HIV Eradication May Require Regime Change in HIV Industry

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

Having collected the data in 2012, the Kenya Aids Indicator Survey (KAIS) was released last week. Prevalence has fallen in most provinces. The exceptions are Northeastern Province, where data was not collected due to civil unrest, and Nyanza, where prevalence has increased from almost 14% in 2008 to 15% in 2012. 37% of Kenya's HIV positive people reside in Nyanza. So the news is not so bad if you don't come from Nyanza, especially if you don't come from any of the exceptionally high prevalence towns on the shores of Lake Victoria.

Prevalence is now 5.6%, closer to Tanzania's 5.1% than Uganda's 7.2%. As usual, HIV prevalence is generally higher among women (6.9%) than among men (4.4%), higher among urban dwelling people than rural dwelling people and higher among employed people than unemployed people. Prevalence is lowest among females and males who have less education and higher among those who have completed primary or reached secondary or beyond. Prevalence tends to be higher among wealthier quintiles in rural areas and among poorer quintiles in urban areas, which may represent a change in HIV prevalence by wealth quintiles in earlier surveys.

With about 100,000 people being newly infected each year, incidence is said to be 0.5% and the highest number of new infections occurred among people aged between 25 and 34 years, with incidence estimated at 1.2%. Incidence has barely changed between 2007 and 2012, what the report refers to as 'stable'. The entire epidemic could be described as stable, rather than declining, as prevalence has remained much the same for more than ten years.

Predictably, there are quite a few figures relating to the mass male circumcision program. You don't put tens of millions of dollars into a program without making sure that you collect data showing that the program was successful. Clearly the program is not successful yet, with the bulk of circumcisions claimed for Nyanza province, which has a prevalence figure nearly three times the national figure. But there is a lot of triumphalist stuff about how high HIV prevalence is among uncircumcised people. Of course, none of the data throws any light on why HIV prevalence is so high among people in this province, so high among Luo people especially, yet not among Kisii or Kuria people.

The level of bullying and manipulation by those running mass male circumcision programs (which the HIV industry likes to refer to as voluntary medical male circumcision or VMMC) becomes apparent when you read some of the literature. Although the invasive operation's claimed protective value against HIV (and goodness knows what else) has never been very convincing, people are systematically browbeaten over a period of years about hygiene benefits, which have never been demonstrated at all, 'modernity' of circumcision, ease of using condoms, increased sexual pleasure and a host of other things for which there is no evidence whatsoever.

According to the abstract "older men should adopt the practice to serve as role models to younger men", as if there is some moral value in circumcision being provided by a benevolent dictator. UNAIDS addsn a commonly heard claim about "queues of young men and boys awaiting" mass male circumcision, which is clearly drawn from publicity materials rather than from any kind of independent research.

Talking of invasive operations, there is a chapter on blood and injection safety, ironically appearing straight after the mass male circumcision chapter. The figures for blood safety do not sound very encouraging, especially remarks about 'misclassifications' in donor records. UNAIDS' 'all men are bastards, all women are victims' theory of HIV transmission gets a bit of a knock as well since nearly four times as many men as women said they donated blood in the 12 months before the survey. The findings about injection safety have been mentioned already on this site  when a full paper was published on the subject in May.

The question now is 'what next'? Mounds of data have been collected over many years, mostly high level data that gives few clues about how people are becoming infected. Data about 'attitudes', sexual behavior, economic circumstances, education, etc, have not allowed any useful 'targeting' because the usual conclusion is that 'it is all about sex' and other kinds of victim blaming. So it's heartening to hear that data is being collected about blood and injection safety, albeit a very small amount.

The next step needs to involve comprehensive contact tracing, finding out about people's non-sexual as well as their sexual contacts, visits to health facilities, traditional practitioners, cosmetic providers and anywhere skin-piercing procedures are carried out. If someone is HIV positive it must be asked who, or what did they come into contact with, whether as a result of sexual or any other kind of behavior. Will the deep prejudices of the HIV industry allow them to take these investigations where they need to go, or will the eradication of HIV have to wait until there's a regime change in the HIV industry?

[For more about non-sexually transmitted HIV through unsafe healthcare, cosmetic and traditional practices and how to protect yourself, visit the Don't Get Stuck With HIV site.]

Did Health Facility User Fees Cut HIV Transmission in 1980-90s Kenya?

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

Rick Rowden argues that the World Bank was negligent in imposing structural adjustment loans on very poor countries in Africa from the 1980s onwards. He notes that there was little or no evidence at the time that privatizing healthcare would be in any way beneficial in developing countries; on the contrary, the World Bank itself had warned against the introduction of user fees for healthcare in 1980.

After putting tens of millions of people through the disastrous consequences of these untried policies, there is now so much evidence of how damaging they are that even the World Bank agrees user fees are not a good thing. But they have not yet been held accountable, as Rowden argues they should be. Countless numbers of people have suffered and died, health services remain decimated in the worst affected countries to this day; is the World Bank going to try and put right the little that may still be salvaged from the wreckage?

Maybe those in the UK arguing for the imposition of user fees in the National Health Service (NHS) could peruse some of the copious amounts of evidence available showing that such a move will put the health and lives of the poorest and neediest people at risk, while making a handful of wealthy people even wealthier. They can't use the excuse some would make for the 'free' market lunacy of the 1980s, that it was not known what the consequences would be.

But Rowden raises another tantalizing point. He cites one 'H Stein' as arguing that the exemption of some preventive services such as vaccinations from user fees, but not curative services, such as STI treatment, "led to the imposition of user fees in STD clinics in places like Kenya in the early 1990s. These fees lowered attendance rates at the worst possible time: the early stages of the HIV/AIDS epidemic in Africa."

This argument is tantalizing because in the early 1990s HIV transmission among a large cohort of sex workers observed for 20 years had started to decline, and declined fourfold from the 1980s onwards. It is still not clear why HIV transmission declined in this group as members were selected precisely because they were engaging in 'unsafe' sex throughout the 20 year period.

Indeed, the national rate of transmission of HIV (incidence) peaked and started to decline in the early to mid 1990s in most parts of the country; it peaked and started to decline long before the government accepted there was a HIV epidemic in Kenya, even before any of the multitude of NGOs turned up to do whatever it is HIV prevention NGOs do (finger-wagging and other variations on that theme).

The authors of a paper on this cohort of sex workers started off their article assuming that HIV transmission is entirely down to sexual behavior. When sex workers who said they always used condoms were found to be HIV positive it was assumed they had 'overestimated' condom use. It was assumed that HIV prevalence was at a constant level of 30% among their male clients, although this is likely to be a far more telling overestimation. Other groups among whom HIV prevalence was found to be high were also assumed to have been infected solely through 'unsafe' sexual behavior.

It is surprising that risks for non-sexual transmission through, for example, unsafe healthcare (also traditional and cosmetic practices) were never considered for HIV positive people. Facilities were badly run, understaffed, undersupplied and, frankly, dangerous. STI clinics would have been more dangerous still. Why is it that only clients' sexual risks were considered? Why is that still the case, more than 20 years later?

However, the introduction of user fees and the consequent massive drop in access to STI clinics and other health facilities could have given rise to the observed drop in HIV incidence in the 1990s, which continued into the 2000s. Non-sexual risks for HIV transmission, data for which was never collected, include treatment at an STI clinic, multiple injections, visits to an antenatal clinic, hospitalization, etc.

A 1987 paper by Peter Piot and colleagues finds very high HIV prevalence figures among sex workers, also among men attending STI clinics and women attending antenatal care clinics. But these three groups clearly face the abovementioned risks of being infected with various diseases in health facilities, especially those facilities that are on the brink of collapse; HIV is only one possible healthcare associated infection to which people could have been exposed.

Being a beneficiary of the admirable NHS, I would argue that the service should be further developed as a model for other countries to follow. That is especially true for African countries with very poor healthcare currently, but who, according to the economists who have so far failed miserably to get anything else right, are 'rising' economically, riding on a wave of buoyant economies and eye-watering potential for this to continue.

But striving towards universal primary health care is not enough. African countries need safe healthcare, not just any old healthcare. If healthcare access suddenly increases without improvements in safety and infection control, some of the currently declining epidemics may start to increase again. Botswana is an example of a country that decentralized its health services and ended up with one of the worst HIV epidemics in the world, one that is showing little sign of declining right now.

Given continuing high HIV prevalence in wealthier African countries with better access to health services and higher prevalence among wealthier people in urban areas, it is difficult to see Botswana's experience as mere bad luck. If unsafe healthcare has been a factor in Africa's worst HIV epidemics then this needs to be thoroughly investigated so that such avoidable transmission is addressed as a matter of urgency. Universal healthcare that is not also safe healthcare will only expose more people to more risks.

[For more about HIV transmission through unsafe healthcare and how to avoid it, see the Don't Get Stuck With HIV website.]