Kenyan Health Care Suffers From Underfunding and Corruption

Following recent remarks by Kenya's Health Services Minister, Professor Anyang' Nyong'o, to the effect that there major problems with health care provision in the country, there have been a couple of other articles on the same subject.

One of them calls for greater investment in the health sector and suggests that problems in the sector are common knowledge. The article is not very specific and doesn't cite the study it purports to be referring to but it mentions inadequate staffing, drug shortages, lack of equipment and paucity of facilities.

The article claims that conditions are worse in rural than in urban areas, which is debatable, but it says that the rural, slumdwelling poor "simply lack access to quality health services". Indeed, I'd say that in some places people lack access to any health services, quality or otherwise. Staff shortages, the article goes on, leads to the use of shortcuts, longer procedures are avoided and quick fixes are widely used.

Apparently corruption is also a problem in the health sector and "Provisions to public health facilities end up in the hands of crooks, who sell them to private hospitals." The article concludes by calling for more investment, but perhaps any finance or resources involved need to be more carefully monitored as well.

Another article deals specifically with corruption and mismanagement in the sector. Both the Medical Services and the Public Health ministrys are mentioned (there are two on account of the power sharing agreement made following the post-election disputes in 2008). This article also mentions shortages of drugs and poor supervision.

According to the article, the report by the Kenya Anti-Corruption Commission "found absenteeism by medical staff, flawed procurement processes, theft of drugs and other medical supplies, and unnecessary referral of patients to private clinics as major forms of corruption." There is also, apparently, a lack of clarity about fees that patients are charged.

Minister Nyong'o specifically draws attention to the possible contribution that unsafe health services could make to the HIV epidemic and various other blood borne viruses. But the health problems that Kenyans face are numerous. In addition to greater awareness about these there should also be far more spending on safe health care that is accessible to everyone.

Nosocomial and Iatrogenic HIV Transmission in Kenya

I have mentioned non-sexual HIV transmission, and especially transmission through unsafe health care, on a number of occasions. However, some people have interpreted such phenomena in very different ways. Though I have never claimed it, some people seem to think that I am saying that most HIV transmission in Africans countries is non-sexual. I am not claiming this, only that a lot of HIV transmission could be non-sexual and a lot of the 'evidence' for sexual transmission is being manipulated, even though it points to something other than sexual behavior as being behind very high rates of transmission.

Nor am I claiming that every person who visits a health facility is at the same risk of being infected. Even in countries with very high prevalence of HIV and other blood-borne viruses, this doesn't mean that HIV transmission in health facilities is common. Safety and hygiene may be a priority most of the time. Even if the odd procedure is missed now and again, this doesn't mean someone is likely to be infected through a medical procedure. For a start, equipment used needs to be contaminated. And even then, the probability of being infected might only be a few percent.

Most health professionals may follow guidelines religiously. The worry is when there is a shortage of equipment, a lack of clarity about roles or procedures, a temporary drop in vigilance. The fact that such events don't often occur might make them even less likely to be spotted in time. But even when such things go wrong, they still might not give rise to a high risk of people being infected with HIV or anything else. It depends on many circumstances.

I argued recently that sexual transmission of HIV, being quite inefficient, cannot give rise to infections quickly enough or in high enough numbers to explain very serious HIV epidemics like those found in many Southern African countries, or even those found in East Africa and other countries with medium epidemics. I used the terms 'Mediocristan' and 'Extremistan' from Nassim Nicholas Taleb's book The Black Swan and suggested that sexual transmission of HIV is a phenomenon of Mediocristan but that transmission in health facilities is from the realm of Extremistan.

In other words, medical transmission of HIV may not happen all the time, it may not even happen very much. But when it happens, it can affect large numbers of people. Some events may not affect many people, they may just peter out without anyone noticing. Perhaps a few infections will be found, of HIV, hepatitis or something else. But they may never be identified as medically transmitted. This sort of event is still one of Mediocristan. But if the conditions are right and some unsafe procedure results in HIV being transmitted, the number infected could be very high. Inordinately high rates of transmission are possible in health settings that are not possible through unsafe sexual behavior, no matter how much of it may take place.

There have been quite a number of documented (though mainly uninvestigated) outbreaks of HIV that have taken place in medical facilities. These have taken place in both rich and poor countries. The only difference is that in rich countries it is possible to recall and attend to tens of thousands of people. And the risk of infection is not too high if HIV and prevalence of other blood-borne diseases is low in the population. But in poor countries, even if the possibility of an outbreak is noticed, it is unlikely that their health services will have the capacity to investigate, let alone identify all those infected.

So, I am not saying that most HIV infections in Kenya, for example, come from some kind of medical treatment, possibly unsafe injections. I'm saying that in a medium prevalence epidemic, such as Kenya's, some non-sexual transmission must have occurred, especially in areas like Nyanza. There, prevalence is exceptionally high among members of the Luo tribe. Also Western province, where prevalence is exceptionally high among Luhya women. There are probably still plenty of medical transmission events occurring and, if not, there probably will be some in the future.

In countries with the highest HIV transmission rates, such as Swaziland, Zimbabwe, Namibia, Botswana, South Africa and others, medical transmission is likely to contribute a far bigger proportion of infections than in lower prevalence countries. Access to health services is also quite high in these countries. But some of the lower prevalence countries, such as those in East Africa, have lower levels of health services, accessible to far fewer people. And there are many low prevalence areas that also have low access to health services and high prevalence areas with high access to health services. So this connection, if it really is a connection, needs to be investigated.

There are other non-sexual risks relating to HIV transmission, such as through cosmetic practices, head, face and body shaving, manicure, pedicure, tattooing and others. These probably happen, but the question of how often is an empirical one. In countries where most people don't attend medical facilities very much, an epidemic could bump along at a relatively low prevalence for years, much as it has done in Kenya, Uganda, Tanzania and various other countries, with all modes of transmission contributing a steady proportion.

An increase in medically transmitted infections could have quite a profound impact on prevalence, but there's no reason why such an outbreak should be noticed. Or rather, the effects of the outbreak might only be noticed little by little and might not seem like an event with a single, identifiable cause. Especially if no one is looking for the cause or they assume there was a sudden spike in 'unsafe' sexual activity, the extent of which surpasses credibility, if anyone was worried about what is and is not credible about African sexuality.

This is why I have drawn attention to the comments of the Kenyan Medical Services Minister, Professor Anyang' Nyong'o. He has alluded to the state of Kenya's health services, shortages of personnel, overuse of injections, unsafe practices and the consequent risks of nosocomial transmission of HIV, hepatitis and other blood-borne diseases. Now that the country is aware of this risk, it's time to take steps to improve safety in health facilities and rethink the approach to HIV that limits itself to lecturing people about what they should and shouldn't do in their private lives. People need to be aware of the serious non-sexual risks that exist and they should be made aware of how to avoid such risks.

The yearly rate of new HIV transmissions in Kenya may presently be low. Sexual transmission, I would argue, is always low; cosmetic and other practices may also contribute very little. But in a country with health service provision as poor as Kenya's, it's only a matter of time before a significant outbreak occurs. Some significant outbreaks may have already occurred, surveillance is far to low to detect such an event. Unless UNAIDS and others with control of finance and policy are prepared to, like Minister Nyong'o, accept that nosocomial transmission takes place, has always taken place, and will continue to take place, HIV epidemics in African countries will never be reduced, let alone eradicated.

Will Kenya Challenge UNAIDS Over Health Care Transmitted HIV?

Despite resolute denial from UNAIDS and other parties that a significant proportion of HIV transmission could be from medical procedures, injections in particular, there is at least one Kenyan politician who disagrees. And he is the Medical Services Minister, Anyang' Nyong'o.

Mr Nyong’o is quite frank about problems in health care provision, especially for poorer people. He points out that between 33 and 50% of Kenyans are taking the wrong drugs and up to 75% of antibiotics in Africa are prescribed inappropriately.

The minister has drawn attention to shortages of nurses, with only about one quarter the number required to meet WHO guidelines. There are also shortages among other health care personnel and overall standards are deteriorating.

Of particular importance, the minister said that there is “widespread use of the injection and prevalence of unsafe practices which put communities at risk of blood-borne diseases like Hepatitis B and C and HIV.” This is a courageous remark to make in the current climate of denial about blood-borne infections, in particular HIV. If UNAIDS could excommunicate, they would surely excommunicate the minister.

This is not the only courageous statement I have heard recently about blood-borne HIV. A Ugandan journalist, James Lutaaya, said in relation to criminalization of HIV transmission “The deliberate infection Uganda wants to prosecute…would not involve sexual relations as it is relatively unlikely that sex will lead to HIV infection...hence sex would be a very ineffective method of passing on HIV if someone was really intent on doing so.”

Lutaaya is right, but this is not the orthodox view. According to the orthodoxy, HIV is almost always transmitted sexually in African countries, despite there being little evidence supporting this view.

Interestingly, Lutaaya refers to the case of Nadja Benaissa, who was given a two year sentence for knowingly spreading HIV. Lutaaya feels that both Benaissa and the man she is said to have infected (the court didn’t have to prove that Benaissa infected him) share equal responsibility. That may be so, but the case also highlights another serious problem with prosecuting in such circumstances. The man Benaissa is said to have infected could have already been infected and he could have been fully aware of this. He could have been guilty of the same crime for which Benaissa was given a suspended sentence, yet he wasn't tried for such an offence.

Because the orthodoxy assumes sexual transmission and Benaissa, who knew she was HIV positive, had unprotected sex with the partner, it is also assumed that she infected him sexually. She may not have infected him at all, or she may not have infected him sexually. He could have been, as mentioned, already infected. Or they could have shared injecting drug equipment or some other form of exposure may have taken place. Certainly, the probability of her infecting him sexually by having unprotected sex with him a few times is very small indeed.

A woman is far more likely to know her HIV status, especially if she is or has been pregnant. It is also harder for her to hide her status, especially in countries where testing is routine for pregnant women. A man is less likely to know his status and more likely to be able to keep his status confidential. This doesn’t exonerate Benaissa, but it shows that the law is counterproductive if it aims to reduce HIV transmission. And its negative impacts will affect women far more than men.

The insistence that HIV is almost always sexually transmitted in African countries, or anywhere else, is quite illogical. Non-sexual transmission of HIV and other blood-borne viruses is not uncommon, even in countries where health spending per head of population is very high.

Per capita health expenditure in the US is over $7,000. But a possible two and a half thousand people were recently exposed to risks of blood-borne HIV, hepatitis B (HBV) and hepatitis C (HCV) virus in a government run hospital in the US as a result of unsterile equipment. Five thousand have been notified that they might have been exposed to similar risks because a radiologist with a drug problem and suffering from HCV used injecting equipment that was then used on patients.

In Australia, where per capita health expenditure is over $3,000, an anaesthetist with a drug problem has infected some patients, although it’s not quite clear how the infection was transmitted.

In African countries, per capita expenditure on health is about $10, on average. In Kenya, it’s about $6. The least UNAIDS, WHO and other institutions could do is investigate the extent to which HIV is transmitted non-sexually. Their claims about HIV almost always being transmitted sexually are no longer reassuring for the many people who have been infected and know they could not have been infected sexually. Perhaps Minister Nyong'o will take up the matter and challenge the ruling elite of the HIV/AIDS world?

The Limits of Human Promiscuity

In response to a raft of articles challenging the view that heterosexual transmission is by far the major mode of spread of HIV, 15 academics penned a paper that concluded that “there is no compelling evidence that unsafe injections are a predominant mode of HIV-1 transmission in sub-Saharan Africa”. One of their ‘main arguments’ is that “Unsafe injections are not sufficiently common to play a dominant part in HIV-1 transmission in Africa”.

But how common do unsafe injections need to be? Even the WHO accepts that up to 40%, and in some areas, as much as 70% of medical injections are unsafe (also that as much as 70% could be unnecessary). They accept that 30% of hepatitis C (HCV) and 40% of hepatitis B (HBV) is transmitted through unsafe injections.

Another of their arguments against medical transmission of HIV is that “Transmission efficiency of HIV-1 for injections in African health-care settings is overestimated and is far less than 2·3%”. Ok, but what is the figure and how does that refute the significance of the WHO’s findings? And what about other procedures, aside from injections? UNAIDS has acknowledged that little is known about unsafe injections, yet they seem very confident in dismissing their contribution to HIV epidemics in African countries.

This group of academics suggest that “Analyses to assess the association between a history of injections and HIV-1 infection do not adequately take into account reverse causality and confounding”. And what analyses have they and their colleagues in the HIV industry carried out? There is such a thorough lack of papers on nosocomial and/or iatrogenic HIV transmission, anyone would think that the industry was afraid of what such research may reveal. If analyses to date have been lacking, they don’t seem in a hurry to fill the gap in our knowledge.

The authors seem to be suggesting that those who receive a lot of injections may already be infected with HIV and, therefore, suffer from a lot of illness. But this simply underlines the need for further investigation. They claim that people who get a lot of injections may be receiving treatment for sexually transmitted infections (STI), so they are already at risk of being infected with HIV. But there is still a danger that people receiving injections for any reason, including STIs, are at risk of being nosocomially infected with something they don’t already have.

Many people receiving injections for STIs do so in clinics that specialize in STIs and have a lot of clients who have multiple risks for STIs and other blood borne viruses. This doesn’t mean they must all have been infected sexually. Rather, it could point to clinics being even more hazardous than previously recognized. They have a tendency to concentrate those most likely to be infected with HIV in the one place and thereby increase their risk.

Their argument that “Apart from mother-to-child transmission, HIV-1 infection is rare in children” is swiftly dealt with in a paper by Savanna Reid, who points out that childhood prevalence does not increase with age because many HIV positive children die. Indeed, the number of cases of infants and children who are HIV positive and their mothers are HIV negative has long been a cause for concern. Yet it has gone uninvestigated by the industry.

They have a few other ‘main arguments’ but almost everything they claim seems to follow from the ‘behavioral paradigm’, the belief that almost all HIV transmission in African countries is through heterosexual sex. Every piece of evidence that appears to challenge the paradigm is dismissed as being impossible by reference to the paradigm itself.

One must ask, what level of HIV transmission from unsafe injections would be acceptable? When the mere possibility of nosocomial infection occurs in Western hospitals, such as in the UK, the US or Australia, tens of thousands of people are recalled and tested for blood borne infections of various kinds. This never happens in African hospitals, despite there being ample evidence that such infections occur. Even UNAIDS' 'estimate' of 0.6% transmission still represents thousands of preventable infections.

Although I think the (predominantly) heterosexual transmission theory of HIV in Africa is grossly under-supported by evidence, this is not the only objection. There seems to be a complete lack of fellow feeling among those who cling to the theory, a lack of humanity. I believe that some people all over the world have a lot of sex, but most don’t. And I don’t believe anyone, let alone the majority of people in a handful of countries, can possibly indulge in levels of sexual activity that would explain HIV prevalence levels found in these countries. But such perverse views as the behavioural paradigm are the orthodoxy.

The ‘Unknown Knowns’ of HIV Epidemiology

In his book ‘The Black Swan’, Nassim Nicholas Taleb distinguishes between two realms, Mediocristan and Extremistan. The law of Mediocristan is: when your sample is large, no single instance will significantly change the aggregate or the total (p32). The law of Extremistan is: inequalities are such that one single observation can disproportionately impact the aggregate, or the total (p33).

An example from Mediocristan that Taleb gives is of sex workers, who can’t scale up their workload beyond a certain number of clients per hour or day (p27). Their earnings, no matter how high, are limited. In contrast, a successful financial trader can earn (or lose) more in one day than in their entire career. The financial trader’s job is scalable and is from the realm of Extremistan.

Wars used to belong to Mediocristan but modern technology makes it (theoretically) possible to wipe out whole populations, cities or even humanity in a single act (33-4). I would argue that it is also possible to infect huge populations with a virus through modern technology. There have been many documented instances of this.

Therefore, HIV, being difficult to transmit heterosexually, is stuck in Mediocristan. Despite the best attempts of UNAIDS and others to claim that sex workers can become infected and infect many others in a short space of time, a HIV epidemic driven by sexual transmission alone would never reach very high levels. The HIV epidemics of most countries, UK, Germany, USA, Australia, etc, are safely inside Mediocristan.

But there are countries where levels of HIV transmission can not be explained by heterosexual transmission alone. Prevalence figures in these countries, especially in certain groups within these countries, are extreme. In fact, they appear to be from the realm of Extremistan. There is a limit to how high they can go and, thankfully, none have reached 100% yet. But the highest prevalence figures can be hundreds of times higher than the lowest.

An example that stands out comes from Nairobi in the mid 1980s, only a few years after HIV was identified and not long after the virus probably reached Kenya. Prevalence among sex workers was found to be 4% in 1981 and it had increased to 61% by 1985. By what means were these women infected? In order for four sex workers to (indirectly) infect 61 sex workers (to keep the numbers simple) in the space of four years, how many men would they have to infect? Because the 61 would have been, according to the sexual transmission theory, infected by HIV positive men.

In 1980 in Nairobi, a particular sample of men being treated for a sexually transmitted infection was found to contain no HIV infections. In 1985, a similar sample had a prevalence of 15%. Unless the sex workers were all having enormous amounts of sex with a handful of men, these findings are completely inexplicable. Even over a longer period of time, such as fifteen or twenty years, such high sexual transmission rates are not credible. And over that length of time, most of those originally infected would be long dead.

Even less explicable are the HIV prevalence figures for people who are neither sex workers nor sex worker clients. Prevalence for Swaziland as a whole is in the mid twenties. For young, sexually active women, figures are in the thirties and forties, though they remain consistently lower for men at any age. What kind of amounts of sex could these women be having? And with whom could they be having so much sex? In order to become infected sexually, they don’t just need to have lots of sex, they also have to have lots of sex with HIV positive men.

Rather than imputing inhuman feats to Africans, as UNAIDS and their friends have been doing for many years, it is worth looking at where very high rates of transmission could come from. And the obvious source for transmission rates that could only come from the realm of Extremistan is unsafe health care (and possibly unsafe cosmetic practices).

A clinic could give hundreds of injections a day. Vaccination programs can cover tens of thousands, even hundreds of thousands of people, in a very short period of time. It could take years, even decades, for one HIV positive person to infect a few more, and for them to go on and infect others. But unsafe injections could, potentially, infect hundreds or thousands in far less time.

I’m not claiming that current HIV epidemics in African countries are Black Swans, because the risk is not incomputable. It’s just very high. The knowledge required to prevent these transmission events from happening does not consist of ‘unknown unknowns’. Far from it, the knowledge required consists of ‘unknown knowns’, information about the efficiency of transmission through unsafe health care, coupled with information about the quality of health care available in high HIV prevalence countries.

UNAIDS and their collaborators have gone through a process of ‘unknowing’ things that have long been well-established, sometimes by their own employees. But rather than investigating the many instances of health care transmission of HIV, they have built up a literature that simply ignores the very possibility of such transmission. Occasionally, nosocomial and iatrogenic transmission are mentioned, only to be dismissed as very slight and unimportant.

Documented outbreaks of HIV from medical procedures have identified hundreds, even thousands of infected people. Disturbingly, most of these outbreaks have never been investigated to find out how many people have been infected. One of the most infamous outbreaks occurred in Romania in the 1980s, thought to have infected about 10,000 children. No search was made to identify all those infected. An estimated 100,000 were infected in China but again, no effort has been made to identify all those infected.

There are plenty of other outbreaks like these. A number of African countries have estimated the proportion of incident HIV infections caused by unsafe injections. The median is 19% but Malawi estimated in the early 2000s that 54% of HIV infections in women were attributable to injections. That’s a lot higher than the UNAIDS estimates of 2.5% or less for Kenya and other countries.

Where HIV prevalence figures are extreme, as they are in many African countries and regions, transmission rates must also be extreme. It is not possible for such extreme rates to occur from even the highest levels of sexual transmission imaginable. But such high rates could come from unsafe medical practices. And this is what needs to be investigated.

It may be a mammoth task to investigate and eliminate such practices. But it is a mammoth and pointless task to shake a warning finger at half a billion Africans and tick them off about their sex lives when sexual behaviour is clearly not the main problem.

Such investigation is vital because the one or two people that a sexually active HIV positive person might infect in their lifetime is dwarfed by the hundreds or thousands that health facilities may be causing or may cause some time in the future. Everyone infected, whether sexually or non-sexually, can go on to infect others sexually or non-sexually. If they infect others sexually, the resulting number may be low. But if their infection becomes part of a health facility based outbreak, as any single infection could, the numbers infected as a result could be very high.

Unsafe Health Care and Risk of HIV Transmission

Frederik Joelving, in an article entitled ‘Did Doctors Jumpstart the HIV Pandemic?’, looks at the recent research which finds that public health programs carried out 50 to 80 years ago may have played a part in spreading HIV. I mentioned this research recently. But it’s interesting to hear what the scientists involved have to say to a journalist.

According to Joelving, “What is still a matter of debate is how a blood-borne disease infecting one or a few individuals in a remote area could ever spread to the more than 33 million people who were infected by 2008, and kill two million of them.”

However, Thomas Strickland, one of the researchers, says "Everybody now is getting infected from having sex”. This is not the case. HIV has never been entirely sexually transmitted and the extent to which it is sexually transmitted is not known.

Worse still, Strickland goes on to say that sexual transmission is not very efficient and that “You can have heterosexual sex ten or fifteen times without getting infected.” Heterosexual HIV transmission is far less efficient than that. Transmission risk is very contentious but estimates run into hundreds or even thousands of sex acts (Risk of transmission of HIV varies from 1 in 200 to 1 in 10 000 coital incidents, depending in part on the integrity of the vaginal epithelium.)

Strickland is right in stating that “if you get injected with a contaminated needle, the risk is much higher”, but he seems to assume that the chances of being injected with a contaminated needle nowadays are pretty low because standards of hygiene are high. Standards are not high in many countries, Kenya being just one.

It’s a pity that this research has been interpreted so narrowly but there are even narrower views. One Michael Worobey blames urbanization and prostitution for the eruption of HIV from a rare virus to a global pandemic, whereby “an infected villager made his way to the city, setting off the HIV epidemic like a spark falling on a dry savanna.” Worobey goes on: "I think a train is a much better way to get a virus to a city than a needle".

Somehow, I think a needle is of far more danger than a train when it comes to spreading viruses. As for the urbanization explanation, this just doesn’t wash. In a paper entitled ‘Spatial phylodynamics of HIV-1 epidemic emergence in east Africa’, the authors conclude that migration, population growth and warfare contribute marginally to the spread of HIV.

The authors do show that transport infrastructure was vital to the spread of HIV over long distances. But they don't show that once the virus arrives in distant places, that it must have been spread sexually.

Jacques Pepin feels that both reuse of needles and sexual transmission are compatible and that both probably contributed to the pandemic. But he argues that “single use needles are now commonplace” and that “unprotected sex is the major reason people get HIV”. Perhaps he doesn’t read publications from the WHO (though who could blame him?).

Sexual transmission is, as mentioned, not very efficient. There is a limit to the amount of sex and sexual partners a person can have. Their chances of having a HIV positive partner may increase as an epidemic spreads. But even if someone had hundreds of sexual partners a year, the risk per sex act is still low. In other words, most people will only transmit HIV a small number of times through heterosexual sex, if at all.

In contrast, if a hospital or clinic is giving injections with unsterilized equipment, the risk of infecting patients is many times higher than the risk of sexual transmission. Not only that, a single health practitioner can potentially infect many people per day, week or year. People infected through unsafe health care can also transmit HIV sexually, though they are no more likely to do so than those infected sexually. And every HIV positive person treated in a health facility that engages in unsafe practices can give rise to more HIV transmission. The potential for health care transmission is of a different order of magnitude than that for heterosexual transmission.

Research to quantify the contribution that unsafe health care makes to HIV epidemics in African countries would not require groundbreaking techniques. Normal infection control investigations should be able to establish levels of unsafe practices in hospitals and clinics and measures to reduce such practices are well known in Western hospitals. But even researchers doing groundbreaking work seem unwilling to upset the orthodoxy.

HIV Incidence Has Been Declining Since Before UNAIDS Was Established

A couple of recent studies lend considerable support to the theory that HIV was originally spread widely throughout Africa via unsafe injections (cited in this article). In the first half of the 20th century, syringes and needles were frequently reused without being sterilized, with the result that various blood-borne viruses were transmitted to very large numbers of people.

The article also claims that medical procedures are now safer, which may well be true. There has certainly been awareness among health professionals since HIV was first identified that the virus can be transmitted through unsafe injections. As a result, some countries introduced strict health care guidelines, some even enforce them.

But countries with underfunded and declining health services, like Kenya, may still be transmitting HIV and other viruses in this way. It's difficult to be sure or to say exactly how much this may be contributing to the country's epidemic because UNAIDS and the rest of the HIV industry have little interest in investigating. But the state of Kenya's health services, according to a Service Provision Assessment, suggests that many people are probably not accessing health care services at all; and the ones that are could be receiving low quality and unsafe health care.

One of the big mysteries about HIV is how it quite suddenly went from being rare and difficult to transmit sexually to becoming a pandemic, reaching extremely high levels in some African countries. And this is without becoming any easier to transmit sexually.

This led to some pretty racist theories about African sexual behavior which now form the orthodox view of HIV in Africa: that 90% of transmission is through heterosexual sex. The orthodox view sometimes cites high rates of urbanization as giving rise to increased levels of 'unsafe' sexual behavior.

However, urbanization trends started before HIV emerged and it's still happening. There are plenty of places where urbanization is high, even in Africa, but HIV prevalence, the number of people living with HIV, is relatively low. Yet HIV incidence, according to UNAIDS, has been dropping for some years. Having said that, even in countries where urban rates of transmission have gone down, rural rates can be going up.

Of course, holding such views as they do about African sexuality, UNAIDS and the industry claim that incidence has been declining because unsafe sexual behavior has gone down. And they claim that their policies and prevention interventions have been behind the decline in unsafe sexual behavior.

In reality, there is no evidence that African sexual behavior is extraordinary enough to give rise even to a relatively low rate of HIV transmission, let alone the high rates of transmission that have been seen in some African countries. Nor is there evidence that sexual behavior has changed significantly. And there seems to be little correlation between knowledge and behavior relating to safe sex and HIV transmission rates. In fact, it has long been clear that most HIV prevention interventions don't have any impact on HIV transmission.

Recent press releases by UNAIDS, the marketing and publicity wing of the HIV industry, widely copied and pasted by the world's press, now claim that incidence, the yearly transmission rate of HIV, has declined. And this is very likely to be true. Except that incidence rates have been declining since long before any of the current rash of prevention interventions had begun.

Incidence rates in Kenya peaked in the early to mid 1990s and have never returned to levels seen then. Among sex workers in Nairobi, HIV incidence peaked in the mid 1980s. Incidence peaked earlier in Uganda than Kenya because Uganda's epidemic started earlier. Again, incidence levels have never returned to those seen at the peak of transmission. Why? We just don't know.

The Kenyan government hadn't even got around to accepting that there was a HIV epidemic in the 1990s. The various prevention programs, such as they were, didn't get started until some time in the 2000s. By this time, prevalence had been falling for years. It would do, given that incidence had peaked and declined about ten years previously. And prevalence rates kept falling because death rates were peaking at about this time.

Embarrassingly, the time that Kenya started plugging the various prevention programs paid for by the global HIV industry was also the time that the rate of decline in incidence probably reduced. Prevalence now is at the same level as it was at in the early 2000s. It could be claimed that prevalence remains high because many people are on antiretroviral (ARV) treatment and so are living for longer. But death rates of people on ARVs are probably quite high, too. It's hard to tell because so many are lost to follow up. Health record keeping is not one of the health service's strong points.

But then, despite using words like 'evidence', 'evidence-based' and 'evidence informed' a lot in their publications, UNAIDS doesn't seem to distinguish between genuine evidence and something published by people who get paid very well to say the right thing. It would be unfair to suggest that all UNAIDS policy is based on prejudice and research of dubious provenance, and I wouldn't want to give that impression. They also rely heavily on not talking about anything that may undermine the orthodoxy. In this respect, most academics and all the global media support and defend them vigorously.

(For discussions of Pre-Exposure Prophylaxis, seem my PrEP Blog.)

HIV Has Always Been Good News for Ambulance Chasers

I recently mentioned that there is some evidence that the aims of the mass male circumcision campaigns currently taking place in some African countries might also be achieved by provision of soap and water. But yesterday, I mentioned that soap and water are not even available in most health facilities in Kenya. Those findings are pretty shocking, but some researchers recently found that fishermen operating in Lake Victoria are reluctant to ensure their own genital hygiene for various reasons, including that they don't wish to wash their genitalia in public.

This is quite understandable. Few people would wish to wash their genitalia in public. But the authors of the paper recommend penile microbicides, which they can apply in the 'privacy of their bedrooms'. People who do not have the privacy to wash themselves properly probably do not have privacy in their own bedrooms, either. Many people, by no means the poorest, live in one and two room houses, shared with other members of their family.

If the problem is lack of hygiene, and soap and water is adequate to solve the problem, why bring in penile mcirobicides (unless you are trying to promote them for commercial reasons)? UNAIDS review the article in their weekly 'Good News for Ambulance Chasers' and note that penile wipes have been used in the past. Great. But if people can find a private place to use a penile wipe, with or without a microbicide, then they can also apply soap and water.

Lack of penile hygiene is cited as an argument for mass male circumcision. But this research claims that there is also a traditional proscription against fishermen washing with soap and water. I don't really see how this would make the case for penile wipes or topical microbicides. But there is also a traditional proscription against circumcision among the dominant Luo population.

If the stories about the success of mass male circumcision campaigns in Luo areas are true, the proscription against use of soap and water can also be overcome. But the HIV industry seems very keen on circumcision, regardless of how little it may affect HIV transmission in the long run. The Ugandan government is now also offering 'free' circumcision. Rates of circumcision are even lower in Uganda than they are in Kenya, but conditions in hospitals are similar.

Would you go for an operation on your penis in a country where health services don't guarantee running water, soap and adequate supplies of latex gloves, injecting equipment, sterilizing equipment, disinfectant and pain killers? Consider the question rhetorical. But the point that needs to be made (apparently) is that people are in need of things like water and sanitation more than they are in need of pharmaceutical products and trendy cosmetic operations.

As for privacy, this points to a need for improved housing conditions. But that need, like the need for water and sanitation (education, infrastructure, health and other social services), long predates the need for HIV interventions. Indeed, they are all prerequisites for the success of HIV interventions and it is their lack that has resulted in many HIV interventions having no impact on HIV transmission. The more technical solutions can wait. In fact, they have to wait until far more basic rights have been provided for.

(For discussions of Pre-Exposure Prophylaxis, seem my PrEP Blog.)

Concentration Clinics for the Usual Suspects

The WHO have just finished a forum on medical devices and they note the lack of access to such equipment in developing countries. However, developing countries have a far bigger problem than that. There are also too few medical facilities, too few trained personnel and too few drugs. As a result, in many developing countries the majority have little access to health care. And in some countries, access to health care is relatively high but the quality of the health care is very low.

Anyhow, the WHO does conclude that up to 40% of injections are unsafe in developing countries, probably around 6 billion or more injections. This is a particularly interesting figure for a country like Kenya, where UNAIDS insists that HIV transmission through unsafe injections only accounts for between 0.6 and 2% of all transmission. If you thought that 40% of injections were unsafe, you might avoid health facilities altogether, as UN employees are advised to do. But if it's the only health care available, many will probably risk it, especially when the alternative is far worse.

But there is a difference between UN employees and Kenyans (and most other Africans). Not only is there no alternative to poor quality care in most African countries but Kenyans and other Africans are generally not aware about the risks they face when they visit a doctor, dentist or other health care practitioner. Even among health professionals there appears to be little awareness of the risks. Therefore, neither health professionals nor patients will take any of the relatively straightforward steps required to reduce the risks.

Making health facilities safe could significantly improve overall health in countries like Kenya. HIV transmission through unsafe health care could be avoided, probably entirely. But also, transmission of hepatitis C and B (HCV and HBV), which are very commonly transmitted in health care facilities, could also be reduced. Kenya's health services are not going to become top class over night, not after decades of neglect, but they could become safer.

But at the rate things are going, even safety is not considered a priority. The percentage of spending allocated to injection safety in Kenya's latest National Aids Strategic Plan is small, less than one percent. And there is an even bigger question mark over where, exactly, this money will be spent. The country doesn't have a very big health infrastructure. More than half of the health providers sampled (supposedly a representative sample) in Kenya are either private pharmacies or otherwise limited to a handful of services.

Kenya's Service Provision Assessment Survey looks at what is available at 440 facilities and reports data on, among other things, 'elements for preventing nosocomial infections', that's infections that are due to unsafe health care. Included are running water, soap, latex gloves and facilities for disposing of 'sharps' (needles and the like). The majority of facilities, about 90%, don't provide all of these basic facilities. More than half the hospitals don't have running water. Similarly shocking figures apply to stocks of things like disinfectant, needles, syringes and latex gloves. In fact, only 3% of hospitals have all three. Most providers don't even have guidelines for infection prevention or sterilization.

The Kenya Modes of Transmission Analysis rather confidently states "It is unlikely that there is much medical injection transmission these days, given the raised awareness (both amongst health professionals and the general public) of the importance of clean needles." The confidence seems particularly unwarranted when they say, much later in the document, "[there is v]ery little information on injections safety - [it is]...hard to get baselines". That's a contradiction that even UNAIDS would be proud of.

Putting the various documentation together, sketchy as it is, the picture of health services in Kenya and other African countries is that they pose a lot of risks for blood-borne infections. Research earlier this decade showed that over 32% of HCV and over 40% of HBV were being transmitted through unsafe injections. In clinics where many of the clients are infected with some blood-borne virus, the probability of nosocomial HIV or other blood-borne infection would be even higher.

Consider, for example, clinics that deal primarily with sex workers and intravenous drug users, even clinics for pregnant women. Current HIV strategies herd together those most likely to be infected with HIV and play a barbaric form of Russian roulette with them and all their other less 'high risk' clients. It's no wonder that HIV is unbelievably high in STI (sexually transmitted infection) and ante-natal care clinics. These clinics are probably the source of much of the prevalence in countries with such deplorable health services.

Some evidence may point to sexual transmission of HIV. But some evidence points to nosocomial transmission, too. Without investigating the considerable evidence for nosocomial HIV transmission, targeting sexual behavior and not bothering about unsafe health care is condemning an unknown number of people to disease, stigma and early death. Given the weight of evidence, it's becoming more and more difficult to understand why UNAIDS and the HIV/AIDS industry continues to insist that, in African countries, HIV is almost always transmitted sexually.

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.

Harm Reduction Needs to Start in Health Facilities

Now that PEPFAR (the US President's Emergency Plan for AIDS Relief) have revised their Bush era decision to refuse funding to harm reduction programs, the Kenyan government may also consider changing their policy towards intravenous drug users (IDU). According to the head of Kenya's National Aids Control Program, addiction will be treated as a health issue and needle exchange, methadone and condoms will provided for IDUs.

Although the contribution of intravenous drug use to Kenya's epidemic is currently estimated to stand at about 4%, this kind of exposure is a highly efficient transmitter of HIV. Heterosexual sex, on the other hand, is not such an efficient transmitter. In some countries, sex workers are only likely to die of Aids if they are also IDUs.

Commercial sex work can be one of the few ways to make enough money to feed a drug addiction. The drugs have to be paid for, but injecting equipment can be, and often is, shared. So a source of clean injecting equipment for IDUs could play a big part in reducing HIV transmission by this route. However, the decision to fund HIV programs that target HIV transmission among IDUs may also allow better estimates of their full contribution towards Kenya's epidemic. It may also allow a better evaluation of the part that commercial sex work plays in the epidemic.

Very few HIV positive IDUs are currently on antiretroviral treatment. Such treatment could significantly reduce sexual transmission of HIV, though it may not reduce non-sexual transmission so much. But giving IDUs better access to diagnosis and treatment should improve conditions for them and reduce further HIV transmission.

Sadly, the Kenyan police force may need more than a change in the law. As long as they and others can make money out of drug users, it's unlikely they will all turn into social workers overnight. Nor are NASCOP in a position to decriminalize drug use on their own. So let's hope decriminalization becomes a reality. If the administrators of PEPFAR can change their minds for ideological reasons, I'm sure the relevant people in the Kenyan government could change theirs for pragmatic reasons.

But any kind of re-evaluation of non-sexual modes of HIV transmission would be welcome in Kenya, in fact, in all African countries. If donors, governments, health professionals and other big players in the HIV scene start to think about highly efficient modes of transmission, as opposed to the low efficiency of most types of sexual behavior, ordinary academics, epidemiologists and others may eventually be allowed to research and publish data that currently appears to be deprecated (to put it mildly).

Those with the money, however they managed to get hold of it, decide how that money should be spent. There's little point in waving a lot of drug addicts in front of donors if those donors are opposed to working with drug addiction. With such restrictions lifted, who knows, drug addiction, and therefore HIV transmission among IDUs (and those they associate with), may turn out to be more common than previously assumed.

Perhaps donors and governments will eventually revise their attitude towards commercial sex work, especially in view of its interconnections with drug use. This could even lead to questions about exactly how much sex has to do with HIV when the far more likely transmitter is non-sexual.

And, it's a long shot, but if the HIV industry is willing to accept that some HIV is transmitted non-sexually, even among people who are said to have a lot of 'unsafe' sex, they may even wonder if ordinary people engaging in ordinary amounts of 'safe' sex are being infected non-sexually too.

Drug users are not the only people who use injecting equipment. More disturbingly, they are not the only people reusing injecting equipment. Some people get a lot of injections, because they are sick, pregnant, an infant, a sex worker, whatever. And in populations with high HIV prevalence, all of those people are at heightened risk of being infected with HIV, non-sexually.

Maybe we’ll live to see the day when sex is viewed once again as an aspect of health and life rather than as a spreader of disease. But first, we have to accept that poor health care can be a significant source of disease. Harm reduction programs, now that health care professionals and governments are allowed to talk about them again, need to start in health facilities.

HIV Industry Withholding Vital Evidence

Some former sex workers in Uganda have set up an organization to represent sex workers , called the Women's Organization Network for Human Rights Advocacy (WONETHA). WONETHA believes that women who are involved in sex work should be supported as sex workers, rather than persuaded to change occupation. Trying to persuade sex workers to find another way of making money may be well intentioned (though it probably isn't). But in addition to not bothering to ask sex workers what they would like, such attempts fail to take into account the economic realities.

If you take a large number of women off the streets and give them other jobs, several things happen. Other women move into sex work, probably attracted by the higher price that sex work receives because there are fewer doing the work. Also, wages in the more conventional job market go down, as a result of more people looking for jobs and employers being able to pay even less than before. There are already lots of people doing some kind of subsistence or low paid work. It's often because they are so badly paid that they get into sex work in the first place.

People here have assured me that it is always possible to get a job or find some way of making money, that it is not necessary to resort to sex work. They don't seem to see that it is the fact that some people are not competing with them for these other jobs that makes it possible for them to find such work. Many other people, too, benefit from sex work, directly and indirectly. Police, security people in bars, clubs and hotels who get money from sex workers to allow them to do their work, other people who 'protect' sex workers or just bribe them, bar, club and hotel owners and various others.

Sex workers very often do look for alternative work, sooner or later. Many that I have spoken to have tried to work in the hospitality industry, to make money buying and selling things or by providing various services. But they often return to sex work, if they are not too old to do so, because there are already too many people trying to make money in these ways. The best thing civil society can do for sex workers is to advocate for better conditions for them, the protection of the law, access to safe medical services and full recognition of their human rights.

The motivation behind some of the efforts to persuade sex workers to give up sex work is the HIV epidemic, to which commercial sex work was said to have contributed greatly. Perhaps it did, though this is not clear. The most recent Modes of Transmission Survey for Uganda finds that sex workers, their clients and the partners of their clients contributed around 10% of new infections in 2008. Compared to this, over 40% of infections were from people in monogamous relationships. In other words, it is safe sex that is giving rise to a lot of HIV transmission, not unsafe sex.

The greatest contribution to HIV prevalence is said to come from people engaging in multiple partnerships and their partners. However, the percentage of people engaging in multiple partnerships is no higher in Uganda than it is in many Western countries and it is lower than in some. Very high rates of HIV transmission in Uganda are not explained by sexual behavior when the same behavior only results in very low transmission rates in other, more developed countries.

In the mid eighties, HIV prevalence among sex workers in Nairobi was found to be 81%. However, HIV rates, along with rates for other sexually transmitted infections (STI), began to fall over the next few years and continued to fall thereafter. And this happened in the absence of any HIV prevention programs. Whether earlier STI prevention vaccination programs had spread HIV among sex workers is debatable but such high rates among sex workers are unusual. In some countries, sex workers are unlikely to be HIV positive unless they are also intravenous drug users. So there is still a problem explaining why HIV rates are so much hither in developing countries than in developed countries.

Sex workers may face high risk of being infected with HIV and other STIs through their work. But they also face other risks that are much easier to avoid than sexual risks. For example, sex workers (and others) often use injectible contraceptives. They also regularly visit clinics for checkups and vaccinations against various STIs. If any of these clinics are reusing needles, syringes or any other equipment, a lot of infections could be transmitted by such unsafe practices. The Modes of Transmission Survey finds that 0.06% of HIV infections are transmitted in this way. But this figure is questionable in a country that has ongoing shortages of medicines, contraceptives, equipment, trained personnel and clinics.

Non-sexual HIV risks could be avoided but no one is going to avoid them if they don't know they exist. Sex workers are constantly being told about the risks they face through unsafe sex. But they are never told about the risks they face in clinics. Yet, they are being sent to these clinics in ever growing numbers. Sex workers have a right to know that HIV is not just transmitted sexually. Telling them about condoms and unsafe practices will not help them avoid non-sexual risks. And people who are not sex workers also need to know about non-sexual risks. They are quite mistaken in their belief that sex workers play a big part in transmitting HIV.

The most disgusting thing about the belief that HIV is almost always transmitted sexually in African countries is that it emanates from the HIV industry, which goes on about reducing stigma. There is no better way to promote stigma than to label people as 'most at risk', especially when they are known not to be most at risk. The HIV industry is well aware that unsafe medical practices can be far more efficient transmitters of HIV than unsafe sexual practices. And while they warn their own employees about these risks when they are visiting developing countries, they tell people who have to live in those countries that they needn't worry about injection safety or anything else that may result in exposure to contaminated blood.

Much of the stigma that sex workers and HIV positive people face is manufactured by the HIV industry, who know that non-sexual HIV transmission plays a part in the epidemic. They just don't want to admit that this phenomenon exists or to carry out any research that could reveal the exact contribution it makes to HIV epidemics in developing countries. Sex workers, HIV positive people, HIV negative people in developing countries and anyone concerned about human rights should be advocating for the right to know about something that represents such a huge threat to people's health and welfare. Until people know, they will not be able to protect themselves.

Don't Just Repeat the Mantra; Follow it!

One of the people who came up with the idea of a 'no sex month' to reduce HIV transmission by 10-45% (for that month) has published a paper which finds that neither poverty nor wealth drive the HIV epidemic. The no sex month idea suffers from what could be a major flaw: it will only reduce sexually transmitted HIV infection. That may sound obvious but this researcher assumes that most, perhaps even all HIV, is transmitted sexually. So his analysis of the finding that neither poverty nor wealth drive HIV is similarly flawed.

This latest paper may be more comprehensive than previous ones. But the suggestion that wealthy people are often more likely to be HIV positive than poorer people has been made a number of times over quite a few years. It has also been noted that higher levels of education can be correlated with higher rates of HIV. And it has been clear that these trends can change, with the correlation becoming less pronounced and even reversing over time. Whereas earlier in an epidemic, wealth and education may correlate with higher HIV rates, they may correlate with lower rates later on.

It has been clear also that HIV rates differ strongly among men and women, with prevalence among women being far higher than that among men at later stages in epidemics. Correlations between wealth and education are often stronger for women and less pronounced for men. And correlations can be stronger in poorer countries than in wealthier countries. So far, so good, these findings are all interesting and revealing. Before they were established, many pronouncements were made about connections between HIV and poverty and HIV and education which resulted in ineffective strategies.

But the paper's author links all these findings to the unspoken assumption that HIV is mostly transmitted through heterosexual intercourse, that the 'behavioral paradigm' is true. The extent to which HIV is transmitted sexually is not clear because the extent to which it could be transmitted non-sexually has never been properly investigated.

Many poor African countries have high HIV rates. But many richer African countries have even higher rates. Even within Kenya, the highest HIV rates are not found in the poorest areas. North Eastern province is by far the poorest province, with the worst education indicators, yet HIV prevalence is very low. Higher rates are found in Nairobi, whose population is richer and better educated, on the whole. But no matter how you slice up the population, high HIV prevalence does not correlate with wealth, poverty, inequality, education or anything else that is obvious.

If you assume that HIV is mostly transmitted sexually, you wonder why infections among women can be four times as high as those among men. Just who is infecting these women and under what circumstances? You could assuage these doubts somewhat by pointing out that women are more susceptible, for various different reasons. But then you find the richest women with the highest levels of education in Tanzania are far more likely to be infected than the poorest. This changes over time, but the trend certainly doesn't reverse. And the pattern among men is completely different. With the behavioral paradigm, you have to tie yourself in knots to understand just what sort of sexual behavior is going on here.

It helps if you are quite racist, which is lucky for UNAIDS because as an institution, they are racist through and through. It also doesn't do any harm to be sexist and UNAIDS also ticks that box. You then make up various different (and fairly improbable) hypothetical scenarios and you come up with this:

Poor people in some settings undertake particular risky practices – e.g. earlier sexual debut or reliance on transactional sex – whereas wealthy individuals may engage in other risky practices, such as participation in broader social and sexual networks or sex with higher numbers of (voluntary) regular partners.

It doesn't mean very much but it sounds good, especially as there are some citations in the original article, giving the whole thing a veneer of authenticity. But there is no evidence that Africans, rich or poor, male or female, engage in large enough amounts of the sorts of behavior considered risky enough to explain the devastating epidemics found in Sub-Saharan African countries. Sexual behavior varies from place to place, but not in the way UNAIDS and the author in question would like. Most Africans do not have lots of risky sex, only some do. But some Europeans do, as do some Americans. You just don't find HIV epidemics in Europe and America like the ones in Africa.

The author goes on :

Effective action requires unpacking the black box of behaviour by recognizing that HIV infection in poorer groups may arise from certain lifestyles and risky behaviours related to poverty, whereas HIV infection in wealthy groups may be due to different lifestyles and risky behaviours related to their wealth.

This may all be true but it is only true of sexually transmitted HIV.

If you don't assume the truth of the behavioral paradigm and you accept that some HIV is transmitted non-sexually, they you can consider less improbable and more testable scenarios. For example, you could look at the different behaviors of males and females relating to health care. Women could be exposed to more of the kinds of medical procedures and cosmetic procedures that might carry a risk of HIV infection. Richer women could be exposed to more of these procedures than poor women. Earlier on in the epidemic, education and wealth may have had little influence on women's attitudes towards health and cosmetic treatments but this could have changed as more became known about the epidemic.

If it is assumed that all or most HIV is transmitted sexually then you will end up with HIV prevention programs that aim to change people's sexual behavior. That's what we have ended up with, even worse, most of the programs don't work. Unless we also target non-sexual transmission, which means establishing its contribution to the HIV pandemic first, we will never 'know our epidemic', in the words of UNAIDS. And if we don't know our epidemic we will never 'know our response', either. The key to a mantra is not just to repeat it, you also have to follow it.

You've Been Bad: No Sex for a Month

One of the noticeable characteristics of many HIV researchers is that they seem to have a liking for telling people how to run their sex lives, who to have and not to have sex with, when to have sex, where to have sex and what sorts of sex to have. Crucially, they feel the need to tell people in developing countries these things. They certainly don't tell people in rich countries, unless they are men who have sex with men (MSM) or commercial sex workers.

This is because, typically, HIV researchers toe the line on HIV transmission: that in high prevalence countries, it is almost all transmitted through heterosexual sex but in low prevalence countries, it is mainly transmitted by MSM, intravenous drug users and perhaps commercial sex workers. These researchers seem to see themselves as arbiters of good sexual behaviour and they can even threaten to come along and circumcise anyone who misbehaves, as long as they are not already circumcised, of course. If they are circumcised they are considered to be better behaved than the uncircumcised, anyhow.

So two of these intrepid researchers have come up with a plan to have an official 'no sex month'. The thinking behind this is that HIV positive people are most infectious when they have just been infected. At this stage, they will probably not know they have been infected and even if they test, they will probably not receive a positive result. Anyone going through this stage of HIV infection during a no sex month will avoid transmitting the virus, at least for a while. Once they have gone through to the next stage, they will be far less infectious and, hopefully, they will be tested before they reach the third stage, during which they will be highly infectious again.

There are people to whom this proposal will not appeal, specific groups that these researchers will probably want to include. Commercial sex workers will be unlikely to forgo a month of earnings, for example. (And intravenous drug users could be relatively unaffected by the cunning plan.) But the researchers point to the Muslim month of Ramadan, where Muslims abstain from sex during daylight hours. I wonder if they have done any research into whether this has had any impact on HIV transmission, aside from their assumption that because HIV is often lower among Muslims, Ramadan could the the key. And is daytime sex more likely to result in HIV transmission than nighttime sex? Or perhaps daytime sex is seen as more in need of censure.

Well, because we are talking mainly about African countries, it will probably be seen as perfectly reasonable to 'test their hypothesis' on the people. After all, they clearly have too much sex, of the wrong kind and possibly even during the day. Why these researchers see their proposal as a one off is not clear. But they are wrong in saying that it 'does not create additional stigma'.

The behavioural paradigm, which says that HIV is mainly transmitted heterosexually in developing countries, is what causes the main stigma that attaches to HIV. It is because people in developing countries are being told that they have too much sex, and sex of the wrong kind, that HIV is stigmatized, that people are made to feel that they are bad people, who must be censured and punished, if necessary.

More importantly, the behavioural paradigm is completely unfounded. HIV is not mainly transmitted by heterosexual sex in developing countries. The extent to which HIV is transmitted non-sexually is not clear precisely because researchers like the two in question refuse to consider non-sexual transmission as being important enough to research.

If, as a result of this 'experiment', HIV rates are found to have dropped, this will not necessarily mean that sexual transmission will have been cut. Non-sexual transmission, for example, through unsafe medical practices, could also go down during the no sex month. Sex workers and MSM, if they do give up sex, will have less need to visit sexually transmitted infection clinics to receive jabs and contraceptive injections (very popular among sex workers). These are likely routes to HIV infection through unsafe injections. Will the research take such circumstances into consideration?

Perhaps the researchers would like to carry out another experiment on this obliging and convenient population of human beings: perhaps they would like to have a medical safety month. During this month, it would be ensured, not just that every health care worker takes the utmost care during every procedure, but that there are enough health care workers everywhere and all of them have enough equipment so that they don't need to reuse anything or do anything that could put their patients at risk. During this month, Everyone in the country would have access to safe health care, no one would have to resort to some quack wielding a much reused needle and no one in the health care industry would have to take any risks because of lack of resources.

Apart from seeing how this affects HIV transmission, it would be interesting to see what sort of demand there was for treatment and what levels of diseases and other health conditions would be revealed. But if no sex months provide a 'potential strategy', then so do medical safety months. Indeed, medical safety months would have benefits that go far beyond HIV transmission. Perhaps we could have clean water and sanitation months, where people are provided with enough water and sanitation facilities to reduce some of the biggest killers in the developing world. The possibilities are endless, we could have infrastructure months, electricity and lighting months, connectivity months and many other types of month.

The researchers assure us that a no sex month would produce "easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign". And I'm sure all the other types of month would also supply vast quantities of data, such as maternal health figures, infant mortality figures, child mortality health figures, nutrition figures, disease mortality figures, more data than you could shake a circumciser's scalpel at. In fact, I don't think you would need to threaten people at all, I really think they would go for these dedicated months without any incentive. They may even demand that such benefits be granted to them all the time, not just for a month.

Even the researchers themselves warm to their theme and suggest that such months could be adapted for different populations "depending on what is driving the epidemic". So, among miners in South Africa they suggest a 'no commercial sex' month. But how about a no mining month? Then they could have a significant impact on the TB epidemic, which is driven by the mining industry and is said to spread hand in hand with HIV.

The researchers conclude that "In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic". But are these researchers open to new ideas? Are UNAIDS and CDC open to new ideas? The biggest new idea, which is only new in the sense that it has been ignored by those who are best placed to apprehend it, is that HIV is not only transmitted sexually, that the behavioural paradigm is wrong. No new discovery needs to be made: these people and institutions simply need to tell the truth. A 'no lies' month from UNAIDS would do more to reduce HIV transmission than all their HIV 'prevention' programs, past, present or future.

Even WHO Admits Unsafe Injections are Ubiquitous

The dental unit of a hospital in Missouri has realised that 1,800 of its clients may have been exposed to diseases such as HIV and hepatitis B and C as a result of poor hygiene. All the people, apparently all war veterans, who may have been exposed, are being contacted and an investigation has been called for to find out how such an incident could occur. A political spokesperson has said that this is unacceptable for veterans. Whether he thinks it would be equally unacceptable for people who have spent no time in military service is unclear.

Still, it’s good to hear that there is a protocol, there is sterilization equipment and that someone is checking to see that the protocol is adhered to. It’s also reassuring that there are people who know that lack of care in using such equipment can give rise to infection risks and that if there is any possibility that clients are at risk, they can be and will be contacted and given a full check-up. Presumably, the staff involved will be retrained and those found to be responsible will be disciplined appropriately.

A similar occurrence in California resulted in 3,400 patients being contacted because they underwent a colonoscopy and it was found that correct hygiene precautions may not have been followed. And in the UK, 519 people have been contacted because a healthcare worker who may have treated them was found to be HIV positive. The worker, who has worked in a number of hospitals, has been moved to a role where there is no risk of blood contact.

The two American incidents are probably more worrying than the UK incident because patients are unlikely to be infected by HIV positive healthcare workers, in practice. But infections from unsafe medical procedures are thought to be common, especially in countries where there are low levels of training, staffing, safety and funding. The World Health Organisation (WHO) estimates that in some regions, up to 70% of the 16 billion injections given in transitional and developing countries are unnecessary. They estimate that up to 40% of injections worldwide are given with syringes or needles reused without sterilization and this could be as high as 70% in some countries.

One doctor in Kenya relates how he has stuck himself with needles on several occasions. He also says this is common among healthcare workers. However, the likelihood of a healthcare worker becoming infected is quite low, in practice. The biggest worry is of patients being infected by contaminated equipment. And this doctor says that they don’t always have enough needles, for children in particular. He describes how they improvise to get around this problem but also admits that this means the patient can be infected with hepatitis. He doesn’t mention HIV but presumably they are at risk from any blood borne disease.

This one medic can see up to 100 patients a day, as can many practicing healthcare workers in other facilities all over Kenya and East Africa. Doctors and other healthcare practitioners receive a lot of training but if they don’t have the equipment, they either need to ‘improvise’ or refuse to treat people. But what of all the other people who give injections and carry out other procedures that involve potential blood exposure? The risks may be lower but some of them only receive a few weeks training. And there are those with no training at all who also give injections, informal practitioners and the like.

UNAIDS ‘estimate’ that unsafe healthcare results in around 0.6% to 2.5% of HIV infections in Kenya. Yet the WHO estimate that globally, 2% of HIV infections are caused by unsafe injections. Is it really credible that countries with high prevalence of blood borne diseases and low levels of safety in healthcare settings could have such low transmission rates through unsafe medical procedures? WHO estimates that up to 9% of HIV infections may come from unsafe injections in South Asia. How could the figure be so much lower in African countries, where healthcare is known to be of a very low standard and prevalence of HIV is so much higher than it is anywhere in Asia?

In the US and the UK, where there is a relatively small risk that people will be infected with HIV as a result of medical procedures, hundreds, even thousands of people are screened to make sure that they were not infected. But in developing countries, where HIV prevalence is high, we are told that most HIV transmission is through heterosexual sex and therefore transmission through unsafe medical procedures cannot be high. Where there is doubt, people are not recalled and screened. Potential nosocomial cases (ones that occurred in healthcare settings) are not investigated. There is overwhelming evidence that heterosexual behaviour in African countries does not explain high levels of HIV, but because they are African countries, it is accepted that they have lots of sex, that they should stop doing so and when they do, everything will be ok.

Health facilities in African countries lack adequate drug supplies, have chronic shortages of trained personnel and do not even have enough condoms at a time when they are faced with rising HIV prevalence. It is not credible that, at the same time, there is a very low risk of HIV infection through unsafe medical practices. Global HIV policy is obsessed with sexual HIV transmission to the extent that non-sexual transmission is being completely ignored, especially in developing countries. Informing people of the non-sexual risks of HIV transmission, and how to avoid them, is just as important as informing them of the sexual risks. People have a right to the information they need to protect themselves.

Test All, Treat All for HIV: Just Another Shot in the Dark

The authors of an article entitled ‘HIV drugs for treatment, and for prevention’ write as if to ask why we would delay using antiretroviral (ARV) drugs for preventing, in addition to for treating HIV, when so much evidence points to the effectiveness of such a strategy. But their rhetoric could be interpreted another way. They and others in the HIV industry seem to be saying, in a tone of mounting desperation, “Look, nothing else has worked so far, let’s try it until something else comes along”. In a list of failed possibilities including condoms, behaviour change of various kinds, circumcision, vaccines, microbicides and treating other sexually transmitted infections (STI), something else probably will come along. Whether that something will also fail remains to be seen.

The authors may object that some of those possibilities have not failed, for example, circumcision. Well, results of circumcision trials and even large scale circumcision rollout are shrouded in controversy but in Kenya, the only place where substantial numbers have been circumcised, the issue is far from resolved. And the biggest worry for some people is that Kenya does not have adequate health facilities to rollout any widespread programme safely. Aside from that, some worry that the program is being rolled out before its effectiveness has been adequately demonstrated. Maybe circumcision can help in areas where levels are currently low but this is by no means clear.

The effectiveness of condoms, also, is not as clear as one might expect. The latest results from the Kenya Demographic and Health Survey, 2008-09, suggests that people using condoms are often more likely to be HIV positive. It’s not certain why this is so and people would be unwise to give up using condoms, but a major problem with condoms and contraception in general in some countries, Uganda, for example, is availability and accessibility. The Kenyan DHS report, along with many other DHS reports, also cast doubt on the value of various behaviour change campaigns. Behaviour often doesn’t change, for various reasons. But even where it does, this doesn’t seem to have much impact on HIV transmission.

Testing everyone for HIV and treating everyone found to be HIV positive, the strategy advocated by the authors in question, may well have its virtues. If it’s possible to test everyone in every country that has high HIV prevalence regularly, perhaps every year, that would be a good start. Then, being able to treat all of them, for the rest of their lives, would also be required. Mathematical models have shown, apparently, that if such massive numbers of people could be tested regularly and then treated for the rest of their lives this would, under optimal conditions, quickly eradicate HIV (although not all models are in agreement). All we have to do is ensure optimal conditions.

Uganda doesn’t currently have optimal conditions for such a strategy, nor does any other high prevalence country. Testing is slow, many have never been tested, others return for testing more than once but most don’t. There is even an unmet demand for testing which may take some time to meet, given the country’s poor infrastructure and health network. Condom distribution is failed by a stop-start supply and contraception more generally suffers from similar problems, despite family planning being pursued in the country for several decades before HIV was recognised.

In fact, the country’s reasonably modest aim, to treat all HIV positive people who have reached a specific stage of disease progression, is not being met either. Drugs often don’t reach their destination or arive too late. Some remain in storage, even until they have expired, because of lack of infrastructure and health systems. Funding for ARV treatment comes exclusively from external donors. And these donors are talking about reducing funding substantially, some have already done so. An important question is not just about whether these conditions will be changed but would it really be possible to successfully implement a strategy like ‘test and treat’? Does the country’s performance over the past 25 years suggest that it would be possible?

The results of trials that show that HIV transmission is very low when people are on ARV treatment seem impressive. But a universal ‘test and treat’ programme would be, presumably, rolled out under the same conditions as previous HIV prevention programmes. Or maybe the latest one will be rolled out under optimal conditions? Maybe health institutions, infrastructures, education and other social services will be improved to the extent that this test and treat programme will work. It seems likely that HIV transmission would reduce somewhat without a test and treat programme under these conditions. At least it would be a possibility, however surplus to requirements it may become.

But there is still the same worry about this and all the failed or failing programmes that went before: shouldn’t we be frank about what we know and don’t know about HIV transmission, especially the extent to which HIV is sexually transmitted? We know HIV is not always transmitted sexually, but the HIV industry is very coy about admitting the extent of non-sexual transmission. And all the programmes listed above presuppose sexual transmission of HIV, whether they involve vaccines, microbicides, condoms, behaviour change, circumcision, STI treatment or a selection of these combined. Maybe test and treat is different, perhaps it will also reduce non-sexual HIV transmission. But it won’t, on its own, alter the circumstances that result in non-sexual transmission. Rolling out a disease prevention programme that is indifferent as to how that disease is spread seems foolhardy.

HIV Industry Admits They Got it Wrong? Sort of!

The US has launched a new grant to help developing countries to strengthen their health systems. The term 'health system strengthening' has become quite fashionable recently. But it's usually used by defenders of the likes of PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global fund, who argue that their funds do not target HIV at the expense of other diseases or of health systems strengthening. Remarkably, the article about this new fund, the Global Health Initiative, flatly contradicts these claims and even reads like an admission that mistakes have been made. Such admissions are rare, but vital if serious diseases such as HIV are to be controlled.

In another article, it is noted that the amount of money spent on HIV in Tanzania has risen by over 2000% between 2001 and 2007, from 17 to 381 billion Tanzanian shillings (11.5M to 259M USD). And the author is encouraged that in the same period, prevalence has dropped by 1%, from 6.7% to 5.7%. Is that encouraging? Hard to say, but apparently "Some of the biggest challenges in the fight against HIV/Aids are embezzlement and mismanagement of funds." One wonders where prevalence would stand if the money hadn't been embezzled and mismanaged. In some sectors of the Tanzanian population prevalence has been increasing.

The article ends with the conclusion that HIV was not adequately addressed because the focus was on the health sector, whereas this disease in particular is not simply a health problem. But you could argue that diarrhoeal diseases and intestinal parasites are a matter of water and sanitation, respiratory diseases are a matter of environment and housing and malaria is a combination of all of these factors and perhaps some others. None of them are 'simply' health problems.

Yet, it is true to say that you can't just reduce HIV transmission by sending everyone to a clinic and giving them counselling and drugs if they are infected and lecturing everyone who is not infected about safe sex and perhaps giving them condoms. This has been tried and has failed. Amazing amounts of money have been thrown at HIV and the result has been a continuation of very high levels of transmission and a distinct lack of understanding of why some countries and parts of countries have such profound HIV epidemics and why some do not.

So, like other diseases, HIV epidemics are not just a matter of dealing with a particular pathogen, you must also consider the host and the environment. Looking at it (and other diseases) from this point of view, there are a lot of ways of spending 381 billion Tanzanian shillings aside from on health aspects alone. Many people are said to be more susceptible to HIV infection because they don't have a choice about when, how often or with whom they have sex. Others are susceptible because they have various health conditions that make them so, for example, malnutrition, intestinal parasites, sexually transmitted infections, TB, malaria, etc.

As well as dealing with host factors, then, money could be spent on environmental factors, water and sanitation, infrastructure, gender relations, equality, poverty and many other things. But anyhow, the claim is that the money was spent on the health sector, not on health systems (supply chain management, health worker retention, information management, etc). And it seems fairly clear that money has not been spent on health systems, pace the argument for the Global Health Initiative and contra the unconvincing arguments of Global Fund and PEPFAR proponents.

But here's a thing, you could argue that those tenets of epidemiology leave out something very important, perhaps most important when the epidemic is HIV: nosocomial infections. This is where the disease is spread by medical procedures. The pathogen is clearly being introduced into a host, but artificially so and the environment is a rarefied but highly risky one. Do nosocomial infections, to some extent, elude epidemiologists altogether (or just those who work for UNAIDS, WHO or CDC and a few other institutions that have a lot of influence in the HIV industry)?

Following the pronouncements of those august institutions, you would think that nosocomial infections hardly infect anyone in developing countries, with the rare exception of some of their own employees who happen to be working in those countries and have to use the same medical facilities as the natives. Don't worry, that has probably never happened, though that doesn't stop them from warning their employees.

Ignoring other diseases, health in general, water and sanitation, nutrition, environmental conditions and structural conditions in the fight against HIV has been unbelievably stupid. Equally stupid is the failure to ensure that there were adequate health structures in place to implement various HIV prevention and treatment initiatives, however misguided some of these may have been. In fact, in countries like Kenya, health structures were being dismantled from the 1980s onwards at the instigation of institutions like the World Bank (yes, the one that came up with the Global Fund!).

In admitting that health systems have been ignored, the HIV aristocracy may be getting just a little closer to admitting that their view of HIV transmission in developing countries is in bad need of reconsideration. They still tell us that HIV is almost entirely transmitted through heterosexual intercourse in developing countries. But it would seem very hard to maintain this view when the Global Health Initiative is admitting that health systems have been ignored and this has done a lot of damage and has wasted much of the money that has been poured into HIV so far.

Huge amounts of money have been and still are being spent on trying to get people into medical facilities, to be tested and/or treated for HIV and many other diseases. Pregnant mothers are encouraged to go to clinics and to bring their babies and infants to be vaccinated. Men are being encouraged to go to clinics to be tested and/or treated for HIV and sexually transmitted diseases and even non-communicable diseases. But if health advocates want people to go to health facilities, they would need to make sure those health facilities are safe enough that people do not become infected with something as life-threatening as HIV. People need to be made aware of the risks they face in health facilities and those health facilities had better be improved quickly and thoroughly. I don’t think the admission that grotesque mistakes have been made was intended but it has certainly let the genie out of the bottle, well, one of them.