We do them in Black for 14.99

I was recently sent an article which stated that “Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.”

The operation is provided free of charge. But this ‘intervention’ randomized participants into three groups, the first receiving about $2.50 in food vouchers, the second receiving about $8.75 and the third about $15, conditional on getting circumcised within two months. There was also a control group of men who received no compensation.

You may wonder why an operation said to be so highly beneficial requires a financial incentive; your wonder may (or may not) be assuaged by the assurance that some men face certain “economic barriers to VMMC and behavioral factors such as present-biased decision making”.

‘Present-biased’ suggesting that people will not spend money now on something that promises a future benefit only. However, perhaps these men don’t see any benefit; perhaps they use condoms, have only one, HIV negative, sexual partner, don’t have sex at all, live in a place where HIV prevalence is extremely low (there are many in Africa, far more than places where prevalence is high), etc. It’s also unclear what proportion of HIV is transmitted through heterosexual sex, which is the only mode of transmission circumcision enthusiasts even claim to reduce.

So those providing the operation propose ‘compensating’ each man for some of the costs involved in having the operation, possibly including the opportunity costs of missing work for a few days. You could argue that there will be no net financial benefit, and that this is nothing like bribing people to conform to a practice that some western donors from rich countries see as beneficial, but that the majority of people, even in rich countries, consider useless, perhaps even harmful.

The claimed future ‘benefit’ comes to this: one person out of every one hundred or more men who are circumcised (we don’t know the number because mass male circumcision trials have been biased towards showing the effectiveness of the operation) may be ‘protected’ from infection with HIV; ‘protected’ if it really is the circumcision that protects the man; no causal protective mechanism has ever been convincingly demonstrated.

The upshot of the trial will not surprise anyone. Hardly any of those in the control group went on to avail of their free circumcision. Slightly more of the men receiving $2.50 did so. The same goes for those receiving $8.50 and those receiving $15. But the overall impact was “a modest increase in the prevalence of circumcision after 2 months”.

The several hundred thousand Kenyans claimed to have already agreed to be circumcised under these mass male circumcision programs (many of whom would have been circumcised anyway in accordance with tribal practice), and the millions claimed to have been circumcised under similar programs in other African countries, may be disappointed that they will not receive anything at all to reflect “a portion of transportation costs and lost wages associated with getting circumcised”.

Depending on whose figures you use, circumcisions in African countries are claimed to cost as little as $60. Other figures suggest that the cost is at least twice that, and NGOs profiting from these programs would have an interest in claiming costs as high as possible. All the figures are puny compared to what the operation would cost in a rich country. But with an estimated 22 million men said to be currently eligible in Africa, and several tens of millions more boys not counted in the original estimate, just how much money is available?

Much of the literature about mass male circumcision is about notional economic benefits and quite superficial issues, such as assumed cleanliness and hygiene (for which there is no evidence), aesthetic aspects, improved sexual experience, and the like. Very little is about ethics, politics or, god forbid, human rights.

The ‘benefits’ of circumcision are easy enough to exaggerate and any disbenefits can be discounted because the ‘beneficiaries’ are male Africans, whose ‘unsafe’ sexual behavior is said to be responsible for the bulk of HIV transmissions.

To those promoting mass male circumcision, the useless piece of flesh on the end of a penis is a man, an African man, at that. Whereas the foreskin represents a vast funding opportunity and permits unbridled expression of a pathological belief in the multiple virtues of genital mutilation. The right to bodily integrity has, apparently, been suspended.

Uganda’s HIV Prevention and Control Act May Fall Foul of Itself

The Ugandan HIV and AIDS Prevention and Control Act, 2014, has been rightly criticized for potentially criminalizing certain kinds of HIV transmission and for compelling pregnant women (and their partners) to be tested for HIV.

It is felt that the law will result in people avoiding testing in order that they cannot be accused of attempted or intentional transmission of the virus. However, pregnant women who are not tested are unlikely to receive prevention of mother to transmission treatment or treatment for their own infection.

But there are other flaws in the act, which appears to have been put together in a hurry and without any proof reading. For a start, it seems to be assumed that HIV is almost always transmitted through sexual intercourse, aside from transmission from mother to child.

In Uganda, this is ridiculous. Children with HIV negative mothers were found to be HIV positive in three separate published studies, in the 80s, the 90s and the 2000s. More recently, several men taking part in the Rakai circumcision trial were infected even though they did not have sexual intercourse, and several more were infected despite always using condoms. (There are links to all the studies on the Don't Get Stuck With HIV site.)

The act makes no explicit mention of non-sexual transmission through cosmetic and/or traditional skin-piercing practices, though tattooing and a handful of other practices are mentioned. But there is no mention of circumcision (or genital mutilation), male or female, whether carried out in medical or traditional settings.

The above incidents raise questions about the act's definition of 'informed consent', which requires that people be given "adequate information including risks and benefits of and alternatives to the proposed intervention". Were mothers informed about all of  the risks that their infants faced? Were they even made aware of risks to themselves, through unsafe healthcare?

Were the men in the Rakai trial informed about unsafe healthcare risks? Trials should not endanger the health of those taking part, and participants should be adequately informed about the risks. But where people appear to have been infected with HIV as a result of taking part in the trials, this possibility has not even been investigated.

The act does not include transmission as a result of infection control procedures not being followed (or not being implemented). Nor does it include careless transmission, as a result of not following (or implementing) procedures, not training personnel adequately, not providing health facilities with the equipment and supplies needed, etc. The Ugandan state itself has an obligation to prevent and control HIV transmission, according to the act.

Curiously, the act states that there will be no conviction if transmission is through sexual intercourse but protective measures were used (also if the victim knew the accused was infected and accepted the risk). Protective measures probably include condoms, but do they also include antiretroviral treatment? Vast claims are made about reductions in HIV transmission when the infected party is on treatment. Yet people have been convicted of intentional transmission in countries other than Uganda; being in antiretroviral treatment didn't always protect them from conviction.

Part one of section 45 reads: "All statements or information regarding the cure, prevention and control of HIV infection shall be subjected to scientific verification"; part three reads: "A person who makes, causes to be made or publishes any misleading statements or information regarding cure, prevention or control of HIV contrary to this section commits an offence and shall be liable on conviction...".

So it’s not just pregnant mothers and other parties who may fall foul of the HIV Prevention Act. Those who wrote the act may have contravened it themselves in a number of ways. Even those running drug and other health related trials, health practitioners and traditional and cosmetic practitioners may also risk contravening the act.

South Africa: Don't Panic About Ebola, We Have Extremely Effective Surveillance Systems

Some may beg to differ with the health minister. While TB is very different from ebola, South Africans will (I hope) recall hearing about an epidemic of multidrug-resistant (MDR) and extensively drug resistant (XDR) TB being transmitted in health facilities in South Africa and surrounding countries, perhaps since the early 2000s. Scaremongering about infectious disease outbreaks doesn't do anyone any good, but nor does underestimating the ease with which diseases can spread, within a country and internationally.

A three decade HIV pandemic has shown us that surveillance systems on their own are not enough. The XDR/MDR epidemic is very closely connected with the HIV epidemic in South Africa and has been attributed to poor infection control. Countries that wish to control disease spread need strong health systems. However, the reaction to HIV has not been a sustained strengthening of health systems as a whole, but rather a vertical, cherry-picking approach. The result is that most countries in sub-Saharan Africa now have crumbling health systems, massive shortages in skilled health personnel, inadequate equipment and unreliable vital supplies.

Conditions are so dangerous that UNAIDS advises UN personnel not to use health facilities in developing countries, although the institution seems to believe that the same facilities are fine for Africans. Guinea, Liberia and Sierra Leone have relatively low HIV prevalence, whereas the number of HIV positive people in Nigeria could be the second highest in the world; South Africa is home to the highest population of HIV positive people. This has only weakened health systems further.

Nor is there any need to single out South Africa, Nigeria or the three countries that have the worst ebola outbreaks so far. There are Service Provision Assessments and other reports for many African countries showing that basic supplies such as gloves, soap and water, drugs, even injecting and other equipment, are frequently lacking. There are also scores of articles alluding to dangerous conditions, some published many years ago.

The South African health minister, and health ministers in all African countries, would be better off using outbreaks of ebola, MDR and XDR TB, hepatitis and HIV as arguments for investing in health systems that can provide safe health services for everyone, rather than for the rich alone, or for those suffering from headline grabbing diseases. Nosocomial TB in South Africa is thought to have started more than ten years ago, and affects many health facilities, in several countries. Therefore, there have been numerous outbreaks over that period, not just a few isolated instances.

Many of the people who have died of ebola are health professionals and others who are probably more aware of the risks they face than their patients are. Claiming that health systems are fine and that they are able to cope is a betrayal of the work their health professionals are doing. Minister Dr Aaron Motsoaledi should tell the WHO and other international institutions something that is an open secret about healthcare safety in African countries - it is in very urgent need of attention.

Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics

An article in a Nigerian newspaper highlights the very serious hepatitis epidemic there, with an estimated 20 million people, about 12% of the population, infected with either hepatitis B (HBV) or C (HCV). Although one of the ways HBV can be transmitted, and the way HCV is usually transmitted, is through blood, it is less common to find explanations of why or how people come into contact with someone else's blood, or how to avoid this.

The Don't Get Stuck With HIV site gives details of numerous ways you can come into contact with someone else's blood through healthcare, cosmetic and traditional practices. Healthcare practices include antenatal care, birth control injections and implants, transfusions, child delivery, dental care, donating blood, injections for curative and preventive reasons, catheters, male circumcision and others.

Cosmetic practices include manicures and pedicures, shaving, tattooing, body piercing, use of Botox and other products, performance enhancing drugs and perhaps colonic irrigation. Traditional practices include male and female genital cutting (FGM and MGM), traditional medicine, scarification and various other skin-piercing practices.

The Don't Get Stuck with HIV site also lists some of the steps you can take to protect yourself from exposure to HIV, HBV, HCV or other bloodborne pathogens, even ebola. The site also links to articles and sources of data about unsafe healthcare, unexplained HIV infections and other indications that risks for bloodborne transmission of various viruses are not always so widely recognized.

As a result, people often don't know there is a risk and they don't know how to protect themselves. This is as true of HIV in high prevalence countries with inadequate health services, HBV and HCV in countries where those viruses are common, and even ebola or other haemorrhagic viruses, when such an outbreak occurs. Indeed, ebola epidemics have only occurred in countries where healthcare is known to be unsafe, such as Democratic Republic of Congo, Sudan, Uganda, Guinea, Sierra Leone, Liberia and most recently Nigeria.

Two lengthy reports on healthcare safety in Nigeria have been published in the last few years. The second was a survey using the WHO's 'Tool C', also used for the survey from Philippines mentioned in a recent blog. Bearing in mind the warnings we are currently hearing about ebola, and the warnings we should have been hearing about HIV and hepatitis:

"Of the health facilities observed, only 23 (28.8 percent) had soap and running water for cleansing hands, and no facility had alcohol-based hand rub available.

Overall, fewer than half of all injections observed were prepared on a clean surface...

They found that injection providers only washed their hands in 13 percent of cases; none used an alcohol-based hand rub...

Fewer than half of the providers were seen to use water or a clean wet swab to clean the skin before vaccination, therapeutic, and family planning injections...

For vaccination, in 79.7 percent of cases, auto-disable syringes were used.

However, for dental procedures, there were two observations where providers used sterilizable syringes, and of these two, one of them also used a sterilizable needle...

18.7 percent had a needle left in the diaphragm of a multi-dose vial.

When glass ampoules were used during vaccination, the providers used a clean barrier in 1 of the 11 vaccination injections observed. Providers used a clean barrier in the only such dental injection observed, 3 of 11 family planning injections, and 4 of 43 therapeutic injections observed (9.3 percent).

Providers generally used standard disposable needles and syringes (70 percent) for phlebotomy procedures, and lancets for procedures requiring lancing (78.6 percent). Providers were rarely seen to use safety devices such as auto-disable and retractable syringes...

62.6 percent of procedures were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs was unlikely (in 42 out of 67 hospitals and 20 out of 32 lower-level facilities).

[for blood draws and intravenous procedures] Overall, providers washed their hands with soap and running water in only 2 of the 99 observations.

Data collectors observed that patients shared a bed or stretcher with another patient in 17.6 percent of IV infusions. This was also the case for 4.5 percent of IV injection patients.

Data collectors observed that in 69.3 percent of cases, the provider used a clean gauze pad and gently applied pressure to the puncture site to stop bleeding after the procedure.

Only 10.5 percent of providers cleaned their hands with soap and water or an alcohol-based hand rub following the observed procedures. In the 35 cases in which there was blood or body fluid contamination in the work area, the area was cleaned with disinfectant in 20 percent of observations (see Table 14).

During interviews, five percent of providers (11 out of 217) reported that they used sterilizable needles in injections, phlebotomies, IV injections, or infusions. Of the 5 out of 187 supervisors who reported use of sterilizable syringes and needles, three said that fuel was always available to run the sterilizer, while the remaining two reported that fuel had been unavailable for less than one month at some point.

Half of the 80 health facilities had infectious waste (non-sharps) outside of an appropriate container."

This list includes only some of the risks to patients. There is also a section on risks to the provider, risks to other health staff, such as waste handlers, and risks to the community. Nigeria is unlikely to have the worst health facility conditions in Africa and there are many areas of healthcare safety requiring urgent attention.

When news reports about ebola constantly emphasize things like eating bushmeat and 'traditional' practices at funerals, think of the kind of conditions that can be found in Nigerian hospitals even when healthcare personnel are aware that an inspection is taking place. When reports about hepatitis concentrate on intravenous drug use and other illicit practices, and when reports about HIV seem to be almost entirely about sexual behavior, conditions in health and cosmetic facilities and contexts where traditional practices take place must also be relevant.

Seek and you shall Find: Evidence in Support of HIV Drug Sustainability

A recent piece of research claims to find that mass male circumcision programs do not result in 'risk compensation', the idea that some HIV interventions can result in an increase in 'risky' behavior, such as sex without condoms. Happily for those aggressively promoting mass male circumcision, they say they found no evidence of risk behavior. Whether they found evidence that it doesn't occur, rather than failing to find evidence that it does occur, is another matter.

Similar research into the use of pre-exposure prophylaxis (PrEP), the use of HIV drugs before some kind of exposure to HIV, such as through sexual intercourse with a HIV positive person, also found no evidence of 'risk compensation', although this research was carried out in the US; PrEP is more of a rich person's intervention at the moment.

And a meta-analysis of "every study that has looked at the sexual behaviour of people after starting HIV treatment" has found no evidence of 'risk compensation'. Most of the studies took place in African countries. These results must have found a welcoming audience at the HIV industry's annual back-slapping event that has just finished in Melbourne.

But these findings may suggest something very significant that the researchers have not mentioned: perhaps HIV positive people are nowhere near as promiscuous, careless and uncaring as they are depicted as being by the HIV industry thus far.

It is not known what proportion of HIV transmission is a result of sexual intercourse and what proportion is a result of other modes of transmission, such as exposure to contaminated medical instruments, unsafe cosmetic or traditional practices.

The assumption that most transmission is a result of sex is a prejudice, rather than an empirical finding. The assumption that transmission through various non-sexual routes is low is a result of not looking for evidence that would demonstrate such transmission and ignoring any evidence that comes to light, which it usually does inadvertently.

Those promoting mass male circumcision and other revenue streams do seem to be inordinately blessed when it comes to finding 'evidence' that the intervention is safe, acceptable, effective and worthy of the hundreds of millions that has been spent, and the billions that has been earmarked for moving from adult and child circumcision to include infant circumcision, the latter being a far more sustainable proposition.

Now that so much money can be made from various mass HIV drug administration strategies, such as pre-exposure prophylaxis, early treatment, treatment as prevention, treating HIV positive pregnant women for life (as opposed to a shorter course of treatment), etc, it seems unlikely that any of the big funders will wish to put much money into finding out how people in high prevalence countries are infected in the first place, and aiming to prevent such infections from occurring.

Of course, like infant circumcision, allowing a substantial number of people to continue to be infected with HIV is far more sustainable than aiming for the industry's claimed goal of virtually eliminating HIV by 2030. A steady stream of new infections from the worst epidemics should keep the industry afloat for at least a few more decades, and perhaps even ensure their survival for the rest of the century.

Kenya's HIV Prevention Revolution: Beating Swords into...Condoms

Kenya's recently published 'HIV Prevention Revolution Road Map - Count Down to 2030' presents various HIV data for each of the 47 counties, based on their new constitution. National prevalence is estimated at 6%, 1.6 million people (compared to 5% in the latest Aids Indicator Survey). But instead of getting rough data for each of the 8 provinces, it is now possible to see just how heterogeneous the country's epidemic is.

Prevalence ranges from a very low .2% in Wajir to a massive 25.7% in Homa Bay, 128.5 times higher. The estimated number of people living with HIV in Wajir is 500, compared to 140,600 in Homa Bay, 281 times higher. Of course, people can work that out for themselves. But try working out how the situation in these counties can be so different if you also believe that HIV is almost always transmitted through sex.

Because that is the conclusion of the experts who put together this research. The contribution made by Homa Bay alone is said to be roughly the same as the contribution of sex workers plus their clients in the country. Over 60% of new infections are said to be a result of the sexual behavior of the populations of 9 counties, making up less than a quarter of the population. In contrast, the 10 lowest incidence counties are said to contribute 1% of all infections, through their sexual behavior, of course.

It is now claimed that 93.7% of all new cases of HIV are sexually transmitted. Only 20% of the hundreds of millions of dollars being pumped into the epidemic is to be spent on prevention, and most of that will be spent on condoms, finger wagging and a lot of other rubbish that has failed to have any influence on the epidemic so far. And yet it is expected to reduce transmission to about 1000 cases by 2030.

One of the most disturbing aspects of the report is a photograph that sums up the attitude of UNAIDS and other big players in the HIV industry (a lot of drugs are being sold through reports like this) towards Kenyans and other Africans. It depicts a crowned 'King of Condoms', with a paper crown on his head, demonstrating to the country's first lady how to put a condom on a wooden dildo, while others look on.

Or perhaps others don't see that as an instance of crass infantilization? Perhaps they don't find anything questionable about the idea that HIV is transmitted almost entirely through sexual behavior in African countries? But the assumption is based on an entirely flawed 'Modes of Transmission' spreadsheet, rather than on research. Thirty years into the epidemic, with next to nothing to show for the billions that have been spent on prevention, shouldn't we start collecting empirical data to guide future efforts?

Why 'Reducing HIV Transmission' Must Never be an Excuse for Genital Mutilation

The English Guardian has put together figures for female genital mutilation (FGM) and the top ten are Somalia, Guinea, Djibouti, Egypt, Sierra Leone, Mali, Sudan, Eritrea, Gambia and Burkina Faso. But the top ten for HIV that I have been looking at recently are Swaziland, Botswana, Lesotho, South Africa, Zimbabwe, Zambia, Namibia, Mozambique, Malawi and Uganda. The table below shows just how dramatic the non-correlation is.

The English Guardian is calling for an end to FGM, of course. But a far less dramatic non-correlation has been used to justify three randomized controlled trials of mass male circumcision in African countries. The results of these trials are have been used to justify a continuation of mass male circumcision, involving tens, even hundreds of millions of men, boys and infants and several billions of dollars. While HIV prevalence is lower among uncircumcised men than circumcised men in some countries, it is lower among uncircumcised men in others, while in several more countries circumcision status makes no difference. The correlation coefficient is roughly zero.

Results of further research into mass male circumcision is being presented to 16,000 attendees at the Melbourne HIV conference this week, research carried out on people who are not aware that they are guinea pigs for the current obsession with the operation. Because, as the figures show, we have no idea why circumcision sometimes appears to 'protect' against HIV and why it sometimes appears not to. Nor do we have any idea what proportion of HIV is transmitted through sexual contact and what proportion is transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

Similarly, we have no idea why HIV prevalence is so high in some African countries but so low in others. The fact that HIV prevalence is very low in countries that practice FGM is not seen as justification for carrying out trials of the operation on millions of people and presenting the results at an international HIV conference (such trials would probably be carried in secret). In fact, it is assumed that FGM status is seen as irrelevant to HIV transmission, and that, even if it is somehow relevant, carrying out trials into the operation as a HIV intervention would be entirely unethical.

International health and development institutions, the UN, the mainstream media, political and religious leaders all around the world, and many others, condemn FGM and would not consider it as a means of reducing HIV transmission. They would not even condone carrying out field trials into any kind of FGM, not even the less damaging kinds, not even the kind that leaves no permanent damage, because it is not ethically justifiable to carry out such an operation for no medical reason, on infants, children, or even unconsenting adults. Quite right, too.

But the research carried out by the people slapping each other on the back in Melbourne, presumably at some considerable cost, were financed by the likes of the Gates Foundation (which also funds the English Guardian's Development section, where the FGM article appears), FHI 360, Engender-Health and University of Illinois at Chicago. Several (if not all) of these institutions have their origins in a 'population control' theory of development, the belief that the population of developing countries is too high, and lowering birth rates will increase development and reduce poverty; less polite people would call this 'eugenics'.

I wonder if these parties have some information about, or beliefs about, mass male circumcision having some negative influence on fertility. Because, if they were to believe the same thing about FGM, would they also promote it with the same energy and persistence (and funding, and institutional backing)? What about other means of reducing fertility, such as Depo Provera, which has been associated with higher rates of HIV transmission? Gates and other 'population control' organizations certainly do promote that.

So promoting your favorite 'public health' intervention as a means of reducing HIV when the evidence is slim is bad enough. But this intervention involves something that is ethically unjustifiable unless it is carried out for medical reasons. So these various parties went a step further: they carried out, and continue to carry out, 'trials' of this operation on millions of people. The excuse is that it 'reduces HIV transmission'. But using that kind of evidence, so does FGM.

Genital mutilation without consent is not ethically justifiable; the fact that HIV prevalence is lower in countries where genital mutilation is common does not justify mass male circumcision programs, where millions of people are unwitting guinea pigs to this neo-eugenicist experiment. Those promoting mass male circumcision programs, funding them or working on them are involved in a crime of inestimable proportions, and must be stopped.

Kenya: Needle Exchange Programs Could Save Lives

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

Despite the success of needle exchange and other harm reduction programs around the world, there people and institutions who still reject them. Even though injection drug use is said to contribute a relatively small proportion of HIV infections in Kenya, apparently some community and religious groups don't always wish to support them. Perhaps they do not understand harm reduction?

Canada has been particularly open to needle exchange and other programs, and the view that "Drug users shouldn’t be given clean needles...it only encourages them" is a minority view now, thankfully. If needle exchange reduces transmission of HIV and hepatitis, it must be encouraged. While it may not cut injection drug use directly, it provides a means of reaching out to users in a meaningful way.

Persecuting durg users and suspected drug users, searching and questioning them, using possession of syringes as a reason for arresting them and confiscating their injecting equipment, do not ultimately result in a reduction in injecting drug use. Worse still, these actions result in users facing potentially more dangerous conditions, as well as increasing syringes and needle reuse.

Community and religious groups may be influenced by a hangover from the Bush era. Bush had a sort of 'victorian' influence; if he believed something, no matter how stupid, his supporters (sort of hard to believe he had them, but he must have) would believe the same thing. This is especially true of his supporters who were in receipt of US funding for their activities.

The contribution of prison populations to the HIV epidemic in Kenya is also said to be high. Even Canada, the US and Australia don't have a needle exchange program in prisons, but it would be wise for Kenya to establish where infections are coming from among prisoners.

Aside from the copious innuendo about what men do in prisons, male to male sex is likely to be an issue in a country where it can land you in prison. Prisoners must face other risks, too. Injection drug use is one possibility, but also perhaps tattoos, body percing, blood oaths, traditional practices occur in prisons? Even sharing razors and other sharp objects carries some risk.

Kenya's Modes of Transmission Survey is not a reliable means of estimating the combined contribution of several groups, such as injection drug users and prison populations. People who fall into these groups may face a high risk of being infected, yet few intervention programs are currently aimed at them.

Needle exchange programs would be a good start and may help to launch other programs, such as opioid replacement therapy, in the long run. But other programs addressing prisoners, men who have sex with men, sex workers and others could address between 20 and 30% of HIV transmission, which is a very substantial figure.

Too many African countries have been swayed by Western prudishness about sexual behavior in their approach to HIV. They have adopted some of the homophobia, xenophobia and other prejudices on which various wars on 'terror', 'drugs' and the like have been based. This has not led to rapid reductions in HIV transmission; so it's time for a change.

[For more about HIV transmission through unsafe healthcare and cosmetic practices, visit the Don't Get Stuck With HIV site.]

The Only Certainty About Unsafe Healthcare and HIV is Ignorance About It

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

An article by Ndebele, Ruzario and Gutsire-Zinyama, who work for the Medical Research Council of Zimbabwe, claims to dismiss the 'wait and wipe' finding, which came from circumcision studies carried out in Africa. This refers to the finding that men who waited at least 10 minutes after coitus and used a dry cloth to wipe their genitals were far less likely to be infected with HIV than both circumcised and uncircumcised men who did not follow this procedure.

What is most extraordinary about this finding is that it has been feebly denied by some, but ignored by far more; in contrast, the findings about a rather weak association between circumcision and HIV transmission was used to push an extremely aggressive, well funded and loudly publicized program to circumcise as many African males, both teenagers and children, as possible.

One should no longer be surprised when researchers embrace the results they expected, while at the same time distancing themselves from those they don't expect, and certainly don't want. The 'wait and wipe' finding was presented at a conference some time back and was covered by US media. But it never received the attention, or subsequent funding, that mass male circumcision programs received.

So, seven years after those hyped mass male circumcision programs started, and a claimed several million men and boys circumcised under the programs, no further research appears to have been done into this interesting finding. Ndebele et al, who don't seem aware that HIV prevalence in Zimbabwe is higher among circumcised men, rebuke several commentators, including myself, for suggesting that 'wait and wipe' could become an alternative strategy to circumcision.

What I said was that appropriate penile hygiene is a lot simpler, cheaper, safer and less invasive than mass male circumcision. The circumcision enthusiasts have encouraged people to associate circumcision with hygiene, but they have never shown that HIV transmission has anything to do with penile (or vaginal) hygiene. It simply suits their purposes that people seem ready to believe in such a connection.

So how can Ndebele et al question the findings about penile hygiene without also questioning those about mass male circumcision? And how can they not call for further research to be carried out? They accuse myself and other commentators of engaging in 'pure speculation', which we do engage in. But we are not the ones who collected the original data, some of which we now wish to selectively dismiss, and the rest of which we wish to use to aggressively promote circumcision programs.

So they proceed to engage in pure speculation of their own, and they seem to believe they are 'dismissing' arguments about the possible role of unsafe healthcare with a rhetorical question: they ask "With all the campaigns on safe needles that have been going on, where on earth can one still find health professionals using unsafe needles?" The answer is that syringe reuse is likely to occur in every high HIV prevalence African country.

Merely running a campaign about unsafe healthcare and syringe reuse does not reveal the extent of HIV transmission through these routes. Nor does running a campaign ensure that unsafe healthcare simply ceases to be an issue after a few years. No number of strategies, position papers, frameworks, roadmaps, multi-page reports, toolboxes or other pen-pushing exercises so beloved by the HIV industry will tell us the extent of non-sexual transmission of HIV through unsafe healthcare.

Nor will 'putting unsafe healthcare on the agenda' (no matter for how long) ensure that any meaningful changes will come about. Most people know little about non-sexually transmitted HIV and are constantly told that 80% of transmission or higher in Africa is a result of unsafe sex. Researchers rarely even mention HIV transmitted through unsafe healthcare, except to dismiss it, without evidence.

The authors argue that the results they wish to embrace are correct and that the results they wish to deny are merely a "coincidental finding", and conclude that "there is no need to conduct further research" into the 'wait and wipe' finding.

This just about sums up the HIV industry's approach to mass male circumcision. This has been a process of scrabbling about for data, any data which appears to support the program, and denying or ignoring any data which shows the program to be a hoax; all cobbled together by greedy (and probably somewhat pathological) 'experts', who will do anything to promote circumcision, ably supported by an institutionally racist HIV industry.

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

Could PrEP be in Competition with Mass Male Circumcision Programs?

[Reposted from the Pre-Exposure Prophylaxis (PrEP) Blog]

After years of trying to create a market for pre-exposure prophylaxis (PrEP) pills, such as Truvada, Big Pharma has turned to their favorite mass marketing ploy: dumping their products in African countries that are starved of health funding. Of course, why wouldn't they dump them in Africa, won't they be paid for with donor funding?

An article in Kenya's The Star entitled "Kenya: 'Wonder Pill' for Risky Sex On the Way" takes the unusual step of raising some difficult questions about PrEP, rather than repeating the Big Pharma press release, despite a shaky introduction. The article continues "Kenyans involved in risky sex behaviours will soon get a 'wonder pill' that can prevent HIV infections. Experts say Truvada, which some call the 'new condom', can reduce chances of catching HIV but there are fears the drug may be misused by the youth".

What, exactly, would constitute misuse of the drug? If it can cut the risk of infection by "up to 75 per cent if one faithfully swallows it daily", what could go wrong? Well, as the article eventually reveals, most people don't swallow drugs daily and most people can not expect 'up to 75%' reduction in risk. That figure is not even from a randomized controlled trial, but from a 'sub-group' study, where the best results are used to exaggerate the level of protection people, in (comparatively) strict trial conditions, may expect. Outside of that sub-group, and outside of drug trial conditions, risk reduction is far lower.

It's odd that such reports talk about studies and proofs for something that they then refer to as a 'wonder pill', a 'new condom' and talk of 'up to 75% protection' (although that's a bit weak compared to the term 'invisible condom' used by those marketing mass male circumcision), and the like. These are PR buzzwords, not scientific findings.

It is said that PrEP programs intend identifying those most at risk of being infected, such as sex workers, intravenous drug users and men who have sex with men. This will be a departure from vilifying these already stigmatized and criminalized groups; it remains to be seen how much donor funding will actually be spent on these groups to provide them with PrEP, given that it has been so difficult in the past to provide them with condoms, injecting equipment and even basic sex and sexuality education.

As the article says, Truvada is expensive, and it has made billions of dollars for Gilead. So it's worth their while pushing as much of the stuff as possible in countries with high HIV prevalence while the patent guarantees that their product will face little competition. By the time the patent expires the likes of Bills Clinton and Gates will surely have set up some program whereby the drugs can continue to be purchased at inflated prices.

The article makes the important point that nearly 1 million HIV positive Kenyans currently need antiroviral drugs just to keep them alive. So why would donors want to provide these same drugs to people who are not yet infected with HIV (aside from an obvious desire to enrich big pharma)?

Oddly enough, a cost effectiveness study makes its estimates using existing levels of male circumcision and antiretroviral therapy. This means that the three multi-billion dollar programs will be in direct competition with each other for funding, and each one will be trying to claim that any drop in HIV incidence is a result of their work. The study also seems to assume far higher levels of success than have been achieved so far. But that's big pharma for you.

While Gilead and other pharmaceuticals can gain a lot from any increase in antiretroviral therapy and PrEP programs, they may not stand to gain from mass male circumcision programs. Their assumption that their PrEP programs will be cost effective only in countries where circumcision levels are low suggests that by the time their product may be approved, the circumcision programs will already need to have failed, some time around 2015.

Worries that people may use PrEP as a kind of recreational drug, so they can dispense with the use of condoms when they are engaging in sex with people who may face a high risk of being HIV positive are not very convincingly addressed; nor are worries that overuse and misuse of antiretrovirals, either for HIV positive people or as PrEP, are brushed aside, with remarks about "government policy" and making the drug available "in form of a package that probably includes HIV testing and other prevention methods".

I seem to remember condoms, circumcision, ABC and various other programs being made available in the form of a package, without that leading to extraordinary results. But it will be interesting to see if PrEP will erode some of the funding currently being made available to, or earmarked for, mass male circumcision programs.

Circumcision programs stand to rake in billions for the big providers, but widespread use of PrEP would be worth far more. It's unlikely that a full scale version of both programs could co-exist; they are not mutually exclusive, but their cost effectiveness is predicated on their being the only or the main program in high HIV prevalence countries.

Whether one program displaces another, or whether they all get funded, the losers will be people in high HIV prevalence African countries, which will continue to suffer from under-funded health and education sectors. They will continue to be a mere 'territory' for sales reps, who will continue to carve things up in ways that should be very familiar to us by now.

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

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

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

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

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

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

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

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

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

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

The Sound of a One Legged Argument Kicking Itself

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

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

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

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

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

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

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

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

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

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

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

Concurrency Regurgitated: Dubious Evidence Found Increasingly Credible by Experts

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

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

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

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

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

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

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

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

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

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

Presentation at Kilimanjaro Clinical Research Institute

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

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

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

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

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

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

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

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

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

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

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

Sometimes Targets of Prejudice Embrace that Very Prejudice Themselves

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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