sentence if they turn out to be HIV positive. This sort of law is particularly hard on women, who are more likely to test at an earlier stage in the disease. The more people who test early and regularly, the better.

It is things like stigma, persecution, gender and economic inequalities, poor legislation and enforcement, corruption and political and religious interference that have allowed HIV to spread rapidly in many countries. These problems are, in most countries, getting worse. This is not the time to pass laws that make HIV eradication even less likely than it is at present.

Use Condoms, get tested, regularly, be careful and advocate against discriminatory and harmful laws.

Test Everyone; Treat Everyone?

Is it possible to eradicate a disease while ignoring its determinants?

Last December a new HIV prevention strategy was proposed (I covered it in this blog in December). It involved testing every sexually active person in a population for HIV (or as many people as possible) and treating anyone found to be HIV positive. The idea is that people on antiretroviral therapy (ART) have a low viral load, so they are unlikely to transmit HIV to others. A mathematical model of this strategy, using data from South Africa, indicates that it could be possible to almost eradicate HIV by 2050.

It has been widely recognised that it is better for HIV positive people to be diagnosed and put on treatment at an early stage in the progression from HIV to AIDS. This proposed strategy could have a lot of benefits for HIV positive people and their partners. As one of the authors of the proposal points out, "treatment is also about prevention". Preventing new infections should be made a much higher priority than it is now and this strategy should also enhance existing prevention efforts.

On the surface the strategy sounds great. The more people who know their status, the better. The more people on ART as early as possible, the better. The fewer people exposed to a high risk of HIV infection, the better. The modelling that the strategy is based on even gives some estimates as to what the costs may be. And the costs of aiming to eradicate the virus are certainly lower than continuing with current measures, where millions of people are becoming infected every year.

But countries with high HIV prevalence have been aiming for years to get as many people as possible to test, as often as they need to. In Kenya, only about 20% of people know their status. Some countries have been more successful in persuading people to test, others have been less successful. And only about one third of people requiring ART, people who would die without it, are already receiving treatment in Kenya.

What measures could persuade a large percentage of people to test, say 80%? And they would need to test regularly, say once a year. The costs involved in implementing both prevention and treatment and care programmes in Kenya and other countries are high. Pledges from donor countries have never been high enough to meet the costs; often, even the sums pledged never materialize.

But perhaps, in a rare fit of generosity, donors would make enough money available to implement a programme that would need to last many years, perhaps even three or four decades. At present, several countries are finding it difficult to keep existing patients on ART, let alone provide treatment for the many who will probably experience serious illness and possibly even die without ever receiving any treatment.

But maybe the two arms of the programme could work, universal testing and universal treatment for everyone infected; or perhaps a high level of testing and treatment could be feasible. I would be very happy to see these goals being achieved. My only worry is that we may forget the sort of conditions that drive epidemics like HIV in the first place:

• Serious levels of poor health and poor health services, including sexual health, reproductive health, etc


• Widespread discrimination against vulnerable groups, such as men who have sex with men and commercial sex workers


• Low levels of school attendance and low educational standards, including sex and sexuality education


• Few and low quality social services, especially for vulnerable and needy people


• Crumbling basic infrastructure, especially water and sanitation


• High levels of corruption at most levels of society and poor governance


• Low levels of employment and poor labour laws for those in employment


• Low levels of nutrition and food security


• High levels of economic inequality, inequality relating to inheritance, etc


• High levels of gender inequality whereby females and the people they care for are particularly disadvantaged

This is not an exhaustive list and it may seem obvious that we shouldn't forget these things. But HIV is just one disease of many. And there is little point in preventing one disease in people when there are so many other things that cause so much injury or death. But more perversely, failing to deal with some of the structural problems listed above, such as health, education, inequality, discrimination or whatever, can result in failure to halt the transmission of HIV.

Even if everyone dutifully trots to the voluntary counselling and testing clinic every year and everyone found to be HIV positive receives ART, the problems listed above won't just go away. And as long as they continue to be ignored by the international community, as they have been ignored for many years, HIV will not be so easy to eradicate. It is not a 'standalone' disease, without a history and without determinants.

I don’t want to undersell the proposal so it’s worth pointing out that it is predicated on continuing with existing prevention programmes, but most of these also ignore the problems listed above! I am not opposed to the ambitious aim of testing and treating everyone, far from it. I just don't fancy our chances against HIV if we fail to address its determinants.

In Case of Emergency, Maximise Profits

Flicking through articles on the BBC website, I was struck by an article about a type of emergency contraception called the E-pill, currently being marketed in Kenya. Not that it’s strange that emergency contraception should be marketed in Kenya, just that it is being marketed by Population Services International (PSI). They receive tens of millions of dollars in donor funding every year to promote safe sex so that people can protect themselves from unplanned pregnancies and sexually transmitted infections (STI), including HIV.

Emergency contraception is taken by people who haven’t used planned contraception or for whom that contraception has failed. What I find odd is that PSI should market this product without also pointing out the things that the E-pill does not protect you from. Surely this organisation is supposed to be marketing methods, not products? Is it naïve to expect them to be more concerned about broad outcomes rather than narrow indicators? These E-pills are likely to appeal to those who don’t use condoms, the very people who need to recognise the dangers of unprotected sex aside from unplanned pregnancy.

The director of PSI who is interviewed is right in pointing out that marketing contraceptive products to people does not necessarily result in them having sex, having more sex, starting to have sex earlier or having more risky forms of sex. But it is a struggle to promote safe sex as a way of avoiding several inherent dangers that sexually active people face, pregnancy being just one of them.

If young people are being exposed to STIs and HIV, unplanned pregnancy may even be the least of their worries. In fact, people who become pregnant and contract HIV at the same time will probably have their HIV status diagnosed as soon as they attend an antenatal clinic. If they don’t get pregnant, their HIV status may not be diagnosed until they eventually do get pregnant or until they become very ill. At this stage, they will probably have transmitted HIV and other STIs to other people.

One of the problems with marketing a single-issue programme as a means of protecting against HIV, such as male circumcision, is that it ignores the issue of pregnancy and, indeed, several STIs that are not prevented by it. It is senseless to sell safe sex as a means of avoiding just unplanned pregnancy or just STI or HIV infection. Family planning and safe sex marketing must involve all the issues. And PSI is supposed to be concerned with all the issues, not just one at a time.

One of the oddest aspects of this story is that it is not even permitted under Kenyan law to advertise emergency contraceptives in the first place. But because PSI is American and funded by donor funding, the whole thing is ok as far as the Kenyan government is concerned.

I agree that emergency contraception is, as claimed, preferable to botched abortions. It is preferable to unplanned pregnancies. But I think emergency contraception could appeal to the very people that PSI should be targeting: people who don’t want to use planned contraceptive methods, such as condoms.

PSI talks of making ‘the markets work for the poor’ in its mission statement and lists one of its core values as ‘[t]he power of markets and market mechanisms to contribute to sustained improvements in the lives of the poor’. Perhaps the organisation is a little too market driven to claim truly to be working for the benefits of poor people. It seems to me that the markets are working for PSI very well, thank you very much.

It’s Homophobia that is the Problem, Not Homosexuality

The main ‘problem’ with homosexuality or same gender sex, is homophobia. People who are lesbian, gay, bisexual, transgendered or intersex (LGBTI) do not thereby have a problem. Their problems arise because of the attitudes of people who consider themselves to be ‘normal’. These ‘normal’ people also consider themselves to be Christian, Muslim, law abiding, God fearing, righteous and many other things.

In reality they are at best prejudiced, judgemental and guilty of discriminatory practices, at worst, they can be criminally violent, even murderers. At the hands of these self-appointed arbiters of moral and immoral behaviour, LGBTI are subjected to horrific persecution, they are ostracized from communities, they are considered to be and treated like second class citizens.

Everyone has some kind of sexuality and most people express their sexuality in some way. Most sexual behaviour involves other people and much of it is consensual. Of course, forced or coerced sex is a terrible crime. But anyone can force or coerce someone to engage in some kind of sexual behaviour. That means, whatever someone’s sexuality, they can choose to have sex only with those who consent and only engage in types of sexual behaviour to which their partner consents; or they can engage in behaviour that is, hopefully, criminal.

If the self-appointed upholders of ‘virtue’ object to the way that some people express their sexuality, they could object to fact that tens of thousands of people are forced to have sex every year. Thousands of these victims are children, sometimes infants. Many are particularly vulnerable, for example, orphans, young girls who have been married off by their poverty stricken parents or women who have been widowed or abandoned. But others are just ordinary people, neighbours, friends and relatives.

These ‘virtuous people’ could also object to the incalculable number of women and girls (mainly females, anyhow), who are left with no other option than to provide men with sex in return for money, food, security, accommodation, school fees or some other transaction. For every female, there is at least one man involved in these transactions. In reality, for commercial sex work to be viable, there must be a lot more males than females involved. It seems hard to believe that none of these ‘virtuous people’ overlap with the many men who engage in transactional sex.

Amnesty International (AI) have highlighted the plight of human rights abuses against LGBTI in a number of African countries, such as Nigeria, Uganda, Senegal and Rwanda. Kenya may not be the worst offender but I don’t believe their record with regard to LGBTI is particularly good.

It’s particularly galling to hear this about Uganda and Senegal when you compare it to the badly researched journalistic rubbish you also hear about how successful these two countries have been in fighting their respective HIV epidemics. Senegal has one of the lowest prevalence figures in the whole of Africa and Uganda now has far lower prevalence than it once had.

Firstly, I would question their ‘success’ and suggest that there were important factors governing HIV transmission in both countries and these factors were far more significant in determining fluctuations in prevalence than anything the Ugandan or Senegalese governments ever did. But that’s another story.

Secondly, both these countries need to watch out. Discriminating against certain groups of people who are thought to be at highest risk of transmitting HIV is not going to help reduce transmission. People who are at risk need to be targeted with education, testing, health services, support and the protection of the law. Criminalise what they do, be it homosexuality, commercial sex or anything else, and you will have little success in targeting them.

At present, both Uganda and Senegal have pretty poor records when it comes to protecting some of their most vulnerable people. Low prevalence now does not mean low prevalence in the future. Both countries are creating and maintaining conditions where HIV will spread rapidly. There will be little their HIV prevention programmes can achieve if their laws compel or allow homophobia and other discriminatory forms of behaviour to persist.

Apparently, Kenya is considering discussing LGBTI in schools. I’ll believe it when I see it. However, everyone has a sexuality. There is no point in discussing a handful of sexualities without also discussing the whole issue of sexuality with everyone. Tomorrow’s homophobes need to be targeted, future persecution needs to be prevented and that won’t happen by exceptionalising LGBTI. The biggest problems faced by LGBTI stem from the behaviour of people who are not LGBTI.

The best thing Kenya could do to reduce HIV transmission and to help those who are most at risk of being infected is to criminalise discrimination and persecution, to criminalise gender based violence, forced and coerced sex and gender based corruption. They also need to decriminalise non-heterosexual sex and commercial sex work in order to prevent and/or identify and punish criminal behaviour and, at the same time, protect the victims. They need to get away from the current situation where they are just meting out punishment to those who are thereby victimised twice over.

Immediate Needs Sidelined by HIV

Wildly exaggerated estimations of how many lives could be saved by mass male circumcision or universal HIV testing and treatment grab the headlines. But stories about being able to save two million children a year who are dying from diarrhoea don't seem to attract so much attention. The treatment for the acute diarrhoea that kills children, an oral rehydration solution of a pinch of salt and a handful of clean water (CLEAN water!), just doesn't jingle the way expensive programmes and drugs do.

Another thing that doesn't grab headlines is something like a nutrition programme that targets starving children. Free meals in a school in Tanzania has had the effect of increasing attendance and allowing almost all children to graduate from primary to secondary school. Before the programme started, pupils who made it to school were too tired and undernourished to concentrate and most failed to finish primary school. Mainstream media has a taste for good news sometimes, but this seems to lack the high sugar content that appeals to them.

If children just turned up at school to be fed and then left or didn't bother to do any work, this programme would be disappointing. But the fact that they were enabled to go on to secondary school means that the programme could have many benefits aside from nutritional and educational. According to the most recent figures, fewer children go to secondary school in Tanzania than in Kenya or Uganda. And only around 1% go to tertiary level education.

One of the problems with current HIV prevention programmes, the ones that are implemented in schools, anyhow, is that the general level of education in the country is low. I have met people who, at the age of 15, started having sex, usually with an older partner. That's not the surprising bit; the surprising bit is that they didn't know what sex was or if they did, they didn't know that that's what they were indulging in.

I came across a paper about reproductive awareness among adolescent girls (10-19 years) in Bangladesh and many had incorrect knowledge or misperceptions about reproduction, the fertile period, STIs and HIV. This is often connected with the educational status of girls or that of their mother. 18 out of 20 married adolescents who had recently given birth didn't understand why they had become pregnant. Most had never heard of STIs and while 40% had heard of HIV, only 20% had knowledge about how HIV is transmitted.

Many girls experience sex of some kind in their teens, whether they chose it or not. Most of them know so little about sex that they don't know how to avoid doing what someone is coercing them into doing, they don't know how to negotiate precautions, such as using a condom, they may not even know what condoms are, where to buy them or how to use them. To understand what safe sex is, children need to understand what sex is. There is no evidence that teaching children about sex encourages them to try it, all the evidence is to the contrary.

Many school based programmes have had little effect except to give people a superficial ability to answer questionnaires about sex in the required manner. Well educated young people are ones who can make decisions, negotiate, relate to other people at a level other than a reflex level, where they simply say things like 'sex is bad' or 'abstinence is the safest sex' or whatever brainless platitude is the current favourite. People need to learn to think, not just repeat what they are told to think.

Even adults are confused about the 'ABC' strategy, Abstain, Be faithful, use a Condom. The word ‘abstain’ is widely misunderstood, or ignored where it is understood (I certainly ignore it); being faithful is sometimes understood as meaning that it is ok to have other partners as long as your main partner doesn't know; and condoms are a somewhat exotic commodity that used to be really common a few years ago. You can still get condoms free of charge sometimes but, apparently, the free ones are not as common as they used to be. (A packet of three condoms made in Tanzania costs the price of a small bottle of soda. A packet of three produced in rich countries cost about four times that much. Some splash out for the local brands but others spend the money on soda.)

Children (and adults) have rights, that are enshrined in the Universal Declaration of Human Rights, to a good level of nutrition, water and sanitation, health and education. There is nothing in the declaration that says they only have the right to remain HIV negative and to other rights only insofar as they maintain a HIV negative status. HIV is just one aspect of development and underdevelopment. To many, it doesn't even matter that much compared to the urgent need for something that the lack of will kill them very quickly.

HIV has deflected attention from vital areas of development. In fact, many HIV prevention and care programmes have poor results because most areas of development, such as health, education, social services, infrastructure, governance, human rights and equality, have been ignored.

Generic Drugs are Counterfeit, Say Kenyan Government

When pharmaceutical products first became available to treat HIV, they were far too expensive for most people to afford, especially in developing countries. Yet, the majority of people in need of treatment for HIV live in developing countries. So, how could pharmaceutical companies fix a price that would allow them a staggeringly high profit margin but also a large volume of sales?

HIV treatment (antiretroviral treatment or ART) is still very expensive, and that's just the drugs. It's still unaffordable to most people, but pharmaceutical companies have successfully lobbied donor governments to pay for the drugs. That gets rid of one problem, how to maximise profits for pharmaceutical companies.

But then there was another problem. Some countries who had the capacity to do the requisite research and planning and production are now producing generic equivalents of HIV drugs. These are much more affordable but this is a terrible headache for pharmaceutical companies. Of course, they are not too worried, most aid money for HIV goes to buying the branded, expensive drugs. Very little is allowed go to generics.

In Kenya, the pharmaceutical companies don't seem to have had much problem. The government produced a piece of legislation that doesn't distinguish between counterfeit products and generic equivalents. Perhaps the Kenyan government thought it was better to buy products that are tens or even hundreds of times more expensive. After all, they are not paying for them. Or perhaps someone nobbled the Kenyan government, it's hard to know. But the legislation makes sure that generics from any country can be considered counterfeit and this is very useful to the pharmaceutical companies.

There are hundreds of thousands of Kenyans in need of ART in order to stay alive and raise their families. Many of them are not on ART because the business of rolling out the drugs is slow. And because so little money is being spent on preventing new infections, the number of people requiring ART continues to increase. In fact, most of the money being spent on HIV prevention goes to programmes that have little influence on transmission of HIV or any other sexually transmitted infection.

I agree that treatment is part of prevention; people who are on treatment are less likely to transmit HIV if the treatment is working properly. But it's not good enough to spend, say, 50% of the 15 billion dollar President's Emergency Fund for Aids Relief (PEPFAR) on treatment when only 20% is going on prevention, especially as many prevention programmes have fairly dubious benefits.

It wouldn't be so bad if some of that 50% is going on something other than drugs. People on ART need more than just drugs, they need a lot of palliative care, a lot of monitoring, good health care, economic and moral support, good levels of nutrition, etc. Perhaps if pharmaceutical companies were to provide these things, donor money would be spent on them. As it is, many people get the free drugs but little else.

Those on ART who are not taking the drugs in the prescribed way, or who are not responding to the treatment for some reason, may turn out to be like the 80% of Kenyan's who don't know they are HIV positive; they could be continuing to have sex, not knowing that they are may be as infectious as people not on ART. Even worse, they may be spreading a resistant strain of HIV.

Resistance is most worrying in Kenya because it could take some time to identify people who are carrying resistant strains. Health and social facilities are not strong enough to monitor people adequately. Many get the drugs and disappear, for some reason or other. Others struggle to get the treatment they need but they don't know if they are or are not responding to the treatment until they become ill. By this time, their life and the life of their partner may already be at risk.

Resistance is a good thing, though, if you are a pharmaceutical company. People who are resistant to 'first line' drugs are usually put on 'second line' treatment. This is far more expensive, meaning higher profits. So if people fail to take their ART drugs properly, that could help the pharmaceutical companies greatly.

The Indian government is protesting because similar legislation is planned in other African countries, one of their biggest markets. And it's not just HIV drugs that are threatened, also cholera, malaria, hepatitis and malnutrition. This is not what Kenya or any other African country needs.