Pregnant African Women Face Both Sexual and Non-Sexual HIV Risks

Researchers in South Africa aiming to estimate how many pregnant women were in the 'acute' phase of HIV infection, where their status would be undetectable using ordinary HIV tests, found that an astonishing 38% of women were HIV positive. They estimate the yearly rate of infection at over 11%.

It doesn't take a genius to work out that at these rates, the majority of women will be infected or dead from AIDS by the time they are in their thirties. These rates may have been found elsewhere, but they are still shocking. And yet, these researchers seem to think that they will achieve something by testing more and more people with better and better testing methods.

How are they being infected? The article assumes that most transmission is through heterosexual sex but this is just not credible. Some of the women were very young, they would hardly have had enough time to have enough sexual experience to become infected with a virus that is difficult to transmit through penile-vaginal sex.

If they are being infected by HIV positive men, who are these men? Incidence among men of similar age is often ten or more times lower. While it is argued that young women have sex with older men, who are more likely to be infected, are there even enough older HIV positive men to explain incidence figures among women? And are these women having sex with them? These have never been demonstrated.

Earlier research in South Africa has suggested that the probability of transmission is often 1, that a woman can become infected despite having only one partner and possibly even only having unprotected sex once. Would the researchers like to claim that there is a different strain of HIV in South Africa? Has the possibility of such transmission rates through heterosexual intercourse ever been demonstrated?

I don't believe so. I believe a lot of things are assumed, despite evidence to the contrary. And the authors of this paper go on making those assumptions. But HIV transmission will not be prevented if we don't even know how it is occurring. Rather than establishing how they may have become infected, it is assumed that most African women were infected sexually and conveniently forgotten that the chances of this happening to a few women, let alone to many, are extremely low.

Non-sexual HIV transmission must be considered. Most women, African and non-African, even young women, do not take stupid risks when they are pregnant. Most women don't take stupid risks even when they are not pregnant. Many HIV infections among pregnant women occur once they are already pregnant, often long into their pregnancy.

Transmission rates may well be higher among pregnant women, but so is the number of risks they face from being infected through unsafe injections or other medical procedures. And interestingly, the percentage of women in South Africa who visit an ante-natal clinic several times during their pregnancy is in the 90s. Compare that to a country like Tanzania, where some may visit once but the majority never visit at all, and where rates of transmission are many times lower than in South Africa.

Is it just a coincidence that HIV rates are often lower in areas where people don't have access to health services? Perhaps it is. But it is vital to find out if it is a coincidence. If it isn't a coincidence, then health services could be busy spreading the very virus they are supposed to be preventing.

HIV Policy Needs to Follow Health Policy, Not Vice Versa

Following my last post, I received a comment raising the issue of the role of sexually transmitted infections (STI) in HIV transmission. This is a vital issue so I gave a brief response but promised to answer more fully in a blog post.

Firstly, health is not just a matter of absence of disease, so health policies should aim to prevent diseases where possible, as well as treat them.

This has clearly not been done with STIs. Preventable and treatable STIs are endemic in many developing countries and, regardless of whether they play a role in HIV transmission, sexual health is in urgent need of prioritization.

Very high levels of STIs, and of all easily preventable or curable diseases, are a symptom of poor health services, services that have been declining for decades. Concentration on HIV has often meant that STIs and other diseases have been ignored, so this has added to the serious STI epidemics that have developed.

However, the role of STIs in HIV epidemics has not been clearly demonstrated and there have been conflicting reports, especially where tests with treating STIs as a HIV prevention intervention have been carried out.

There is an interesting article on this subject called "Confound it: latent lessons from the Mwanza trial of STD treatment to reduce HIV transmission", by David Gisselquist and John Potterat. This is about the STI treatment trial in Mwanza, Tanzania which, according to the researchers involved, showed that reducing STIs could reduce HIV transmission.

The researchers' claim is odd because STIs were not reduced much during the trial, yet HIV transmission did seem to be reduced. Also, similar trials were carried out in two other locations and neither of them demonstrated any benefits for STI treatment.

Gisselquist and Potterat have two suggestions as to why the trial results in Mwanza differed so much from the two in Uganda. For a start, those taking part in the Mwanza trial appear to have received safe health care, which is something most East Africans don't receive. And there happened to be an injection safety initiative taking place at the same time as the STI trial.

The authors warn that continuing to target STIs without also improving health services by making it far safer, especially in relation to injection practices, there is a risk that transmission of HIV and other blood borne viruses will increase.

In the mid 1980s in Nairobi, HIV rates were found to be over 80% among sex workers at a time when they were extremely low among males in the city. The hypothesis, still the dominant hypothesis about HIV transmission in African countries, was that these women were infected through sexual intercourse with HIV positive men.

But if few men were infected, that seems unlikely. To explain such high transmission rates among women, even though they were engaging in high risk sex on a regular basis, the possibility that they were infected through health services must be investigated.

After all, there was an STI reduction program in Nairobi targetting sex workers in the early 1980s. As far as I know, this program did not target sex worker clients, which may well explain why HIV prevalence among men, in Nairobi and most other parts of Kenya, has never been as high as it has been among women.

Not only is it possible for HIV to be transmitted rapidly through unsafe health care, it is far more likely than transmission through unsafe sex. The transmission probability for many health practices is many times higher than the transmission probability for penile-vaginal sex.

Blood transfusions, for which the transmission probability is extremely high, may well have been made safer very early on in the epidemic. But most people don't have transfusions, whereas many people do receive injections and other invasive procedures. And the safety of these procedures has never been adequately assurred.

If these comments are even partly correct, not only is current UNAIDS policy allowing many people to become infected with HIV and other diseases; but it is also ensuring that many people become infected who might remain healthy if they ignore the health advice they are likely to receive. That's if they even have the option to ignore the advice.

Targeting STIs is a good thing in itself and may even reduce sexual transmission of HIV. But there is little point in reducing sexual transmission while at the same time increasing non-sexual transmission, especially that through unsafe injections and other procedures. HIV policy needs to follow health policy, not the other way around.

What Do UNAIDS Call a HIV Positive African? Promiscuous

To continue yesterday's theme about the difference between HIV in Western countries and HIV in high prevalence countries, most of which are in sub-Saharan Africa (SSA):

Treatment with antiretrovirals (ART) is widely touted as a type of HIV prevention because if people are responding to ART their viral load should be low and they should be far less likely to transmit the virus.

In Switzerland, in particular, HIV positive people on ART have been told that they could have unprotected sex and that the risk of transmission would be very low.

However, in SSA countries, people are not given the same advice. But also, it has been suggested that people who are on ART could experience 'disinhibition'. They could engage in higher risk sex because they think their treatment means they are less likely to transmit the virus.

Conditions in SSA are very different from those in Switzerland. For a start, perhaps a majority of people, certainly a lot of people, don't know their HIV status. When it comes to preventing sexually transmitted HIV, the more precautions people take, the better.

Even those who promote the rather unconvincing 'treatment is prevention' strategy admit that if treatment results in significant disinhibition, the modeled reductions in transmission will not occur.

So far, so good. It could be argued that conditions are so different in SSA and in Switzerland that the advice given to HIV positive people on ART should also differ.

But many articles have come out about how disinhibition doesn't occur in SSA countries. And at the same time, articles have also come out about how it does occur in Switzerland.

It would be very convenient if levels of disinhibition in SSA were not high enough to cancel out gains, but it also sounds a lot like wishful thinking. Especially if, in practice, disinhibition does occur in Switzerland.

The orthodox line about HIV, a virus that is difficult to transmit sexually, is that over 80, perhaps over 90% of it is transmitted through heterosexual sex in African countries.

In wealthy countries, the virus is usually transmitted through anal sex or through intravenous drug use. It is not much transmitted through heterosexual sex.

We are supposed to believe that, despite the difficulty of transmitting HIV through heterosexual sex, Africans do so because they have such exraordinary sex lives. But if they have these extraordinary sex lives, why is disinhibition so unlikely?

As I say, probably wishful thinking. Which is not really a good basis for a HIV treatment strategy, and even less so for a prevention strategy.

In countries where hundreds of thousands or even millions of people are infected with HIV, so many will not know their status and so many will not be on treatment even if they need it, treatment and prevention need to continue to be driven by separate initiatives.

There is little point in putting more and more people on treatment and hoping that they will adhere to the drug regime as they need to, supposing their supply of drugs even keeps up with their needs, unless efforts are also made to reduce the incidence of new infections. Drugupplies are often too unreliable to ensure that viral load will always be kept low.

But many people, also, are not being infected sexually. This means that they will not know what risks they are facing when they visit health facilities or anywhere else they may be exposed to contaminated blood or bodily fluids.

It is popular to talk about the need to test as many people as possible and to test people as often as possible. Despite this, most people have never been tested and the ones that have been, have only been tested once.

Testing on its own is not enough. It also needs to be established, for each person who becomes infected, how they are infected. The fact that they are sexually active does not mean they were infected sexually. Many people are sexually active and some of them become infected with HIV, but their partner is not positive. This means they were probably not infected sexualy.

It may take a bit of work to establish how people were infected, especially as most people will blame their own sexual behavior because they have the heterosexual theory of African HIV transmission drummed into them. But it is vital to take appropriate steps to reduce HIV transmission. Assuming that most transmission is sexual does not lead to appropriate steps.

In addition to testing and retesting, there needs to be an honest and creadible assessment of the risks people face and of all the likely routes to transmission. Those who are positive need to be assessed for treatment and those who are negative need to be made aware of all the HIV transmission risks they face, sexual and non-sexual.

HIV transmission rates are still very high in many countries. Transmission needs to be reduced. Treatment of those infected alone is not likely to reduce transmission enough. We have to keep our eye on non-sexual transmission as well as sexual transmission. Concentrating on sexual transmission alone, for example, by targeting discordant couples, is not going to protect them from non-sexual transmission.

All that remains now for HIV epidemics to be turned around is for UNAIDS and their HIV industry friends to lose their highly prejudiced views of African people and to treat Africans as they do their own employees and Westerners, who seem to be considered far more important than Africans.

Apparently, the Truth About HIV is Relative to Nationality and Wealth

A typical article about HIV reads "Cheating spouses have always caused problems for their marriages." That may be so, but it does not mean that 'cheating' drives HIV epidemics in high prevalence African countries. Data about sexual behavior and HIV prevalence show that many people engaging in 'safe' sex become infected with HIV and many engaging in 'unsafe' sex remain uninfected.

It has long been recognised that the majority of HIV infections in several countries, Uganda, Kenya and others, come from people in long term relationships who only have one partner, many of whom take adequate precautions against sexually transmitted HIV.

Of course, you could engage in unsafe sex and become infected non-sexually. You are unlikely to ever find out because if you live in a resource poor country, especially an African country, it will be concluded that you were infected sexually.

Whether you are infected sexually or otherwise, it's good to take precautions against infection of any kind. But it would be pretty stupid to protect yourself against sexually transmitted HIV, for example, and turn a blind eye to the fact that your children are all receiving invasive medical treatment with unsterilized equipment.

Who would be stupid enough to do that? Perhaps people who have been bashed over the head for years about their sexual deviance. Indeed, their sexual deviance is considered so bad that the possibility of their being infected non-sexually by a virus that is difficult to transmit sexually is rarely mentioned.

The article in question, as they usually do, rants on about a discordant couple, where one partner is infected and the other is not. There is no mention of how the one partner became infected nor of how the other is in danger of being infected non-sexually as well as sexually.

Well, UNAIDS and the AIDS orthodoxy are not going to change their tune in a hurry. But they haven't even managed to persuade very many people to use condoms to protect themselves from infection or to get careful advice when they wish to become pregnant. They are even failing in their favorite field, sex.

So underinformed are the majority of people that they know as little about the dual role condoms play in reducing transmission of sexually transmitted infections and preventing unplanned pregnancy as they knew many years ago, before most people had heard about HIV.

The entire process of HIV prevention seems to consist of misinforming people. And the article even refers to a 'myth' about HIV negative people being protected when their partner is on antiretroviral drugs (ARV).

But this is not a myth, even according to the HIV orthodoxy. Big pharma and HIV Incorporated are trying to sell the idea that treatment is prevention; that because those on treatment have a low viral load, they are less likely to infect their partner.

Well, like the myth in the first paragraph, it's more of a half truth. The HIV/AIDS industry has been trying to sell the idea of taking ARVs instead of bothering to carry out any real prevention programs that they might not be able to make huge sums of money out of.

In some Western countries, discordant couples are advised that they can have safe unprotected sex as long as the infected partner has a low viral load as a result of successful ARV adherence. But this is not the advice given in African countries.

And it would be very stupid advice. If we haven't established how most people are becoming infected with HIV, we cannot advise them about what is and what is not safe behavior, about what they can do and what they must avoid.

And that underlines the biggest risk regarding HIV: being African. If you are African, you will not be  told that you face serious risks in health facilities and cosmetic facilities, not just through your sexual partner.

If you are African, you are almost condemned to being infected without anyone noticing until it is too late, especially if you are a woman who is foolish enough to get pregnant.

And when you are found to be HIV positive, because you are African, it will be assumed that you were infected sexually, regardless of how well you may have protected yourself, whether you have had sex or not or anything else. To be African, in the eyes of the orthodoxy, is to be promiscuous.

The most illogical thing is, just because people are promiscuous, and some are, everywhere, that doesn't mean you will be infected sexually. Therefore, the fact that you are infected does not mean you are promiscuous. UNAIDS and the rest of the industry may be obsessed with your sexual behavior, but they don't actually know anything about it, their frequent pronouncements notwithstanding.

An interesting feature of HIV myths is the fact that both those who are in danger of being infected with HIV or of infecting others, and those who are supposed to be responsible for reducing transmission, all have their own myths. And what is a myth in poor countries may be the orthodoxy in rich countries, and vice versa.

Giving Up Sex Will Not Protect You From HIV in Africa

All the HIV/AIDS industry has to do is put out a press release and the global media reproduces it over and over again, without question or analysis. It's hard to believe that such slavish repetition is what counts as journalism.

Even Alternet.org, with their pretentions of offering something different, just pick up whatever is thrown at them. A recent article, typical end of year stuff, rehashes all the hypes of the year about HIV, how it is all going to be sorted out in the end by technology.

The main worry about this sort of article is not that technology will never develop to the extent that it can treat, prevent and even cure HIV one day. The worry is that we don't have to wait till that happens before we do anything to prevent a lot, perhaps the majority of HIV infections in high prevalence countries. Yet, we are still waiting.

UNAIDS and their pharmaceutical industry chums have been putting about the idea that if only people would have less sex, everything would be ok. But some people don't have sex, or they are very careful when they do, and they still end up HIV positive. Others have lots of sex, even unsafe sex, and they generally do not end up HIV positive.

We even know who is likely to be infected. If they are female and living in a handful of mainly African countries, between one third and half of them will be HIV positive or dead before they are 40. Doesn't that strike people as a bit odd?

If they are not from one of those countries in question, they can have as much sex as they like, as long as it is penile-vaginal sex. Outside of high and medium prevalence countries, where epidemics are 'generalized', that is, not confined to high-risk groups, HIV is transmitted by intravenous drug use and anal sex, generally.

Unless you subscribe to the racist and sexist 'oversexed African' view of HIV transmission, and you're in the esteemed company of the entire HIV/AIDS industry if you do, you have to conclude that there is something we are not being told about HIV.

How can it be an almost exclusively sexually transmitted infection in a handful of countries and almost exclusively transmitted by anal sex and intravenous drug use in all other countries?

Even the HIV/AIDS industry knows that HIV is not exclusively, perhaps is not even mainly, sexually transmitted. They don't like to admit it, but sexual transmission of HIV is not very efficient.

However, non-sexual transmission modes, such as unsafe healthcare, are higly efficient. UNAIDS and the UN as a whole are well aware of this and they warn their own employees to avoid medical facilities in high HIV prevalence countries.

For some reason, they don't think it necessary to warn people living in high prevalence countries. Every tourist coming to African countries can read warnings about using health facilities in these countries. It's just people living in them who are not warned.

Worse still, UNAIDS denies that unsafe healthcare plays a significant role in transmitting HIV. They estimate that it may account for 2-5%, but that is certainly not enough for them to consider warning people who have to use health facilities that lack trained personnel, basic equipment and even soap and water.

Testing is of little value to populations as a whole if no attempt is made to find out how people are being infected. And no attempt is being made to find out. If someone is African, it is assumed they were infected sexually, even if they don't have sex, don't have unsafe sex or have a partner who is not infected.

Never mind the technologies that so many billions of aid money is going into, or the technologies that may one be developed. People are being infected, suffering, infecting other people and dying because they are being told half truths and outright lies.

HIV is tranmitted non-sexually, especially through unsafe healthcare. We need to tell people that so they can protect themselves and protect their partners and families. People will not be fully protected if they have 'safe' sex, take various drugs, use condoms or take any other precautions against sexual transmission. They also need access to safe healthcare.

HIV Stigma Doesn't Come from Ignorance, it Comes from Lies

UNAIDS' and the Aids industry's stigmatizing of HIV positive people has many consequences. If you resolutely claim that HIV is almost always transmitted sexually in African countries, people in African countries who are HIV positive will continue to be stigmatized. Telling everyone that HIV is driven by promiscuity means that everyone who is infected is considered to be promiscuous.

Some of the most vulnerable victims of the industry's stigmatization are sex workers or those assumed to be sex workers. Of course, according to UNAIDS, a huge precentage of African women are sex workers, even if they don't know it themselves.

Many women, whether sex workers or not, are aware of sexually transmitted HIV. Most women attend antenatal clinics when they are pregnant, if they can reach one. Those who do engage in transactional sex visit clinics if they can. In fact, the majority of women probably follow the strictures of the HIV industry, especially where they think they might be at risk.

Most women are not, however, aware of non-sexual HIV risks. Those visiting antenatal clinics or giving birth in health facilities are unaware that the majority of injections given in developing countries (70%) are unneccessary. A huge amount of HIV and hepatitis is probably transmitted in such facilities due to reuse of injecting or other equipment.

In some countries, HIV prevalence among sex workers has been found to be as high as 70 or 80%. How can this be? Especially when prevalence among men in the same areas is 5% or less. It is not possible for three quarters of heterosexual women to be infected when such a small percentage of men are infected.

Prevalence among young women of child-bearing age in some countries is 30 or 40%. It is nowhere near this level among men of any age. Who is infecting these women? The Aids industry doesn't even bother checking the status of partners of all these HIV positive women, let alone find out how they became infected.

Even if African women are as promiscuous as UNAIDS and the rest of the industry tell us, we don't know how they are becoming infected sexually, unless a sizeable percentage of men are also infected. There simply is no small group of HIV positive men who sleep with almost all the sexually active women in a particular population.

Sex workers face risks, there's no doubt about that. They have been stigmatized by UNAIDS and the industry to the extent that many of them are afraid to visit health facilities, though they know they have to. And they may be right to be afraid. Perhaps the massive rates of HIV prevalence found among sex workers and others attending sexually transmitted infection (STI) clinics face more serious risks in the clinics than they do from their clients.

But sex workers also face stigmatization and persecution from their clients, who often refuse to pay or demand more abusive or dangerous types of sex. They face stigmatization from police and security people and often have to pay bribes, in cash or by sexual favors. And they are stigmatized by the public, who have been told by UNAIDS and the industry that sex workers spread HIV.

Nauseating articles about how sex workers are so badly treated, when the same articles simply spread the industry stigma, do little to help. Sex workers need to know the truth: that HIV is not spread by sex alone. Indeed, everyone needs to know the truth. Sex may well spread HIV but so does unsafe medical treatment, cosmetic treatment, tattooing, traditional medicine and any other practices that may involve contaminated blood or other bodily fluids.

One of the biggest threats to reducing HIV transmission seems to be the very HIV researchers who don't bother investigating non-sexual HIV transmission, especially in health facilities for sex workers and for pregnant women. They seem utterly oblivious to the possibility that sex is not always transmitted sexually, even when it happens right under under their noses.

It's time to investigate the massive levels of HIV among sex workers whose clients are almost all HIV negative, the mothers whose husbands are HIV negative, the babies and children whose mothers are HIV negative.

Of course sex workers are treated badly and that needs to stop. But articles that simply repeat the half truths about HIV almost always being sexually transmitted is simply adding to the neglect of their health and welfare. The very stigma the Aids industry claims to abhor comes from the industry itself.

Of course the poverty that so many people have to suffer is terrible. But it is not poverty or lack of education, terrible things in themselves, that are driving the epidemic. HIV is a virus that is sometimes transmitted sexually, but not always, probably not even often. We can't continue to refuse to investigate the relatively simple question of the extent to which HIV is transmitted non-sexually.

It's not just sex worker clients, police and others who abuse sex workers and non-sex workers alike: it's researchers and academics who claim to be helping but who don't seem to be able to see Africans as ordinary human beings. Perhaps if they take that first step, the rest will be easy.

UNAIDS Happily Stoke Up HIV Epidemic Using Public Money

Someone recently raised the question in a Kenyan newspaper of whether a negative HIV test result in one partner implied that the other partner is also negative. The answer is a resounding 'No', but the person replying was not quite clear enough on the matter: "There are instances where one partner is HIV-negative and the other is HIV-positive".

In many African countries, half of the couples infected with HIV are discordant, meaning that only one partner is infected. And about half of those in such discordant relationships are female. People in discordant relationships can and do have unprotected sex, often for years, without transmitting the virus. And in couples where both partners are infected, it has often been found that they were both infected by a different source.

More worryingly, you can not imply the HIV status of a woman from the HIV status of her children. Not only can HIV positive women have HIV negative children but HIV negative women often seem to end up with HIV positive children. UNAIDS and others deny that this phenomenon is significant and very little research has been carried out to find out if they are right.

Indeed, the very mention of terms like 'nosocomial', 'iatrogenic', 'hospital acquired' (all meaning roughly the same thing) is something of a taboo. In the same way that people all over the world see talk about sex as taboo, the highly paid and overqualified people who make up the AIDS industry see talk about non-sexual HIV transmission as taboo. Perhaps it's a cultural trait or some kind of institutional tradition, who knows.

Things in Mozambique may be different. Most of the relevant publications are in Portuguese, but Dr David Gisselquist recently sent me some figures for HIV positive children with HIV negative mothers. It was kindly translated by a researcher who knows Portuguese. I just wonder how much other vital data is available but only in a language I don't know. I suspect there's a lot.

Anyhow, the proportion of HIV positive children with HIV negative mothers is around 30%. This is an alarming figure, suggesting that infants and children, as well as mothers (and the population as a whole), face serious risks of HIV transmission from unsafe healthcare.

The AIDS industry has always tried to diminish the likelihood of any form of non-sexual HIV transmission and a similarly embarrassing revelation a few years ago, that time in Swaziland, was dismissed as being a result of babies being raised by someone other than their birth mother. This unconvincing argument is quite telling, too; the industry is not interested and will not investigate.

Cock-ups in health services are not confined to dirt-poor countries with disasterous infrastructures and extreme shortages of skilled personnel and equipment. They also occur in countries that have very high quality, accessible healthcare systems. There have been numerous scares about healthcare transmission of HIV, hepatitis and other conditions. And recently there was a scare about a mother in the UK who was given the wrong (expressed) breastmilk for her infant, several times.

The figures for Mozambique are unlikely to reveal the full picture. Women with HIV positive children who are HIV positive themselves may not have infected their children. And it is also possible that some children may have infected their mother. Or they may both have been infected through different routes. Many women are found to seroconvert late in their pregnancy or just after giving birth. The AIDS industry assumes that this is because they continue to have unprotected sex, probably often with strangers, during their pregnancy.

This is an appalling attitude towards African people and, as it is not the received view of non-Africans, it must also be considered racist, institutionally racist. The picture that is painted of women is similarly bigoted and entirely sexist. In Western countries, if a HIV negative woman is found to have a HIV positive child, there is an investigation, not an outpouring of racist bilge.

To misrepresent HIV as a purely sexually transmitted virus (in African countries, alone) is to condemn people to a lifelong, debilitating disease that will likely reduce the sufferer's lifespan. It also condemns many people to a life of stigma, persecution, isolation and violence.

To stand by and watch people being needlessly infected with HIV is bad enough but to brand them as stupid, careless, ignorant, and even as evil, is beyond belief. The HIV industry, especially UNAIDS, need to be recognised as being more than just ineffective; they are also playing a significant part in fuelling the HIV epidemic.

UNAIDS' Obsession with Sex Helps Spread HIV

According to an article in Tanzania's Citizen newspaper, there is 'growing concern' that HIV transmission is increasing among those in long term relationships and in marriages. Yet HIV prevalence has been high in these groups for a long time. Tanzania may not have carried out a Modes of Transmission Survey recently, as Kenya and Uganda have done. But the three countries have similar epidemics.

The advice that having sex with a long term partner or spouse will protect you from HIV has never been quite true. 'Safe' sex practices may include reducing the number of partners you have and various other measures, such as using condoms, avoiding sexually transmitted infections, etc. But HIV is not, and has never been, solely transmitted sexually. It is also transmitted through unsafe medical practices, such as unsterile injections, traditional medicine, cosmetic practices, such as shaving and tattooing and perhaps other means.

Telling people that they will be protected from HIV if they 'abstain' from sex or obey any of the other paternalistic strictures of the predominantly right wing 'Christian' prevention programs that dominate African country HIV strategies is extremely unethical. Since HIV was first identified, it was clear that it was mainly transmitted through contaminated blood. Sexual transmission was also recognised, especially through anal sex. But the risk of transmission through heterosexual sex was and is quite low.

People are entitled to know that if someone is HIV positive, this does not mean they are promiscuous. You can not tell how someone was infected with HIV without investigating, and even then, the exact cause may still remain unclear. It is worth bearing in mind that heterosexual sex is not an efficient transmitter of HIV. But contaminated blood is a very efficient transmitter.

Many people who are HIV positive are unaware of how they were infected and assume that because they are not virgins, they must have been infected sexually. However, they need to find out if their partner is infected. And even if their partner is infected, they may still not have been infected sexually. It's perfectly possible to be infected through unsafe injections, say, even though your partner was infected sexually.

It is vital that people are made aware of the risks they face and the steps they can take to reduce those risks. They need knowledge, skills and empowerment to be able to ask health and other professionals for evidence that they are observing all safety guidelines. This is necessary to ensure that neither HIV nor any other blood borne infections are transmitted during routine procedures. If people don't know about nosocomial HIV infection, infection through unsafe medical procedures, they will not be alert to the risks and will not take steps to avoid them.

It is heartening to hear that some have made the connection between exposure to contaminated blood and HIV transmission. A group in Kenya, and more recently in Tanzania, has recognised that HIV can be transmitted if care is not taken removing jiggers. This is often done using an unsterilized safety pin or other sharp object. If the object is then used on other people, there is a considerable risk of transmitting HIV and other viruses. Even if a virus is not transmitted, serious infections can result.

But despite small numbers of people in Kenya and Tanzania knowing that HIV is not just transmitted sexually, UNAIDS and others in the HIV industry are reluctant to accept the importance of non-sexual transmission. Official figures estimate that transmission through unsafe medical practices is very low. As a result, only a tiny fraction of the billions being ploughed into HIV prevention goes towards non-sexual HIV transmission.

Exactly why UNAIDS and the rest of the industry wish to ignore non-sexual HIV transmission is not clear. But the organization has always been pretty irrelevant to the HIV pandemic. With our without UNAIDS, people need to recognise the most common and the most serious risks they face. HIV is not just about sex and it has never been just about sex. Anything that involves exposure to blood or certain other bodily fluids can carry a risk of transmission of HIV and other viruses.

[For more about UNAIDS' and the HIV industry's obsession with sex, see my other blog.]

African HIV Pandemic: Do Condom Manufacturers Worry About Bad Press?

I've asked the question a number of times, most recently on my other blog about pre-exposure prophylaxis (PrEP): why are condom manufacturers not worried about some of the bad press they are getting in one of their biggest markets in the world, sub-Saharan Africa?

Several microbicide trials that have shown the gels to be of little or no use have also shown that people who don't have sex very often, don't engage in much 'unsafe' sex and almost always use condoms, still become infected with HIV. Heterosexual sex is not a very efficient transmitter of HIV, so why do condoms seem to fail so badly during these trials?

For those who reject the behavioral paradigm, the claim (it's not a belief, those who make the claim know it's not true) that almost all HIV is transmitted through heterosexual sex in African countries, there is no conundrum. Those who become infected with HIV under the circumstances listed above were unlikely to have been infected sexually.

There are a number of other ways they could have been infected. They are unlikely to have been intravenous drug users, unless the trial screening process was highly flawed! But they probably received some kind of invasive medical treatment, such as injections.

Unsterile medical injections are a very efficient means of transmitting HIV and other blood-borne viruses, especially in high HIV prevalence areas, where these trials tend to be carried out.

The problem is that the trial protocol didn't involve investigating how participants became infected. The protocol could have attempted to determine the risks that people in the area faced because if people were being infected by any other route aside from sexual intercourse, that would invalidate the results of the trial.

This is where the condom manufacturers should be coming in. Trial results show that rates of HIV infection are very high, even among people using condoms. But if people are being infected via unsafe medical injections, cosmetic procedures such as tattooing, or anything else, this does not indicate that condoms have failed.

The denial that non-sexual HIV transmission could play a part in high prevalence countries leads to a lot of confusion. A group of people in Nigeria, along with a HIV research foundation, are suing the government for promoting condoms because they 'didn't work'. Members of the group used them but still ended up HIV positive. They are demanding $50 billion in compensation and an order against further promotion of condoms.

They should be demanding an investigation into how they might have become infected. Condom manufacturers should also be demanding such an investigation. Because every country in the world is, at least to some extent, promoting condoms as a means of preventing HIV transmission. Few seem to realise the non-sexual risks they face, even though they may be aware that condoms will not protect them from these.

As a result, HIV is still spreading quickly and will continue to do so for the forseeable future. Condoms are not the problem. They have a pretty high success rate when it comes to preventing sexually transmitted HIV. But they are not relevant when it comes to non-sexually transmitted HIV and it's important that this be made clear.

Condom manufactures should be very worried about the misrepresentation involved here. Their products are being promoted in circumstances where they are guaranteed to fail. Some day other people, like this small group of Nigerians, will start to ask why they are HIV positive even though they have not been exposed to any possibility of sexual transmission.

Of course, it's not the business of condom manufacturers to inform people that condoms won't prevent non-sexual HIV transmission; that should be pretty obvious already. But unless people are informed of the probability of their being infected non-sexually, the probably currently being unknown, it will continue to appear as if the billions of condoms being supplied to African countries are not having much impact.

Condoms are about the only hope that people in African countries have when it comes to preventing HIV transmission through sexual intercourse, whether vaginal or anal. They are vital in the overall public health goal of cutting transmission. But there is also a need to establish levels of non-sexual HIV transmission and to implement public measures to prevent it. If condom manufacturers wish to continue to receive billions of dollars of public money, they should help to make the distinction between sexual and non-sexual HIV transmission clear.

People need to know the whole story about HIV: it is not just transmitted sexually and they will not be protected if they think it is. They need to know that HIV can also be transmitted through unsafe health care and cosmetic procedures; they need to know how to avoid this sort of risk; and the risks people face in medical and cosmetic facilities need to be reduced. There is nothing to be gained from emphasizing sexual risks and completely ignoring non-sexual risks.

Idle Arguments Support Blinkered Policy

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

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

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

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

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

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

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

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

UNAIDS Can't Put the Shit Back in the Horse

As a result of the historical association between HIV and sexual behavior, especially sexual behavior considered to be unsafe, illicit, immoral, or whatever, HIV testing is unusual among medical tests by being 'opt-in'. People need to request that they be tested or agree to be tested, in theory, anyhow. Michael April discusses the merits of the WHO's recommendation that HIV testing become 'opt-out' rather than 'opt-in', with reference to the greater availability of HIV treatment.

April wishes to argue for opt-out [apologies, earlier I wrote 'opt-in' in error] testing on ethical grounds, in terms of the themes of consequentialism, liberalism and libertarian paternalism. In deference to his expertise in these themes, I shall not comment on them. This is partly because I'm a very deferential person but, more importantly, because they are quite irrelevant to the issue of whether HIV testing should be opt-in or opt-out. (Although I would point out that, despite the precepts of liberalism and libertarianism, epidemics are factors of whole populations of people, people interacting with other people; they are not factors of individuals.)

First, I take issue with April's claim that "Treatment provision is currently the most important benefit of HIV testing." Treatment provision is important, but it is no more important than establishing, not just whether someone is HIV positive or HIV negative, but finding out how infected people became infected. Treatment is not, and April accepts this in his paper, the same as prevention. But HIV would be exceptional in yet another way if preventing further infection was not also a primary aim of HIV testing.

In order to find out how HIV is spreading, we need to go beyond the highly prejudiced assumption that HIV is mainly transmitted through heterosexual sex in African countries. We need to document people's medical histories in a way that helps us to identify the contribution of non-sexual HIV transmission. Once we have done this, we can best advise people on how to avoid infection if they are HIV negative and how to avoid transmitting the virus if they are HIV positive. Testing aims to screen the whole population, not just those who are HIV positive.

The current practice is to follow UNAIDS advice that HIV is almost always sexually transmitted in African countries (though not in other countries, even in contexts where 'unsafe' sex is very widely practiced). 'Counselling' involves all manner of verbal contortion in the attempt to explain to HIV positive people that they had some kind of unsafe sex, whether they ever remember doing so or not. People who have not had any kind of sex or any kind of sex that could be considered unsafe may be puzzled, but their pleas are generally ignored. They are African and everyone in the HIV industry knows what African sexuality is like, don't they?

April surmises that treatment should be an important consideration for someone weighing up the respective consequences of not getting tested or getting tested. They could risk becoming very sick and eventually dying, also transmitting the virus to others, on the one hand. And they could face the almost inevitable stigma if found to be HIV positive on the other hand. Is the promise of being treated, and therefore less likely to become sick and die relatively soon and less likely to transmit the virus to others enough to assuage people's worries about facing HIV related stigma?

You could argue that, given the availability of treatment, people should reasonably be expected to be tested and, if found HIV positive, face the stigma. The benefits could be seen to outweigh the potential stigma. Or you could argue that the stigma would be unbearable and that, under such conditions, a person would be better off to take their chances and possibly suffer terribly and die prematurely from AIDS.

But people should be able to decide whether they want to be tested without the fear of being stigmatized if found to be HIV positive. There should be no fear of being stigmatized, such that a person might refuse to be tested and even treated, and go through the rest of their remaining years suffering as a result of their decision, and possibly not even managing to avoid stigma in the end. And I'm not just saying 'stigma is bad, we shouldn't stigmatize', as UNAIDS and the HIV industry tend to do (though stigma is bad and we shouldn't stigmatize).

I mentioned above the 'historical' association between HIV and sexual behavior, not because HIV is never sexually transmitted. Sometimes it is. But we should have moved on from the knee-jerk reactions of journalists and other commentators in concluding that because HIV is sometimes sexually transmitted, anyone who is infected almost definitely engaged in some kind of unsafe sex. Not only have journalists and other commentators not moved on; a whole UN agency was built around a virus that is known to be transmitted sexually and non-sexually, and it hasn't moved on, either.

Ok, that's a bit inaccurate. UNAIDS does realize that HIV can be transmitted non-sexually and they realize that it can be transmitted non-sexually in African countries. They just don't tell people in Africa. They warn their own employees to avoid medical facilities in African countries but they deny that medical transmission of HIV plays a significant part in the worst HIV epidemics in the world. Most African countries have inadequate medical facilities, unbelievably low numbers of skilled personnel, shortages of equipment and drugs. If medical transmission of a blood-borne pathogen hardly every occurs in African countries, where does it occur? Let’s, at least, investigate.

So, Mr April, if HIV is seen as a disease of whole populations, one that can be prevented as well as treated, testing can benefit everyone. If it is seen as a virus that can be transmitted both sexually and non-sexually, that might help reduce the stigma that has been driven by the HIV industry itself. But more than that needs to happen. The HIV industry, and especially UNAIDS, need to re-examine their adherence to the behavioral paradigm, which says that preventing HIV (in African countries) is just a matter of influencing sexual behavior.

Evidence against the behavioral paradigm is plentiful, certainly too plentiful to rehearse in a brief blog post. But it should be clear now how the 'dilemma' Mr April would 'solve' through ethics has a far more pragmatic solution (or ‘dissolution’). It's not certain that we can ever undo the stigma that UNAIDS and the HIV industry have spread. That will certainly take a lot of work. But we need to start by reforming and, if necessary, dismantling the institutions that are the source of this stigma.

We need to gather evidence of how HIV is being transmitted in order to mount a viable prevention campaign. We should no longer resort to the mathematical models that pander to the industry, the innuendo that panders to the press and the pseudo-morality that panders to politicians. If there is a possibility that medical, cosmetic or any other facilities could be sources of HIV transmission, that needs to be investigated. It's not good enough to carry out investigations in wealthy countries, it's poor countries that have the facilities that are most likely to be transmitting HIV.

HIV is not just a matter of individual responsibility, as it's been painted. In relation to viruses like HIV, people are not mere individuals. It is their interactions with others, many and various interactions, that give rise to epidemic spread. Reuse of unsterile medical and cosmetic equipment provides the perfect conditions for transmission of HIV and other blood-borne viruses. It’s only the prurient association of HIV and illicit sex that allows such a dogmatic and irrelevant notion of individuality to arise in the first place.

Spread of HIV will not be prevented through individual behavior change alone when it was not individual behavior alone that resulted in the virus becoming endemic. But sexual behavior is, par excellence, group behavior. This is not to say that people shouldn't receive sex education and take precautions against infection with all diseases and against unplanned pregnancy. But nor can you accuse every HIV positive person of being promiscuous or careless. Sex, in itself, is not wrong, not even for Africans. There’s no ethical dilemma. But there is a pragmatic problem of how to undo the damage we have done by stigmatizing HIV to the extent that many people would risk suffering and dying rather than be tested and treated accordingly.

If there is any dilemma, it is this: how can the very people who established the extremely racist orthodox view of HIV now replace that view with one that is more appropriate? Personally, I don’t think the same people can take everything back. Why should anyone believe them? So, does the HIV industry hold on to its rather tattered credibility and keep on lying to cover up previous lies? Or does it at least create the possibility of reducing the transmission of HIV and perhaps eventually eradicating the disease? But when you put it that way, there is no real dilemma, is there?

Does the HIV Industry Despise Africans or Just Sex in Africa?

While I commend any activism that opposes the numerous ongoing national and international failures to deal with the HIV pandemic, there is an attitude that treatment for those infected is more important than maintaining the negative status of those who have not been infected. The two are equally vital and they should never be seen as being in opposition. Treatment activists have their legitimate agenda but they sometimes make it clear that they forget that health is a property of whole populations, it is not just a matter of having or not having some disease.

During the recent Vienna Aids Conference, Mark Heywood executive director of Section 27, was widely quoted as saying: "The testing campaign [in South Africa] is only a means to an end...; its intention is to give people access to treatment and to other healthcare services. However, if treatment is not actually provided, then the means cannot be justified."

Mr Heywood is quite wrong. There is talk of testing 15 million South Africans. Are we to believe that this massive number of people is to be tested and no effort made to find out how those who are infected became infected? Is South Africa going to copy the mistake made by most HIV/Aids institutions for nearly thirty years? Will everyone in the HIV industry just continue to assume that HIV is transmitted sexually in African countries, and allow sources of non-sexual infection to continue, unabated?

Testing for HIV is not just the means to one end, that of treating people. Everyone who is infected has the right to treatment, I'm in complete agreement with Heywood there. But people who are not infected have the right to stay that way. And establishing how they can achieve this is another, equally important, justification for mass testing. If we continue to ignore some routes to infection, people will continue to be infected. If campaigns for treatment for all HIV positive people fail to take account of this, the scope for treating everyone infected will start to narrow very rapidly.

Those who advocate treatment for all HIV positive people, and I am one of them, must also advocate for prevention campaigns that are based on the realities of how HIV is transmitted, whether it is transmitted through unsafe sex, unsafe healthcare, unsafe cosmetic practices, intravenous drug use, or any other way. Claiming that mass testing is only justified if those found to be positive are guaranteed treatment is disingenuous and counterproductive.

In the same article, the Nigerian activist Morolake Odetoyinbo said that testing for HIV had been scaled back and was now targeting "people considered to be at high risk, such as sex workers, injecting drug users, truck drivers and people with TB. This stigmatised testing."

Quite, it stigmatizes testing in a very specific way: it assumes the truth of the behavioral paradigm, the assumption that most HIV is transmitted sexually (in African countries) and has the corollary that all (African) people need to do is 'change their sexual behavior' in order to avoid being infected with HIV. Yes, it includes injecting drug users; they also are a stigmatized group. But the majority of people in African countries are not members of any of these groups. Even the majority of HIV positive Africans are not members of any of these groups.

If the Nigerian government wants to follow in the footsteps of other African countries, who have received all their HIV advice and funding from prejudiced Westerners (the HIV industry), all the worse for Nigerians. If you assume that most HIV is transmitted sexually, you will not be looking for non-sexual exposure, nor will you take any measures to avoid it. Nigeria could quite easily pass out South Africa and become the top country in the world for the number of people living with HIV.

Regarding stigma, Odetoyinbo goes on to say “It’s beyond access to medication”. What is the use of life if there is no quality of life? What is the use of life if you just give me pills to stay alive? I don’t want to be alive when there’s such circumstances. I still need my dignity as a human being.”

The HIV industry has set the agenda, the stigmatizing, prejudiced, sexist agenda, that HIV is just a matter of sexual behavior in African countries. With the HIV industry's view of HIV, you will never have dignity. But you can not deplore the stigma without also deploring agenda. And first, it needs to be clear what exactly is being stigmatized. It is sex, simply that. People may say it is unsafe sex or illicit sex or any number of things, but in reality, they object to sex.

Consider that in the early days of development theory, development meant no more and no less than population control. Many institutes haven't gone beyond that development paradigm. And many of the big organizations working towards the aims of that paradigm, to reduce populations in poor countries, are the same organizations claiming that they can reduce HIV transmission by influencing people's sexual behavior.

They were not very successful in reducing birth rates, they are not having much effect on HIV transmission and they will continue to fail, despite receiving the lion's share of funding. Among them are Population Services International, Family Health International, The Futures Group International, the Guttmacher Institute and the Rockefeller Institute, but there are others. A lot of institutions that use terms like 'hygiene' and 'public health' (and various other euphemisms or euphemistic uses of words that sound innocuous enough) have similar histories.

Sex is what people and institutions object to, or say they do. They don't give a damn about diseases, there are plenty of them, sexual and otherwise, but they aren't putting any of their time into reducing their transmission. Sex is what journalists like to write about and what donors like to fund and what politicians make their careers out of condemning and what the public likes to read about. But HIV is a disease, it is not sex, unsafe or otherwise. It is spread in a number of ways, sex being one of them. But the conditions under which people have sex go way beyond mere sexual behavior. Those conditions are part of what makes us human.

Sex is no more wrong than breathing, which transmits TB; drinking water, which transmits water borne diseases; standing too close to someone, which transmits many diseases; eating food, which transmits some of the biggest killers in developing countries; crossing roads, working in mines, playing football or walking home alone on a dark night.

Nor is it sexual abuse, sexual violence, female genital mutilation, male genital mutilation, gender inequality or any other forms of abuse that are responsible for HIV epidemics. They should all be outlawed, but they existed before HIV did and they will continue to exist after HIV ceases to exist, should such a time come.

Some people, who accept that there is nothing wrong with sex, make the objection that if it is recognized that HIV is not always transmitted sexually, that those who are found to have been infected sexually will still be stigmatized. But it is the sex that is being stigmatized, not the HIV. The disease (and people who are infected with it) are stigmatized because of the association with sex. If you think that there will be two tiers of HIV positive people, the sexually infected and the non-sexually infected, you too are moving the target of the stigma!

That people have objections to sex is a complex problem with a long history. It won't be solved by conflating it with something else. HIV, and many other diseases, are being transmitted rapidly when they could all be controlled, to some extent, and many could be prevented or cured. HIV testing needs to ascertain how people become infected, if at all possible, not just whether they are positive or negative. Reading humanity's sexual hang-ups into HIV transmission has allowed the disease to become a pandemic. It could get a lot worse, and it probably will if we don't take our prejudices out of our HIV prevention policies.

The Wrong End of a One Ended Stick

According to the South African Independent, a member of the Swazi royal family has dismissed the severity of the HIV epidemic in Swaziland, where prevalence is the highest in the world. He thinks the HIV industry is exaggerating the number of people infected in order to make money. The royal is sadly mistaken. The HIV industry will do anything to make money but they are not exaggerating. The healthcare industries make enormous amounts of money out of disease and the threat of disease but they don't need to make up the figures.

The deluded personage may also be right in saying that circumcision won't achieve much more than soap and water. But he appears unaware that clean water and adequate sanitation are not available to many Swazis. And he is also right, but for the wrong reasons, if he thinks that abstinence, being faithful and even using condoms will not eliminate HIV transmission. They may reduce sexually transmitted HIV but they will not reduce HIV transmitted through unsafe medical or cosmetic practices.

The thing that the Swazi royal, along with the entire HIV industry, fails to appreciate is that HIV prevalence in Swaziland is 86 times that of, say, India. That's just as well because the population of India is about 1000 times that of Swaziland. So if the ever-hungry HIV industry really wanted to exaggerate the number of people infected with HIV, India would be the place to do it, not Swaziland. But how could the sexual behavior of so many Swazis be so different from that of the rest of humanity, including that of India? Only a handful of countries, all African, come anywhere close to Swaziland's HIV prevalence figure.

Royals, members of the HIV industry and journalists should be able to work out that Indians have sex, quite a lot of it, with much of it being unprotected. And the number of HIV positive people in India is twice the population of Swaziland. But if rampant sexual behavior is enough to explain high HIV prevalence among the Swazis, substantially less rampant sexual behavior among Indians should give rise to a lot more infections, shouldn't it, given the multiple? But even among Indian sex workers, who the same royals, industry members and journalists will agree, must engage in a fair amount of sex, HIV prevalence is less than 5% and declining. That's lower than national prevalence in about 20 other countries, including Kenya, Tanzania and Uganda.

Nearly one fifth of all HIV positive people, about 8 million people, live in five African countries with a combined population of less than 70 million. India and China together, with about one third of the world's population, have about three million HIV positive people. If there were something so extraordinary about the sexual behavior of people in those five African countries, I think it would stand out, somewhat. And it would explain why ABC doesn't work: people are simply too busy to listen to the advice. If they stopped to listen and put on a condom, they wouldn't get enough sex in for that day.

But there is no evidence that sexually active people in countries such as Swaziland, Botswana, Lesotho, Zimbabwe and South Africa have four or five times as much sex as Indian sex workers. Nor is there any evidence that people in those countries take four or five times more sexual risks. Levels of sexual behavior in these and other African countries is similar to those found in countries with far lower HIV prevalence. The behavioral paradigm, which suggests that high HIV prevalence in African countries is mainly due to heterosexual sex, can not possibly be correct.

Despite the obvious falsity of the behavioral paradigm, it still shapes most HIV prevention programs and most national HIV strategies. The one thing the HIV industry refuses to do is establish exactly where HIV infections are coming from. The figures in 'modes of transmission' surveys are mostly guesswork, skewed by the very paradigm that is in question. The Swazi prince is wrong, Aids is not a scam. But the HIV industry's explanation of HIV transmission is a scam. Perhaps his high and mightiness will look into the matter, given the eagerness of the world's press to make his views so widely known.

Deal With Your Anger Wisely, Obama

Obama is 'angry' over the spread of HIV/Aids. It appears he's angry with African governments for not doing anything about the epidemic and perhaps with Africans for doing the spreading. That seems to be the direction his thinking takes. He says "treating patients while others are catching the virus is untenable."

"We are never going to have enough money to simply treat people who are constantly getting infected," he said. "We've got to have a mechanism to stop the transmission rate."

I couldn't agree more. That's why I believe some of the main actors in the HIV industry should find out why HIV transmission is so high in some African countries and in some sectors in some African countries, yet it is low in other countries and other sectors. These actors include UNAIDS, the WHO, the UN as a whole, the US Center for Disease Control, universities such as Johns Hopkins and various other extremely well funded institutions. I assume Obama has some influence with them. (That he has influence in Africa is not in question but how that influence works or how legitimate it is are less clear.)

And while we're on the subject of money, my guess is that the amount of money made out of HIV dwarfs the amount spent on it, it's a good investment. Institutions like the ones mentioned, various commercial interests and other big NGOs have done very well out of funding over the years. So let's not pretend that money is leaking out of the US and the country gets nothing in return. And the absolute amount of HIV money coming from the US may be high, as Obama claims, but as a percentage of GDP, the US is nowhere near the highest contributor.

The “retrogressive culture that makes females satisfy the pleasure of men” that Obama says is responsible for the “upswing in new HIV/Aids infections in Africa” is, presumably, the same culture that gave rise to a Black American politician who won the last US presidential elections. Has he anything to say about the retrogressive culture that allows billions of dollars to be spent enriching rich people and institutions while Africans die?

"In Africa, empowering women is going to be critical to reducing the transmission rate because so often women, not having any control over sexual practices and their own body, end up having extremely high transmission rates”.

Women all over the world have little control over sexual practices and their own body but nowhere in the world are HIV rates as high as they are in some Southern African countries. The entire cash-rich industry has failed to explain what is behind the source of their wealth and power: HIV epidemics in certain African countries.

It's great to hear that the "US has a huge interest in public health systems in Africa" because health systems have been ignored for several decades, with all the attention being concentrated on a handful of diseases considered newsworthy enough to attract funding. Let’s get on with it.

It's hard to believe that such statements as the ones found in this article could really emanate from one of the most powerful politicians in the world. Doesn't he have anyone to do his publicity or to provide him with up to date information? It is not true that in Uganda "infection rate was about 30 per cent in the late 1980s". Prevalence in certain sectors of the population may have reached that level but there was never a time when 30% of sexually active people in Uganda were HIV positive. HIV prevalence did reach such levels some time later, but not in Uganda.

There was no "politically-led three-themed campaign - for Abstinence, Being faithful and Condom use or ABC model - [that] helped drive down the rate to an average six per cent." ABC didn't exist till the late 1990s and it was not dreamed up in Uganda. The abstinence only campaigns imposed by his predecessor on Africa in the early 2000s have had little or no effect in Uganda, just as they had little or no effect in the US. They may have been confusing but most behavior change programs failed, so any damage they could have done may have been similarly limited.

If Obama wants to "explore workable preventive programmes" he needs to challenge the behavioral paradigm, the view that most HIV is transmitted sexually in African countries. He needs to question the view that Africans have unbelievable amounts of ('unsafe')sex with incredible numbers of partners.

If he wants to "build greater public health infrastructure", he needs to be informed about basic distinctions between vertical approaches to health, which target individual diseases and horizontal approaches, which concentrate more on primary healthcare. And he shouldn't be distracted by nice distinctions like 'diagonal' approaches, which claim to be some kind of 'third way'.

And if he wants to "institutionalise country-specific interventions", he needs to campaign for the abolition of UNAIDS and perhaps other big players in the HIV industry. Their programs to date have painted whole continents with the same brush, failing to identify all the ways that HIV is being transmitted and ignoring some of the most vulnerable groups. Buzzwords like 'global health' seem to lead, inexorably, to this sort of broad brush policy.

Massive rates of HIV transmission in African countries can not be explained by resort to myths about the great sexual appetite Africans have. And no research has yet demonstrated that Africans have more appetite for sex than people who live in other continents.

Rapid rates of HIV transmission can partly be explained by very low standards of healthcare, where the majority of injections given in healthcare settings are not necessary and are unsafe, very likely to transmit HIV, hepatitis and various other infections. The extent to which unsafe healthcare could explain high rates of HIV transmission in African countries is unclear, because the HIV industry, in all its splendor, wealth, power and wisdom, has never seen fit to investigate.

Please Mr Obama, before you consider punishing anyone, try to establish what wrong has been perpetrated and who has perpetrated it. The important thing is to reduce HIV transmission, not to apportion blame, despite what the Christian Right may tell you. But unless we are clear about how HIV is being transmitted, and you seem very unclear, we will never reduce transmission enough to eradicate the disease.

Unmixed Messages Could Scupper World Cup ‘Opportunity’

It's all about taking part, not winning, right? It’s certainly not about corporate domination, making money or anything so sordid. The World Cup probably means different things to those who care, can afford it or have something to gain from it. But there seems to be a worry that warnings about public safety could detract from people’s enjoyment of the football. According to the British Guardian, Fifa are blocking attempts to distribute condoms at venues. Fifa deny this and say no attempts have been made to set up condom distribution facilities. But even safe sex information has been banned, apparently.

I imagine people from Western countries travelling to South Africa will receive plenty of information about safe sex before they leave their own safe countries. Many will probably have their own supply of condoms or be able to buy them on arrival. They may even receive information on other HIV risks, such as from medical and cosmetic treatment.

They may be told that some health providers have a shortage of equipment and trained personnel, so they have to make sure that needles, syringes, suture needles and other equipment are properly sterilised if they haven’t taken a supply of medical equipment with them. It’s possible that visitors will also be warned to avoid getting tattoos, body or ear piercings or any cosmetic treatment that breaks the skin. (I’ve seen a warning about avoiding tattoos because they may be regretted later but none about the risk of HIV or any other disease.) Condoms are great for preventing sexual transmission, but I think people will need information about more than just basic safe sex.

Some Aids organizations are said to see the World Cup as a good opportunity to give out messages about HIV. But which messages are they trying to give out? That HIV is sexually transmitted? Report after report has shown that most people in African countries already know that. Whether people from Western countries know that or see that as relevant to them is another matter. But when will Aids organizations start to warn people about non-sexual risk of HIV? Non-sexual risks, especially from medical treatment, have been recognised since the early 1980s, almost since HIV was identified as the virus that caused Aids. But since early on in the epidemic, international health institutions have remained relatively silent about this important mode of infection. It is rarely discussed and every year these institutions publish figures purporting to show that medical transmission is very low and hardly worth worrying about.

Hospitals in South Africa are generally in poor condition, places you would not visit for treatment unless you really had to. Most South Africans really have to put up with these conditions, but rich South Africans (and rich visitors) don’t. They can opt for the expensive and hopefully safer hospitals, such as the ones that are looking for health tourists during the World Cup. Even those World Cup fans who need routine accident and emergency treatment will probably opt for something a bit better than the facilities available to poor South Africans. If Aids organisations see the World Cup as an opportunity to get a message across, that message should be relevant to everyone, regardless of their race, economic circumstances or any other criterion.

It is clear that HIV is transmitted by routes other than sexual behaviour. It is also clear than non-sexual transmission is far higher than UNAIDS and others will admit. Just how high non-sexual transmission goes in African countries is unclear because outbreaks of medically transmitted HIV have, so far, been entirely uninvestigated. UNAIDS is happy to warn UN employees to avoid medical treatment in African countries, except in UN approved hospitals. But they don’t seem to want Africans to know about the risks of medically (and cosmetically) transmitted HIV. This is the message that needs to be broadcast during the World Cup. Why the sudden worry that a few Westerners will become infected with HIV when Africans are being infected every day and much of this transmission could be avoided?

A brief article about preparations for medical emergencies during the World Cup mentions the ‘beleaguered health system’ and the huge HIV epidemic, but says nothing about the risk of medical transmission of HIV. The country is not suddenly going to acquire the capacity to provide adequate and safe medical treatment for everyone, no matter how important the World Cup is perceived to be. But that is part of the important message that Aids organizations should be concentrating on: that people should be aware of all the risks and how to protect themselves in order to avoid HIV and other diseases. The warnings should no longer be just about sexual risk but should include non-sexual risks too, especially risks of medical transmission.

The sort of racism that gives rise to UNAIDS and other institutions claiming that HIV is mostly transmitted by heterosexual sex in African countries results in an overemphasis on sexual risk and little or no emphasis on medical transmission. But another instance of racism seems to come out in the run up to the World Cup. There seems to be a lot more concern about non-Africans becoming infected with HIV than about Africans, who face risks, sexual and non-sexual, every day. They have faced these risks for decades and it looks as if they will continue to do so for decades. Apartheid may have ended, nominally. But every African, as well as every non-African, needs to be aware of how to avoid HIV infection and everyone needs access to information and facilities that will protect them. These are not yet available: that is why around 1,400 South Africans become infected with HIV ever day. HIV risk didn’t start with the World Cup and it won’t end with there. But it looks as if the usual Aids organisations will waste the opportunity by talking exclusively about sexual risk, yet again.