Age-disparate relationships do not drive HIV in young women. KwaZulu-Natal, SA

I commented on this back in March when it was reported at a conference. Now the paper has been published (though it is not available free of charge). It concludes: "In this rural KwaZulu-Natal setting with very high HIV incidence, partner age-disparity did not predict HIV acquisition amongst young women. Campaigns to reduce age-disparate sexual relationships may not be a cost-effective use of HIV-prevention resources in this community."

The HIV industry likes to believe that, although HIV is almost always transmitted through 'unsafe' heterosexual sex in African countries, unlike in other countries, it is men's behavior that is most responsible. This supports their 'all men are bastards, especially older men, and all women are victims, especially younger women' mentality.

It's good timing. After 23 years of monitoring their epidemic in South Africa, HIV experts have seen HIV prevalence increase from less than 1% to almost 30% in that time, and stagnating at over 25% for about the last 10 years. KwaZulu-Natal is the worst affected province, with HIV prevalence in some districts reaching 40% among antenatal clinic attendees.

Perhaps a little less emphasis on sexual behavior and a little more emphasis on non-sexual risks, such as unsafe healthcare, traditional and cosmetic practices, may shed some light on what is driving the epidemic and why efforts to influence HIV transmission in any way seemed to have failed thus far.

[For more about non-sexual HIV transmission via unsafe healthcare, traditional and cosmetic practices, and how to protect yourself from these, have a look at some of our more detailed pages.]

Justine Sacco: Dangerous Truths and Dangerous Falsehoods about HIV

[Reposted from the Don't Get Stuck With HIV website.]

An American on her way to South Africa is said to have Tweeted "Going to Africa. Hope I don't get AIDS. Just kidding. I'm white!" This is a heartless and insensitive remark to make. But what makes it most heartless and insensitive for a white American to say it is the fact that it is so true. In the US, African Americans accounted for 44% of all new HIV infections in 2010, despite representing only 12-14% of the population. Also in the US, men who have sex with men are said to represent about 4% of the population, but account for 63% of all new HIV infections in 2010, and a disproportionate number of them are black/African American.

Even in South Africa HIV prevalence among white people is very low. But national prevalence is amongst the highest in the world and there are more HIV positive people in South Africa than in any other country. While America has the worst HIV epidemic in the developed world, with over 1.1 million HIV positive people, the majority of infections arise among men who have sex with men and (to a lesser extent) intravenous drug users. HIV infection among white heterosexuals who have no serious risks, such as receptive anal sex or intravenous drug use, is very low.

The American who tweeted the first stupid, but sadly true, remark offended so many people that she arrived in South Africa to find that a storm had erupted on Twitter and she had lost her job. So, to make matters worse, she made a statement to a South African newspaper which contained a dangerous but often heard falsehood:

"For being insensitive to this crisis -- which does not discriminate by race, gender or sexual orientation, but which terrifies us all uniformly -- and to the millions of people living with the virus, I am ashamed."

This is completely untrue, as the figures for the US show so clearly. About two thirds of people living with HIV globally are black Africans. An estimated 60% of HIV positive people in Africa are female, compared to only 20% of new infections in the US in 2010. Hispanics and Latinos in the US made up 21% of new infections in 2010; the rate of infection was 2.9 times higher in Latinos than it was in white males; it was also 4.2 times higher in Latinas than in white women.

HIV most definitely does discriminate by race, gender and sexual orientation. This is not a new discovery, either. It may be an acceptable thing to say in certain circles, but we should never forget the differences between HIV in Africa, where the majority of HIV positive people live, and HIV in developed countries, where HIV is less prevalent overall, and is rare among heterosexuals who have no serious risk behaviors.

Justine Sacco, who tweeted the remark, is so right to think that she is very unlikely to be infected with HIV; a lot less likely than a black African, and also less likely than a black or Latino/Latina American. It is disturbing to think that so many people continue to believe or say otherwise. Why is HIV prevalence so high among black Africans and black/African Americans, yet comparatively low among white people, especially white men who engage in no serious risk behaviors?

The Media in Africa: Beware of Natives

BuzzFeed has photos of 10 signs photographed in South Africa during the apartheid era and it is truly shocking to think that, as the article points out, these signs only became illegal in 1994. But that's why it should be even more shocking that instances of extreme racism and apartheid style thinking should still be so common in the international media today. I have listed a number of examples below, with links to some of the most offensive articles I've read in the past few years.

These are just the tip of the iceberg and a full study would take years. But, in no particular order, let's start with the stories about condom 'recycling' in Kenya and condom 'rental' in Tanzania. Whether the journalists who wrote these stories were bored or desperate is just one question; but what about the media outlet that published them and the public who read them?

One that goes back a few years is the 'story' about starving HIV positive people on antiretroviral drugs eating cow dung in Swaziland. Numerous media outlets echoed that one and it cropped up several times. There was even a story about a woman in Namibia who  claimed to have eaten cow dung but then admitted that she had made it up. She didn't attract anywhere near as much publicity, though.

The ever-popular notion of 'African' sexuality is a trusty tool in the journalist's store of prejudices. Although it has been debunked many times, the media picture of Africans has remained faithful to their apartheid agenda. Africans are truly 'other', that's why there are such massive HIV epidemics in some African countries, isn't it?

The UNAIDS Modes of Transmission analysis, which produces the 'science' behind the media's HIV related racism has also been criticized, but why attack the source of so many stories that everyone seems to enjoy and find so completely inoffensive? UNAIDS even recognizes the true HIV danger in African countries, unsafe healthcare. But they keep that to themselves, publishing advice about avoiding non-UN approved health facilities in a booklet for UN employees, courtesy of the sweetly named 'UN Cares' (about its own employees).

Occasionally a journalist may allude to the use of African participants as research fodder, but people are too used to hearing about the oversexed and feckless African to care very much about such abuse, especially when it can always be dressed up as 'helping'.

It's coming up to about six years since the international media 'discovered' the Tanzanian albino attacks and killings, even though they had been reported in local media for some time. The sloppy and offensive coverage that followed this great 'scoop' for the BBC continues, as do the attacks on persons with albinism. Why revise a story that has won praise and awards? Of what importance are accuracy and insight when opportunities for self-adulation are at stake?

The disgusting US Christian right story of the use of adult pampers as a result of anal sex among men who have sex with men has even done the rounds in some of the local media. We see articles about African countries claiming that homosexuality is 'brought in' by foreigners. But where did the homophobia come from?

There are sometimes instances of the kind of media friendly racism that is 'roundly' condemned, trivial matters that keep readers entertained, much easier to write about than anything that matters. But what the media writes is clearly not yet a source of offence to most people. Perhaps in years to come sites will be able to list some of the shockingly abusive things the mainstream media published about African people, who knows?

Transactional Abstinence and the Objectification of Women

Similar to the HIV scare stories before the 2010 World Cup in South Africa (and numerous other sporting events), the mainstream media is full of the same in the run up to Euro 2010 and the London Olympics. According to the Washington Post, Ukraine has a booming prostitution industry, which is going to boom even more while the football is on.

Of course, for the media this is all about sexually transmitted HIV. Much of Ukraine's epidemic is a result of intravenous drug use and even many of the sex workers who are infected may not have been infected sexually. But mainstream journalists seem shy of mentioning that blood-borne infections, such as HIV, hepatitis and others, can be transmitted through unsafe healthcare, tattoos and various other routes.

We are told that an estimated one in ten sex workers in Ukraine is HIV positive. Someone cited in the article says "If a fan is not using a condom, he has a very good chance of getting infected." But even if someone not wearing a condom has sex with a HIV positive sex worker (a one in ten chance), they don't have anything like a one in ten chance of being infected. And wearing a condom won't protect people from non-sexual infection, if anyone happens to visit a health facility or get a tattoo. What constitutes 'a very good chance'?

The article then gets bogged down with some of the horrific experiences a sex worker risks, without questioning the sort of society that allows some women to be subjected to things that would be criminal were anyone else to experience them (which is by no means something peculiar to Ukraine, or even to poorer countries). The article makes it seem inevitable that if someone works as a sex worker, they will be persecuted with impunity.

Aside from allowing the author to express a bit of righteous indignation and fill up some space (and why shouldn't journalists make a bit of money out of the sex trade, lots of other people do?), it's hard to see any point to an article like this. It doesn't promote public health and, far from promoting the interests of sex workers in Ukraine, it appears to advertise the country as the ideal destination for sex tourism and underage sex. Or perhaps that's what Washington Post readers demand?

The anthropologist Laura Agustin expertly denounces the conflation of sex trafficking with sex work, which does nothing for those who have been or are in danger of being trafficked and does a lot of harm to sex workers and those who are thought to be sex workers. There are also protests in the UK about the 'crackdown' on the sex trade, which is unlikely to amount to much more than police redoubling their usual efforts to exercise their prejudices against people who may or may not be sex workers.

In a bizarre twist of logic though, the HIV industry has decided that transactional sex is such a bad thing that they are willing to give girls in some African countries money not to have sex. Ostensibly, the money is to keep them in school, but given that one of the aims is to reduce HIV transmission, and that the industry believes almost all HIV is transmitted through heterosexual sex, it is not a big step to see this as transactional abstinence.

At one time, the message was that it is bad to exchange money for sex. Now the message is that you can make more by not being infected with HIV or a sexually transmitted infection, or by not getting pregnant. It's unlikely to result in people having less sex; nor is it even clear why staying in school for longer appears to have been accompanied by a reduction in HIV transmission.

But the strategy doesn't seem that different from transactional sex by another means. How are the recipients not being objectified? How are they not being seen as sex objects? They are being treated as if they are all potential sex workers, particularly if they are poor. The HIV industry seems to be proposing the control of people's sex lives using financial inducements. Compare this to Laura Agustin's article on the use of 'rescue and rehabilitation' approaches to sex work and their long and venerable history. Except that in the African case the girls are probably not involved in sex work. But there seems to be a danger that the cash incentive will simply underline just how lucrative transactional sex can be.

The media, the HIV industry and various religious and political interests are selling us what amounts to deeply ingrained institutional prejudices against women, sex workers, Africans and many others. If a story sounds like a journalist's wet dream, that's probably exactly what it is. But this kind of coverage can draw attention away from, rather than towards, the worst injustices that are being committed in the name of public health, crime reduction and the protection of vulnerable people.

[For more about non-sexual HIV transmission, see the Don't Get Stuck With HIV site.]

BBC Trying to Fill a Niche Vacated By News of the World?

One of the issues that crops up a lot on this blog is the kind of things that non-Africans would believe about Africans. There was a lot of media coverage (or 'wallowing', even) around albinos being targeted by witch doctors or traditional medicine practitioners in Tanzania.

The problem is not that the media covered these terrible events; the problem is that just because such events were uncovered, this doesn't mean they are just a part of Tanzanian or African life.

So a few months ago I came across an article that was specific about the gory details but silent about anything that would allow the veracity of the story to be examined. The article, run by Reuters and echoed by hundreds, perhaps thousands of others, claimed that three albino brothers were murdered, buried and exhumed so their body parts could be used for something or other.

At the time, I was working with albinos in Northern Tanzania, where this event was said to have occurred. I asked colleagues and friends, including albinos. No one had heard of this story and they had no way of knowing how to check if it were true. I even asked some Tanzania Albino Society (TAS) leaders, one of them being the chairman of TAS, said to have been interviewed for the story. No one knew anything.

I contacted Reuters, posted a message on the article and emailed the author. I received nothing except advice to contact the author. The article is still on Reuters' site. And hundreds of copies and echoes of the article are also scattered around the web for posterity.

In a similar vein, I saw a story during the week on the BBC website claiming that some Swazis taking antiretroviral drugs are so hungry that they eat cow dung to ensure that the drugs 'work'. The drugs are supposed to be taken with food.

The question isn't really about whether the story is true. Someone may have eaten cow dung, somewhere, at some time, or someone may have just claimed that they did. The question is about whether this is a story? If so, is it about Swazis, HIV, food shortages, poverty or prejudice? If you read the sort of things that Nazis said about Jews, it included references to feces, living in feces, being covered in feces, eating feces.

When you 'report' that people are eating feces, for whatever reason, are you trying to raise sympathy, or are you simply playing on the anti-African prejudices that many media outlets have been so happy to hone over the years?

The question is of vital importance. Since HIV has been pinned on Africa, African sexual behavior, African morality, and whatever else suits a story angle and media trends, many seem to have lost sight of the fact that HIV is a virus, one that makes people very sick and eventually die.

Articles appear to be more concerned with slavering over the details about genitalia, tribal practices, non-use of contraception and just about anything else except the fact that HIV is a virus, a sickness, one of many that infect Africans in grotesquely disproportionate numbers.

With rare exceptions, the media doesn't ask questions that they don't already have what they consider to be the answer. So they ask why some African countries have massive HIV epidemics, but not why any country should have massive rates of viral transmission when it is a very difficult virus to transmit, sexually, at least.

Because it is sexual transmission the media is interested in, make no mistake about that. And they have their answer: it's African sexuality, morality, behavior, etc. The men have sex with anyone they wish to have sex with, the women will do anything to have children or to get money for their families, it's all led by sexual desire, rampant brutality, inhuman behavior.

When babies and young children are found to be HIV positive even though their mothers are negative, it's attributed to the fact that they are raped by their father or by a family member. When old, no longer sexually active people get HIV they say 'even old people are at risk'. Pregnant mothers appear to get infected during or just after giving birth, and even when their sexual partner is not infected it is suggested that they simply must have had sex with someone who was infected.

The story about Swazis eating cow dung with their HIV drugs appears to be a symptom of how the media can write whatever they want, with the understanding that they are just pulling strings that people are well conditioned to respond to. The victims of anti-African prejudice are now guinea-pigs in Western drug trials and even charades that claim to relate to health, but are really just mass eugenics exercises.

I'm sure the BBC didn't give this article about Swazis eating cow dung a great deal of thought, and many of their articles look similarly thoughtless, media memes that have as little impact as some of the interstitials that appear on other news sites. But the fact that people can write and even read such an article and not protest means that the corporation has a rotten streak, whether through carelessness or design. Are they trying to fill a niche left vacant by recent changes in the media world?

Tenofovir Gel Still Hyped, Despite Serious Questions About Trial

The rather disappointing 39% reduction in HIV infection among women who received tenofovir microbicide gel during the clinical trials has since been written about as if it is going to turn the epidemic around. It might, but the reduction would need to be a lot higher than 39%. A lot of questions will also need to be answered about the way the CAPRISA 004 trial was run and reported on.

But immediate efforts have been made to 'fast-track' approval so that the gel can be produced commercially. A site has already been identified for the factory, which makes it sound as if the many further trials that are needed to establish if the gel is going to have any impact at all on the HIV pandemic are irrelevant.

Any drug that is overused carries the risk of widespread resistance. This is something pharmaceutical companies are acutely aware of, given the substantial increase in their profits when people need to change to a newer and inevitably more expensive drug as a result of resistance. But if millions, perhaps tens of millions, eventually use this gel, levels of resistance could go far beyond what could be controlled (whatever level that might be).

And an important question, apparently, is that the reasons behind the HIV transmissions during the trial, and therefore the effectiveness of the Tenofovir drug, are not yet clear. One researcher has suggested that anti-inflammatories may be useful in reducing HIV transmission.

Another question that has been raised about effectiveness is that it is possible the gel only protected women if the viral load in their partner's semen was high. The trial results made public were a bit vague about exactly what risks were faced by the women who became infected, and if all of them were really infected sexually. Perhaps the less flattering results of the trial will be made public now?

It is Sweet and Beautiful to Die for One's Scientists

A little while back, I blogged about research that identified HIV prevalence 'hotspots', where high figures were clustered together. This research, carried out in Lesotho, looked at hotspots for males and females and found that they were spatially distant, which may seem anomalous for what is said to be a mainly sexually transmitted disease.

Similar work carried out in South Africa was a bit disappointing. Because, even though it is well known that fewer men are infected than women, often far fewer, this research by Handan Wand and Gita Ramjee only looked at hotspots of high HIV prevalence and incidence for women [Apologies for providing the wrong link yesterday.] Excluding men from such research is odd if it is assumed that women are mainly being infected by men.

But it clearly is assumed that all, not just almost all, transmission is through sex. "At all visits, all participants received counselling on risk reduction and as many male condoms as desired. Counsellors emphasized that condoms are the only known method to prevent HIV and sexually transmitted infections (STIs), and that condoms should be used for every act of sex."

There is something small but crucial wrong with this statement: condoms are the only known method to prevent sexually transmitted HIV. But using condoms during sex will not protect against non-sexually transmitted HIV, which could result from unsafe health care or unsafe cosmetic practices.

Indeed, failing to inform people about non-sexual risks means that they are unable to protect themselves from them and this could be a reason why HIV prevalence is so high in some sub-Saharan African countries. Pretending that HIV is always (or even almost always) sexually transmitted flies in the face of all evidence and is probably responsible for a substantial proportion of all transmission.

As for this research, it found some significant correlations between being HIV positive and certain types of behavior considered to increase the risk of being infected with HIV. 'Significant' in the strict statistical sense of the word, but not particularly large correlations. A non-statistician might think the data needs to be re-examined in the light of such apparently minor differences but not our intrepid authors.

For example: "The proportion of women who reported being legally married was significantly higher among those outside the hotspots than within them (16% vs. 12%, p = 0.001). Significantly more women in the geographical hotspots reported being Christian (94% vs. 90%, p < 0.001) and speaking Zulu at home (91% vs. 86%, p < 0.001) compared with those in non-cluster areas."

The article goes on: "The spatial clustering of HIV cases was found to be related to certain demographic and risk behaviours. Number of male sexual partners was not collected in this study; however, being single, combined with high frequency of sexual acts, gives strong evidence for those women having multiple partners, as well as possibly engaging in transactional sex."

'Strong' evidence? How does this 'high frequency of sexual acts' compare to countries with low HIV prevalence? The same question regarding 'multiple partners'? And would the authors come to the same conclusion of 'possibly engaging in transactional sex' if the risk factors in a low prevalence country were similar? I don't think so.

The authors may be leaving the door open to further research about the safety of health care facilities, but then again, they may not: "These results may be due to fundamental differences between the communities with regard to health care centres, population density and other socio-economic factors. These data provide new evidence to support the need to investigate potential sources of infection and to study transmission patterns in the community in order to apply relevant interventions for prevention of this devastating disease."

Let's hope that 'relevant' interventions means interventions that prevent non-sexual as well as sexual transmission, but it doesn't look as if these particular researchers will see things that way.

It is concluded that "Information on the spatial distribution of populations and services is essential to understand access to health services." But if some HIV is being transmitted nosocomially, as a result of inadequate health facilities, this also needs to be established. Otherwise increasing access to health services could result in higher rates of HIV transmission.

The authors don't just need to "determine and target the specific communities that are most in need of education, prevention and treatment activities", they also need to determine exactly what sort of education and what sort of prevention activities are required. Otherwise, at best, things could remain as bad as they are and atworst, they could get a lot worse. Neither of these would be good for South Africa.

'Counterfeiting' is a Problem That Can Only Be Solved By Big Pharma

If a business produces something and sells it for a price that covers costs and also gives a decent profit, that's a good model. Others may make the same thing, so a business needs to make the best and work hard to make sure they are not undercut. But most people will pay for something good rather than something that isn't up to scratch, if they can afford it.

However, if a business produces something and sells it for a price that is a complete distortion of the above business model, it is worthwhile for someone else to produce the same thing and charge a lot less. They don't even have to cut costs, they can just accept a lower profit. And those who have no chance of affording the expensive product may well be able to afford the cheaper one.

This is an oversimplification, but it is roughly what the pharmaceutical industry does, charges an outrageous price for something because they can. In addition, the industry depends on a form of protectionism called 'intellectual property rights'. Arguably, this has its uses, even that it is vital, but it is still a form of protectionism.

Often, the research that pharmaceutical companies claim to spend so much on is done by publicly funded, or partially publically funded, institutions. But there is little or no return to the public. And the amount spent on PR and marketing far exceeds what is actually spent on research.

So when someone else makes the same product but demands less for it, the industry reacts by resorting to all sorts of tricks to make sure the competition is destroyed. Competition, when you don't have a high level of trade protection, is not appreciated by the pharmaceutical industry.

The word 'counterfeit', therefore, can mean all sorts of things. It can mean a generic version of a branded drug, a fake version of a branded drug, a substandard version of a branded drug and probably other things. But a generic version of a branded drug is not a counterfeit and claiming that it is one threatens to deny  lifesaving treatments to many people in developing countries.

If drug companies don't want generic versions of their drugs to be produced, they should produce affordable versions themselves. There is clearly a huge market for them and a very good profit to be made. Dropping the price to affordable levels would also make the production of substandard and fake drugs a lot less tempting, perhaps not even worth the effort.

But instead of encouraging the production of generic drugs, the EU and, of course, the entire pharmaceutical industry, want to make sure affordable versions of drugs are not produced. They are currently trying to rope India into signing a 'trade agreement' whereby it will no longer be possible for the country to produce cheap drugs. Yet another form of protectionism.

India is one of the main sources of affordable drugs for developing countries. Some drugs will cost many times, perhaps even tens or hundreds of times more, just because they are protected by the sort of regulation that big industry claims to detest.

There is no doubt that some drugs are fake, made of materials that have no effect or are harmless, and this is unacceptable. But as long as ridiculous profits are made from drug pricing models, people will always find ways of selling their versions, no matter how useless or dangerous. It's not as if copyrighted drugs are always effective, or that they are never dangerous, either.

The pharmaceutical industry, already protected and subsidised in so many ways, wants more public money to be used to 'regulate' drug supplies in developing countries. Multinationals refuse regulation for themselves, but they seem to love the idea of regulating any competition.

Big Pharma have effectively created counterfeiting and many other related problems themselves, it's how they keep their profits so inordnately high. So they should sort it out themselves. If people object to the danger to the health and lives of so many people, they should aim their objections at the industry, the problem, not the mere symptoms of the problem.

The Science and Development Network have a selection of articles on the subject of 'counterfeit' drugs and some of the many issues involved. But the article doesn't really point out that Big Pharma don't lose out from counterfeiting because most of those who buy cheap drugs will never be able to afford the expensive versions.

Promoting Female Condoms in Salons is Great But Don't Forget Non-Sexual Transmission!

Some people like to depict vaginal microbicides as being in the control of women, unlike male condoms and other methods of reducing HIV transmission. Pre-exposure prophylaxis (PrEP, the use of antiretroviral drugs by HIV negative people to reduce probability of infection) can also be depicted this way.

However, it is interesting to hear what many people say about contraceptive pills. Most women in East Africa opt for injectible versions of hormonal contraceptives because they say their husband or partner will not allow them to take the pills if they know they are contraceptives.

But if concerned people are interested in female controlled HIV prophylaxis and contraceptives, perhaps they should take a look at female condoms, a simple enough technology that has been available for over 20 years. They are not 100% female controlled, but they are another arrow in the quiver.

Whatever the HIV industry's feelings about female condoms, they are rarely discussed. And while male condoms are often discussed, the issue of women not necessarily having much control over the use of male condoms constantly arises.

Perhaps it's time to take another look at female condoms. There is convincing evidence that they would make an excellent complement to current HIV prevention programs. Maybe those expressing an aversion just don't know enough about them. I have asked a number of people and the ones who express an aversion, all of them, have never used female condoms. (Similarly, those who said male condoms sometimes burst have either said it never happened to them or it happened once or twice).

Apparently there is a program in Zimbabwe which aims to promote the female condom through hairdressing salons. This is a great venue for promoting knowledge of HIV transmission because so many women go to them and because hairdressers themselves need to know a lot more about HIV transmission than they currently do.

For example, most people who have been lectured, sorry, advised about HIV transmission have been told about sexual transmission, mother to child transmission and possibly something about intravenous drug use. Less likely, they'll have heard about transmission through blood transfusions.

It is unlikely they will have heard much about other forms of medical transmission, such as through the reuse of poorly sterilized equipment, such as injecting equipment, IV lines, dental equipment, etc, although such knowledge could reduce this kind of infection.

It is also unlikely they will have heard about the possibility of HIV transmission through unsafe cosmetic practices, such as tattoos, ear piercing, shaving (where cuts and abraisions can occur), hair straightening (where the relaxants can cause burning) and other practices.

Apparently PSI (Population Services International) is running the program, which makes it unlikely they will mention much beyond sexual transmission of HIV, but there is hope. And it's good to hear that they are promoting female condoms, it's time someone did.

If Maternal and Child Health is Bad, Family Planning = Large Families

Would having a vasectomy make some men more likely to have unprotected sex? If they see contraception as just a protection against HIV (and perhaps other sexually transmitted infections), the vasectomy shouldn't, logically, result in a reduction in condom use. But I suspect it would be a good excuse for not using condoms.

If they see condom use and/or vasectomies as a means of reducing unplanned pregnancies, having a vactomy could well result in men having unprotected sex. They could see condoms having a dual purpose, but many HIV prevention and other types of health programs have made little effort to emphasize this dual purpose.

If male circumcision was also involved, how would that affect condom use? Of course, mass male circumcision campaigns do drone on about having to use condoms for circumcision to be effective. But I don't see many men getting circumcized if they don't think they can reduce their condom use, perhaps even dispense with them altogether.

If programs that aim at reducing heterosexual HIV transmission are combined with programs that aim at reducing a country's population, this could result in a very mixed message indeed. Who is going to undergo both circumcision and a vasectomy and still use condoms?

If circumcision in conjunction with condom use is intended to reduce sexual HIV transmission, this sort of program might best be kept separate from a program that aims purely at population control.

Besides, people who are not in a position to, or don't see themselves as being in a position to make family planning related choices that we in the Western world take for granted, may require a more subtle approach than 'offering' them vasectomies.

There must be a lot more to family planning than merely reducing the probability of conception in as many ways as possible. This smacks of the eugenicist subtext that seems to be hidden in much of the public health programs one hears about in developing countries.

Apparently Rwanda is combining its population growth program with its circumcision program, which is intended to reduce HIV transmission. Yet, the respective merits of each strategy, circumcision, condom use and vasectomies, are themselves matters for debate.

There is little doubt that correct and consistent use of condoms plays a large part in reducing unplanned pregnancy. But will people continue to use them if they think there is an alternative, or if they take care of unplanned pregnancy?

But it is far less clear that mass male circumcision has a significant impact on heterosexual HIV transmission outside of (relatively) carefully controlled trials. And even those trials only claim that circumcision reduces female to male transmission, which is a lot less common than male to female transmission, which it may even increase.

And a vasectomy may well reduce conception, perhaps even eliminate it completely. But the ethics of encouraging large numbers of people to have vasectomies, perhaps young men, should be considered carefully. And maybe those advocating the combination of all three should also look at the potential incompatibilities involved.

Programs designed to, or even programs that happen to reduce conception need to be accompanied by programs that aim to improve health services and even health education, nutrition, water and sanitation, working condititions, living conditions and everything else that make up the determinants of health.

Rwanda still has high infant, under five and maternal mortality. Life expectancy is low and most premature deaths are due to treatable and preventable conditions. Even HIV positive people tend to die of treatable and preventable conditions. Under such circumstances, the only viable form of family planning is to have big families.

Health programs that ignore the broader determinants of health will have little positive impact and may do a lot of damage. And the combined contraception/HIV reduction/vasectomy approach suggested for Rwanda sounds entirely unethical, as well as ineffective.

Uganda's HIV Epidemic: Mystery or Myth?

I have always worried about the way Uganda is held up as an example to other African countries on account of its early experience with HIV. What happened in Uganda earlier on is not the same as what happened later.

Early on in the epidemic, everything possible was done to reduce HIV transmission, both sexual and non-sexual transmission, in all their forms. Later, non-sexual transmission became more and more excluded and a set of myths about the efficacy of the ABC (abstain, be faithful, use condoms) strategy replaced any semblance of a coherent strategy.

The epidemic in Uganda took off earlier than in most other countries. HIV incidence, the rate of new infections, then declined and several years later, prevalence (the percentage of HIV positive people between the ages of 15 and 49) also declined.

It is not clear exactly why the epidemic took off when it did, nor is it too clear why incidence then peaked and declined. Measures to control the epidemic are likely to have played some part, of course, but how big a part has long been a matter of debate. Prevalence would have declined because of high death rates.

Once global HIV policy was thrown off course by ABC, or even AB or just A, it never got back on course. The burgeoning HIV industry's obsession with sex still rages and non-sexual HIV transmission, for example, through unsafe healthcare or cosmetic practices, is rarely talked about, let alone researched or investigated.

This leaves Uganda in a vulnerable position. The country receives a lot of HIV money, most of which is spent on drugs and care for HIV positive people. And the little left over for preventing new infections is spent on interventions that obviously don't prevent new infections.

Prevalence declines that resulted from high death rates have been reversed by a high rate of new infections. Those on treatment are likely to stay alive for longer, adding to increases in prevalence. But many HIV positive people still die, usually from treatable illnesses.

Not only is Uganda far from eradicating HIV, there is still a very serious epidemic in the country. Prevalence is bumping along, lower than it was during the worst years, true, but it has hardly changed for the last 10 years.

Infection rates in young people is often seen as a proxy for incidence because it's hard to measure incidence directly. But if young people who are just becoming sexually active are infected in large numbers, the epidemic is still very much alive. And 1.5% of people between 15 and 19 are HIV positive, 2.6% among girls and 0.3% among boys.

Of course, many of these teenagers could have been infected by mother to child transmission. But it's unlikely that they all were, unless this type of transmission is a lot more common that has been realized.

We are told that the highest burden of HIV, though, is now among married couples between 30 and 40 years old. In fact, it has been realized for some time that the majority of transmissions in Uganda appear to be a result of sex that is not 'unsafe' by any of the HIV industry's definitions.

HIV is common among those who don't have sex very much, are not likely to have several sex partners, and most of whom only have sex with a long term partner. Many, also, are in discordant relationships, their partner is not infected (or they did not infect each other). And half of the infected partners are female, so there goes the 'all men are promiscuous' theory of HIV transmission.

And that's the problem. If HIV is not primarily transmitted through unsafe sex, interventions that target unsafe sex will have little effect on transmission rates.

Yet the conclusion of Uganda's Ministry of Health is that they should encourage male circumcision, increase use of female condoms and awareness about HIV/AIDS. This may or may not reduce sexual HIV transmission. But after so many years watching HIV transmission stagnate, so many people becoming infected and so many dying, perhaps they could think about changing tack.

HIV is difficult to transmit sexually, yet it seems to be transmitted very rapidly in Uganda. Young people who are just starting to have sex are being infected quickly, which suggests that we are way off when it comes to our knowledge of transmission probabilities. Or perhaps not all HIV is transmitted sexually? Either way, we need to find out why transmission rates are so high in Uganda. Otherwise it will not be the only country with stagnating HIV prevalence figures.

The Futility of Criminalizing HIV Transmission

Yet another blog posting that demonstrates the futility of criminalizing having sex with someone without disclosing one's HIV status. It's quite simple. If you don't want to risk prosecution for the offense, don't get tested. Or make sure you get tested anonymously.

In this case, a man, who says he was infected in the late 1980s (but appears to have survived without antiretroviral drugs until about 20 years later) has unprotected sex, once, with a long term sex partner. How do we know that she wasn't already HIV positive at the time? That doesn't exonerate him, of course, but if she had kept her status secret from anyone, his behavior is punishable and hers is not.

The more people get tested the better. And better still if people get tested regularly if they think they continue to run risks of infection. But if knowing that you are HIV positive means you might accidentally infect someone with whom you haven't discussed your status, it's better to test anonamously.

People are not being criminalized for being HIV positive, they are being criminalized for being tested openly, in a manner that can be traced, should someone wish to trace it. Instead of getting people to test as early as possible, this makes it preferable for them to test as late as possible and to disclose their status as little as possible, perhaps never.

For people in developing countries, it's fairly obvious who is most likely to be punished by such laws. Women are under a lot of pressure to test when they are pregnant, sometimes more than once. For various reasons, it is often difficult, perhaps impossible, for them to keep their status confidential. And there is always the danger that someone else could reveal it.

In fact, if a woman needs any health services, especially before, during and after pregnancy, it is very unlikely that she can remain untested, or that her status can remain confidential, should the matter be scrutinized later.

Women in developing countries are more likely to be infected than men, often substantially more likely. They are more likely to have to test in local facilities (because of relative lack of mobility), where they are known by others.

Far from reducing stigma, this kind of criminalization would increase stigma. People would be under suspicion just because of things that may be known about them, or even because of characteristics that are merely attributed to them.

The orthodox view of HIV in developing countries is that HIV is almost always transmitted through heterosexual sex. But it is people who are felt to be engaging in more sex that will be most stigmatized, sex workers, pregnant women, perhaps young women, because prevalence is so high among them.

In the case mentioned above, both the woman and the man are intravenous drug users. They are both at high risk, far higher than people who engage in a lot of heterosexual sex. If the woman did know her status, it would probably be difficult to prove that.

And if she didn't know her status, perhaps, being an intravenous drug user, it might be suggested that she should have been tested a long time ago. It is claimed she was not tested till 2006, though the unprotected sex act was said to have occurred in 1999.

But why would anyone test if it's safer not to? If there was any chance that criminalization could reduce HIV transmission, there might be some justification for it, though it's hard to imagine what that could be. But in fact, it only makes things worse. It risks punishing people who may have been a lot more careful, or honest, and risks exonerating those who keep their test results to themselves, or don't even bother testing.

Could HIV Policy Be Driving HIV Transmission?

Early on in the HIV pandemic it was thought that if people were to be told about the risks for HIV infection and how to avoid them, they would do so. Those involved in public health, professional and non-professional, took steps to inform people about both sexual and non-sexual modes of transmission and what they could do to reduce their personal risk. Improvements in health facilities were also made to eliminate accidental infection through various invasive practices as much as possible.

In a paper on knowledge of blood-borne HIV transmission risk, Dr Devon Brewer comments that "many Ugandans adopted injection practices that likely reduced their risk of HIV acquisition following the 'massive anti-AIDS education campaigns that began in 1985 [that] warned people about the dangers of sharing unsterilized needles and syringes'" (citing a paper by H Birungi). Brewer notes that "these behavior changes were accompanied by concurrent declines in HIV transmission".

Things changed later and non-sexually transmitted HIV risk is now said to have been taken care of. The entire HIV orthodoxy is built on an assumption that is covertly recognised to be incorrect: the behavioral paradigm. This is the view that HIV is almost always heterosexually transmitted in African countries and that non-sexual transmission, which is not uncommon in non-African countries, hardly ever happens in Africa.

Brewer found that in countries where it was known that certain behaviors carried a risk of HIV infection, sharing razor blades in this instance, HIV prevalence was lower. It is not clear to what extent sharing razor blades contributes to HIV epidemics and there are many other such risky behaviors, for example, the use of contaminated injecting and other medical equipment, contaminated cosmetic equipment, such as tattoo needles and ink, and various others.

But Brewer also found that "countries with high proportions of respondents endorsing condoms also tended to have higher HIV prevalence than countries with low proportions endorsing condoms." This is difficult to explain and, if you accept the behavioral paradigm, you might suggest that it means people do not avoid risks that they have been told how to avoid.

My take on the phenomenon is that those in areas with the highest risk of HIV infection, cities and more populated, accessible areas, are also those most likely to have heard the constant messages about condoms. And apparently they even use them more than those in rural, less populated and less accessible areas. But as HIV is less likely to be transmitted through sex and is very likely to be transmitted through unsafe healthcare and the like, those endorsing condoms also face risks not faced by people in rural areas.

Well, 'safe sex' messages may not have had much of an impact in high HIV prevalence countries. But this is not a reason for not advising people of the risks. In the same token, the fact that most people do not have much influence over those who provide them with health services is not a reason for failing to advise them of the risks involved, and the risks of sharing razor blades, for that matter.

People are entitled to know that HIV is far more likely to be transmitted through contaminated blood than through any kind of sex and that there are steps they can take to reduce risk to themselves and their friends and family.

The HIV orthodoxy think nothing of stigmatizing entire nations, a whole continent, blaming massive levels of HIV transmission on massive levels of unsafe sexual behavior. Yet they balk at the suggestion that those providing health services need to be reminded to avoid any risks of transmitting HIV and other blood-borne diseases. They accuse anyone questioning the behavioral paradigm of branding health care providers, while at the same time branding every HIV positive African as promiscuous, stipid and cruel, as mere spreaders of disease.

Brewer concludes, "Health officials have an ethical duty to warn the African public about blood-borne HIV risks. Where such efforts are currently absent, they should be started immediately; where such efforts are underway, they should be emphasized further and sustained. Public education campaigns should not only highlight blood-borne HIV risks comprehensively but also communicate practical strategies for avoiding the risks."

Public health professionals in African countries are in very short supply, underpaid, overworked, undertrained and underequipped. Conditions in public health facilities wouldn't even be approved for veterinary use in Western countries. Warning about health care transmission of HIV is not pointing the finger at health professionals.

If anything, it is pointing the finger at the over-qualified and extremely well paid policy 'experts' at UNAIDS and other institutions. This doesn't answer the queston of why so many people in the HIV industry have failed to do anything about non-sexually transmitted HIV; perhaps they can answer that themselves. But progress in eradicating HIV transmission will not be made until the truth about HIV transmission is acknowledged.

'We Haven't a Clue, But We're Doing a Great Job', Say Academics

With a population of only about 800 million, sub-Saharan Africa (SSA) has 22.5 million HIV positive people. The rest of the world, with a population of about 6 billion, has 10.8 million HIV positive people. While 2.81% of SSA is infected, only 0.18% of the rest of the world is. In that sense, SSA's epidemic is 15.5 times worse and that of the rest of the world and Lesotho's (an exceptionally high prevalence country) is 75 times worse.

So how do we interpret these enormous differences? If we accept UNAIDS' and the HIV industry's claim that about 80% of HIV is transmitted heterosexually in African countries, does this mean that people there have more sex than non-Africans? And how much more? Ten times more? Fifty times more? Or is it more dangerous? Ten times more dangerous? Fifty times more dangerous?

In a kind of a sort of a way, they do mean this, or something like this. But they don't mean anything very specific. So if most sexually active people had sex four times a month, perhaps Africans have the time, energy and inclination to have sex at least once a day, every day, and often more than once. Actually, they would need to have a lot more sex with this, or it would need to be unbelieveably dangerous, to account for some of the very high prevalence figures found in SSA.

But the industry clings to its behavioral paradigm, the belief that HIV is mostly transmitted sexually in African countries. Some representatives of the industry recently published a paper wondering what kinds of sexual behavior change resulted in substantial declines in Malawi in recent years. The concluded that it may have been a reduction in the number of sexual partners among (heterosexual) men. They weren't sure about this, though, nor are they sure what could give rise to such a reduction.

I'd like to know what caused sexual behavior in Malawi and other SSA countries to increase to non-humanly possible levels in the first place. And why is it that it's always men who engage in the highest levels of 'unsafe' sexual behavior, but always women who outnumber men, often vastly, in numbers infected? And if it wasn't quantities of sexual behavior, but rather increased risks, why did these increase and then decline?

The authors note the lack of success so far for most interventions. They even cast doubt on the potential effectiveness of mass male circumcision, pre-exposure prophylaxis (PrEP) and immediate initiation of antiretroviral therapy for all HIV positive people, without these being accompanied by substantial changes in behavior. This is almost anti-establishment.

Perhaps they would like to reconsider their adherence to the behavioral paradigm? Because in the case of Malawi, it is possible that more than 50% of HIV infection comes, not from heterosexual sex, but from unsafe healthcare. With the appalling health facilities found in many SSA countries, it is plain arrogance to insist that 80% of HIV transmission is heterosexual and that most of the other 20% is a result of mother to child transmission.

In fact, if nearly 20% of infections are said to be from mother to child, it is very likely that many of these are, in reality, also a result of unsafe healthcare. And far from all these infants being infected by their mother, some mothers may be infected by their infants during breastfeeding.

The authors of the paper conclude, as they did in a recent paper on Zimbabwe, that there was the 'funeral factor', the fear of contracting, suffering from and dying from HIV/AIDS that may have given rise to changes in male sexual behavior. It's always good to have something to attract journalists, but this doesn't explain why so many more women are infected than men. If HIV is not all being transmitted through heterosexual sex, then some interventions that address non-sexual transmission are urgently needed.

The HIV industry has been kicking around the oversexed African theory of HIV transmission for almost thirty years. In addition to being insulting to Africans, especially African women, it does not stand up to scrutiny. This paper is just one more in a long line of travesties. These researchers claim that behavior change has averted tens of thousands of deaths. On the contrary, the number of infections and deaths that have resulted from the failure of HIV research is incalculable.

Will Reduced Funding for UNAIDS Mean Less Prejudice?

My first experience of a HIV voluntary counselling and testing (VCT) clinic in Kenya was memorable for the fact that, among the bustle of people coming and going from the public hospital, those wanting anything to do with HIV turned left before the hospital gates. The would sit outside the standalone clinic, in full view of passers by.

This phenomenon, which is still the norm, is just one aspect of HIV exceptionalism and it clearly puts people off going to VCT clinics. It compounds the stigma that surrounds HIV, the fact that anyone who sees you at the clinic will know that you may be HIV positive. Those who are HIV positive face the even greater stigma of having to go to a Comprehensive Care Clinic, dedicated to those with HIV.

Now a pilot program in Western Kenya is trying out the idea of integrated care, where people turn up to see a health professional without being segregated into HIV and non-HIV groups. And aside from reducing the fear people had of being sneered at by other patients and even by health professionals, some are saying that it also frees up scarce resources.

It is good to hear that efforts are being made to see HIV as just one of many illnesses, because people also suffer from and die from so many diseases, often preventable and/or curable conditions. Those who defended the exceptionalization of HIV claimed otherwise, but it is widely felt that resources, including personnel, tended to be deflected away from less prominent conditions.

In fact, one of the groups most vulnerable to HIV, young women of child-bearing age, were unlikely to get much care aside from HIV related care. If they turned out to be HIV positive, they might get just enough care to ensure than their baby was not infected. But then they would be left to their own resources, ignoring the fact that the best way to ensure the health of an infant is to ensure the health of their mother.

Those who turned out to be HIV negative were even less likely to get the care they needed. But recently, there has been talk about putting a greater emphasis on maternal health. Some have even talked about strengthening health systems and improving health facilities, without reference to one, or a handful, of diseases. This may just be a way of reducing funding, but it may also be a genuine attempt to right the balence. I'm accepting that the two could be compatible.

Another of the effects of the exceptionalism of HIV was the way it was never really seen as the business of national governments in high prevalence countries. It was always something that donors controlled. The only interest that health (and other) departments would take seemed to be in the vast sums of money that HIV seemed to attract.

If it is true, as defenders of exceptionalism like to claim, that much of the HIV money was additional, on top of health funding, that's great. And if it is true, as they also claim, that HIV money has also helped strengthen health systems, that's great too. Though I have to say, I don't believe those claims for one moment. But all the better for health systems if they are right, because it's very likely that they will have to get by on a lot less if the pilot is scaled up across the country.

My worry is not that less money will be spent on HIV prevention. Very little is spent on prevention now and most of it is being spent on useless exercises. But if health facilities do not give some attention to levels of infection control, there is a danger that they will continue to expose patients to diseases such as HIV itself, as well as many others.

Conditions in Kenya's hospitals are appalling. Nurses in Pumwani, one of Kenya's busiest state run maternity hospitals, have gone on strike to complain about conditions, extreme shortages of personnel, equipment and medicines. Maternal, infant and under five mortality rates in Kenya are among the highest in the world as a result of these conditions. And yet UNAIDS still claim that HIV is almost never transmitted in health facilities. This is an area of HIV prevention that is in urgent need of attention.

Treatment and care for HIV positive people may suffer if funding for this is reduced. After all, though this amounts to little more than funding for drugs, they are inordinately expensive. But a reduction in donor money for HIV drugs may result in a reduction in the sort of prices that the market has never been able to sustain. And many HIV positive people don't even die of AIDS. They, in common with those suffering from AIDS, often die of preventable and/or curable conditions, despite levels of donor funding for AIDS drugs.

If HIV becomes less exceptionalized, perhaps it will also start to be looked at more realistically. The experience in Kakamega and other districts is, apparently, quite encouraging, especially in the way it has reduced stigma. If HIV is seen as just one of many diseases, it may also be recognised that it can be spread in health facilities, just like hepatitis, MRSA and lots of other diseases. And this would represent a paradigm shift in HIV prevention.

HIV in Lesotho: The Unpopular Questions Are in Most Need of Answers

Yesterday I blogged about HIV in Lesotho and the finding that clusters of high HIV prevalence for women and clusters of high HIV prevalence for men do not overlap very much. I wrote to the corresponding author of the finding, Myong-Hyun Go, to ask if the extent to which HIV is transmitted sexually might thereby be in question. His reply was a definite no, but without any argument or evidence.

And that's pretty much how the HIV industry works. The view that HIV is mainly transmitted heterosexually in African countries is sometimes called the 'behavioral paradigm'. And it is not really amenable to evidence, for or against. It is, let's be frank, a prejudice. So it is worth looking a bit more closely at some figures for HIV in Lesotho.

The study in question uses data from the 2004 Lesotho Demographic and Health Survey (DHS), but as the 2009 survey is available, I'll be referring to it instead. After all, the authors expect their work to influence health policy, so it would need to apply equally to both early and later data.

In common with many other African countries, women usually report very low levels of multiple sex partners, with less than 10% having more than one partner in the previous 12 months and a mean number of lifetime partners never exceeding 3. And while HIV prevalence differs a lot spatially, levels of multiple sex partners and mean number of lifetime partners does not.

Men usually report far higher levels of multiple partnership, double or even triple the levels for women. Their mean number of sexual partners is also up to three times higher. Such differences are equally pronounced among young people. Yet far more women than men are HIV positive in most age groups and in most areas. This is also the case in other African countries.

HIV prevalence by sexual behavior figures show that orthodox thinking about age at first intercourse is in need of review. For women, those who first have sex at less than 16 years old have the same HIV prevalence as those who start at 20 years or over. For men, prevalence actually rises with age, with those starting early having lower prevalence. Prevalence for men and women who use condoms is about the same as it is for those who don't.

But the most remarkable thing about the figures is not that HIV prevalence does or does not correlate with sexual behavior; in some respects it does and in some it does not. What is remarkable is that rates of sexual behavior considered to be unsafe are no higher than other countries with far lower rates of HIV, countries in Africa and elsewhere. People in Lesotho are at higher risk than almost anywhere else in the world, but no research has shown why this is so.

The study authors also claim that their findings provide a 'concrete basis' for male circumcision. Well, there are countries where male circumcision status may be correlated with HIV prevalence. In some countries, circumcision appears to be protective, for example, Kenya. But Lesotho is one of the countries where the opposite may be the case. Of course, these correlations may point to something else entirely.

About half of all men in Lesotho are circumcised. But while uncircumcised men are a bit more likely to be HIV positive in some age groups, overall, circumcised men are far more likely to be HIV positive. It could be argued that many circumcised men were infected before being circumcised, but there is then the problem of explaining how they were infected with a virus that can have as little as a 1 in one thousand chance of being transmitted during heterosexual intercourse.

I would argue that both the spatial data created by Myong-Hyun Go and Co and the DHS data show that Lesotho has extraordinarily high HIV prevalence figures and both sets of data suggest that a substantial proportion of HIV may be transmitted non-sexually. But the disturbing thing about each set of data is that neither really shed light on the possible extent of non-sexual and sexual transmission. Without knowing this, the way forward is no clearer than it was before the data was collected.

GPS Data Analysis Upholds Stork Theory of Where Babies Come From

A story is told about a grumpy conductor who said to a cellist (I'm paraphrasing): 'You have between your legs one of the most sensitive instruments known to man, and all you can do is scratch it'. The story comes to mind sometimes when reading the latest findings about HIV epidemics.

Many researchers come up with great data, data that should change the way that HIV prevention programs are targeted. A lot of recent data, and even some not so recent, clearly shows that HIV transmission is not nearly as closely related to sexual transmission as has been assumed so far. But this never seems to have any influence on prevention programs.

UNAIDS and the HIV industry in general take it as read that 80% of HIV transmission in African countries is a result of heterosexual sex. They claim that almost all of the remaining 20% is accounted for by mother to child transmission. This leaves very little for intravenous drug use, men who have sex with men and various forms of non-sexual transmission, such as unsafe healthcare.

A recent piece of research by Myong-Hyun Go, B Coburn, J Okano and S Blower uses GPS coordinates to depict HIV clusters or hot-spots in Lesotho. Lesotho has one some of the highest HIV prevalence figures in the world. They range from 8.5-46.6% for women and 4.1-39% for men.

Remarkably, the hot-spots for high female prevalence do not overlap with those for males very much. Those for females are mainly located in two lowland urban centres, the most heavily populated areas in the country. Those for males are mainly located in two less heavily populated mountainous areas, quite distant from the urban centres.

The research also finds that travel between most parts of Lesotho is not too efficient. Even travel between areas of high female prevalence and high male prevalence, according to the maps provided, could be quite challenging. These findings are referred to as 'spatial heterogeneity', which sounds rather quaint, under the circumstances.

Do most of the inhabitants of one of the poorest countries in the world expend most of their time and income on travelling to and from different parts of the country for the sole purpose of having sex, with as many different partners as possible, if official HIV lore is to be believed?

I think many people whose minds are relatively unbiased, especially by said official HIV lore, might question the 'behavioral paradigm', the view that almost all HIV is heterosexually transmitted in African countries. There must be something else to these incredible rates of transmission.

Not only must people be having immense numbers of sexual experiences, with immense numbers of people, but if the heterosexual sex theory is true, there must also be something else accounting for the increased susceptibility of this population.

After all, HIV prevalence among sex workers in India is only about 7% and the disease, according to the official story, is something of an occupational hazard for them. National prevalence in Kenya, Tanzania and Uganda is around 7% or less, which is itself shocking when compared to the figure for India.

But even if we embrace the extreme prejudices of UNAIDS and their accomplices, we must still wonder what it is about the Basotho people that accounts for almost unprecedented rates of transmission (and, of course, their superhuman feats of mobility and sexual prowess).

The researchers, however, don't even raise such questions. They merely conclude that prevention programs must be gender specific ones, such as circumcision for men and microbicides for women.

Even if it is true that most transmission is through heterosexual sex, these interventions will have only a relatively small impact, if any. Neither intervention has been shown to reduce transmission very much outside of some highly questionable trials.

But the data screams out for thorough investigation of how HIV could be transmitted heterosexually when so many HIV positive men and women live so far from each other. There is also an urgent need to find out if there is some additional factor that could explain how a virus that is difficult to transmit sexually affects such an enormous number of people. And it would be a further disgrace to the HIV industry if it just lets this data go by without it having any influence on global HIV prevention policy.

Are Racism and Sexism Lessened by Being Passive-Aggressively Pursued?

Following yesterday's blog post I had a brief email conversation with Dr David Gisselquist during which he pointed out that higher levels of education, to some extent, and greater wealth, to a large extent, tend to correlate with higher HIV prevalence in African countries. Researchers are not sure what to make of these correlations, though they are well attested.

Anyhow, neither of us find the World Bank claims particularly credible and they seem to go hand in hand with a purely sexual view of African HIV transmission, the so called 'behavioral paradigm'. The view is both racist and sexist. Imagine a similar handing out of money to Western women aimed at influencing their sexual behavior, and particularly their reproductive intentions.

Anyhow, giving girls money and paying their school fees could be expected to result in higher HIV prevalence among the recipients, unless transmission patterns have changed substantially, and only since all previous population based surveys of the last 15 or 20 years have been carried out.

The same article refers briefly to a Tanzanian study, which gave cash incentives to adults who tested negative for certain sexually transmitted infections (STI). But public health experts are well aware that STIs are more than just a reflection of sexual behavior. They also reflect broaderhealth conditions in a country, that's why certain STI rates are very high in some US and other Western populations.

The idea of handing out money to people in an attempt to influence their behavior or lifestyle is not confined to sexual behavior, nor even to young people in developing countries. Money has also been used to persuade women (and some men) to use birth control of some kind, or even to be sterilized, because an institution called 'Project Prevention' has wished to intervene for one of several reasons.

Project Prevention aims at female drug users in Western countries, because they are said to play a significant part in HIV transmission there. But it is HIV positive women who are targeted in Africa (Kenya, specifically). The aim is not really prevention because if HIV transmission had been prevented in the first place, there would be no need to prevent the possible vertical transmission of HIV from the mother to their children. And Project Prevention aim to eliminate the child, hence, no prevention if they achieve that aim.

Ironically, one of the favored methods of birth control employed by Project Prevention is the intrauterine device (IUD). If Project Prevention gave a damn about the safety of women at all, they would check out the sort of conditions found in health facilities in Kenya and other high HIV prevalence countries. Getting an IUD inserted in Kenya will carry many risks, including the risk of infection with diseases such as HIV.

And that's only if things go reasonably well. If women have any future problems with an IUD they will face further, similar risks and perhaps some additional ones. Many will continue to have little access to adequate health care after Project Prevention have handed over their few dollars a head and, in common with most African women, will probably just have to put up with whatever injury that results.

Whether it is right or even effective to hand over a few dollars to influence people's behavior is one thing. And there is a lot of discussion about these questions. But even if the answer is that it is both right and effective, it will not work, because HIV is not, and never has been, purely a matter of individual behavior, sexual or otherwise.

Some commentators are correct in referring to Project Prevention's agenda as pure eugenics or 'racial hygiene'. But then, so is the bulk of prevention work carried out by the big players in HIV prevention, including Population Services International, Family Health International, The Futures Group International, the Guttemacher Institute, the Rockefeller Foundation, the Gates Foundation and many others.

Most of the billions contributed to the multi-billion dollar HIV industry has gone to treating HIV positive people. But most of the considerable fraction that has gone into prevention, very unsuccessful too, has been frittered away on trying to influence people's sexual and reproductive behavior. Project Prevention's strategy is extreme, but that's really only a matter of degree.

The various commentators abhorring the work of Project Prevention are all rightly concerned about preventing HIV transmission from mothers to their babies and they are also right in pointing out that this is a well developed and relatively successful area of HIV prevention. The problem is that too few women who are about to become pregnant, or are already pregnant, or even who have just given birth, are in any way protected from HIV infection.

It is the very assumption that HIV is almost always sexually transmitted that results in the stigma that these commentators also abhor. Project Prevention is contributing to the stigma, but so are these well-meaning critics. If the HIV industry could lose its obsession with the sexual and reproductive behavior of people in developing countries, they would be able to prevent HIV transmission that is clearly not coming from heterosexual sex.

HIV in poor countries is commonly associated with pregnancy. But this does not mean it is therefore also caused by sexual behavior. Many women are infected when they are in the later stages of pregnancy, or even after they give birth. And this is often the case when they have a HIV negative partner and they have only had sex with this HIV negative partner. At least some of these women were infected non-sexually.

Some HIV negative women have HIV positive babies and, despite the excuses of UNAIDS and others, all of these babies were infected non-sexually, probably through unsafe healthcare of some kind. HIV positive babies can even infect their mothers during breastfeeding.

Project Prevention may be racist and sexist bullies, who prey on vulnerable people in developing countries. But what they are doing is not that different from the more passive aggressive forms of racism and sexism that constitute global HIV prevention policy. HIV is not just another sexually transmitted infection, though it may sometimes be transmitted sexually. Eradicating the virus depends on accepting that and investigating the extent to which it is transmitted sexually and non-sexually.

Could the World Bank be Lying About Conditional Cash Transfers?

Perhaps we should all be kicking ourselves. According to an article in Bloomberg Businessweek, you can reduce HIV infection among young females by giving them some cash every month and paying for their school fees. That's according to the World Bank, anyhow, and they can afford to know such things.

But would that be the same World Bank that has insisted for decades that developing countries, in addition to getting themselves into irreversable debt, need to reduce public service and infrastructure spending, close health and educational facilities, reduce public sector employment levels, including teachers and health personnel and generally place young females, and everyone else, in a position where their health, education, economic and other circumstances suffer?

Denying hundreds of millions, perhaps billions of people, their basic human rights is bad enough. But then handing out a few dollars to some of them and offering to pay the school fees for the same schools that you wanted closed down does not seem like a great way of cleaning up the mess that you have been creating for so many years.

Frankly, I don't believe the results claimed for this exercise. Yes, there are young women and men who sell sex for money, goods, services and other favors. This is intolerable and everything should be done to make sure that it stops. But this phenomenon does not 'drive' (or even 'fuel') high prevalence HIV epidemics like those found in Malawi, Zimbabwe or Tanzania, no matter how much we enjoy the righteous indignation we feel when reading about 'sugar daddies' and the like.

The claim is that several thousand young women were recruited on to the trial and one group received an average of $10 a month and 'payment for school fees' if they attended class. The other group got nothing. And one and a half years later, infection rates were 60% lower among who those received the cash and school fees.

That really would be a remarkable result if it were true, but I think the person producing these results is not being completely frank. But we'll have to wait until the full program results are published. Apparently they are currently being peer reviewed. Although that doesn't seem to prevent the release of their headline figures.

Remarks from the World Bank's Mayra Buvinic sound particularly naive: “It is obvious, but it never occurred to anybody to give girls cash to help prevent transactional sex”. But it has occurred to development theorists to provide girls with education. It is well known that girls who are enabled to attend school have far better health that those who are not; this is not just about HIV.

The expert continues: “They needed money and, you know, since they got money, they didn’t need to interact with older men.” So now that you've made this great discovery about the value of education, perhaps your employers will consider its long running structural adjustment policies; I'm not sure of the current nomenclature, but you know what I mean.

Another expert smugly remarks that cash may be the "ethical policy instrument" of the 21st century. Where the hell do they get these idiots from?

Several others chip in with their stories about some of the terrible things that people in developing countries have to put up with. But these are things that existed before HIV was ever heard of and will continue to result from Western foreign policies, which concentrate on taking what they can get and even causing, or at least exacerbating, many of the problems that these 'experts' seem to think arise spontaneously.

Even if HIV epidemics such as those found in Malawi, Zimbabwe and Tanzania were driven by heterosexual sex, I don't believe you could significantly influence sexual behavior by handing out some money and paying for school fees. But nor do I believe that any severe HIV epidemic could possibly be driven by heterosexual sex, so I don't believe the claims of this article. If I hear otherwise, I'll be sure to blog about it.

'Promiscuous African' Explanation of HIV Falls Flat Again

It seems odd to compare Botswana with Sweden and to conclude that, because cross-generational marriages, usually referring to marriages between teenage girls and much older men, are common in Botswana but not Sweden, that must explain why HIV rates are high in Botswana and low in Sweden.

For a start, I expect there are many stark differences between Botswana and Sweden, including ones that may shed light on why HIV rates are so high in Botswana and so low in Sweden. But why compare those two countries? And why pick out cross-generational marriages, in particular?

Well, cross-generational marriages are just one of the many factors that have been said to increase HIV transmission over the years. Part of the reasoning is that teenage girls are unlikely to be very sexually experienced, but older men are, and so they are more likely to be HIV positive. The hypothesis on its own seems to be enough for the phenomenon to be the culprit.

But in most high prevalence countries, rates of discordance are very high. In other words, many HIV positive people have a HIV negative partner. And, although men are often said to be the main drivers of HIV transmission, especially in long-term partnerships, women are just as likely to be the HIV positive partner.

This means that, where both parties are infected, it may have been either the male or the female partner who became infected first. And this raises questions about how the female partner was infected, if she wasn't infected by her partner.

UNAIDS and the HIV industry have a ready explanation: if the female partner is African, then she is promiscuous. According to the orthodox view, this is just a fact. It may not stand up to scrutiny, but it is the lynchpin of pretty much all HIV prevention policy: Africans are promiscuous, and that's it.

Why so many more women than men are infected is not really clear if HIV is, as the orthodoxy claims, mainly sexually transmitted. HIV researchers often say that women are usually infected earlier and men later, often because of cross-generational marriages. But the figures just don't add up.

Men, on the whole, are far less likely to be infected, so there still remains a question as to who infects all the women where the ratio is something like 1.5 men infected for every 10 women, as is the case among the Luhya of Western Kenya.

Kenya's eight provinces were originally divided on ethnic lines and cross-generational marriage rates vary considerably between provinces. But the province with the highest HIV prevalence, Nyanza, doesn't have the highest rates of cross-generational marriage, not even the second highest. And the province with the second highest HIV prevalence, Nairobi, has almost the lowest rates of cross-generational marriage.

In contrast, the province with the highest rates of cross-generational marriage, North Eastern, has the lowest HIV prevalence. Prevalence there, at less than 1%, is lower than that found in many US cities. The diagram below is rough, but it shows that cross-generational marriage does not correlate with HIV prevalence. Interestingly, in North Eastern province, male and female prevalence figures are also very similar.

A lot more work needs to be done to show why some females in African countries face such high risk and why most males do not. Women may be more 'susceptible' to infection, as the industry never tires of telling us, but who is infecting them? It is unlikely to always be men, even if the promiscuous African 'theory' (in reality, a crude prejudice) so beloved by the industry is even vaguely true.

Rather than focusing on sexual behavior and marriage patterns, the author should have considered the relative quality and accessiblity of health services in Botswana and Sweden. He might have noticed that in places where many pregnant women visit hospitals and clinics in high prevalence countries, they seem to be far more likely to be HIV positive. If men tend to be infected later in life, perhaps women infected in hospitals are infecting them, another possibility not raised in this or most other articles.

The idea that HIV prevalence is higher in places where access to health services is higher and that HIV prevalence is lower in places where access to health services is lower is well attested and has been for some time. Indeed, Kenya's North Eastern province is a very good example. And elsewhere, urban and peri-urban areas have far higher prevalence figures than the most isolated areas, which often have very low rates indeed. Perhaps Dr Flamholc would like to develop his 'observations' a bit further.