Tenofovir Gel Still Hyped, Despite Serious Questions About Trial

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

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

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

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

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

Unethical and Invalid Vaginal Microbicide Trial Receives Fast-Track Status

It was recently reported that the massively hyped microbicide gel that might reduce HIV transmission from men to women by 39% failed to attract enough funding to run further trials. They had only managed to raise $40 million of the $100 million they needed.

Well now it's back, they hype, that is. The funding is not mentioned, though I assume it has been raised. I wrote two posts about this issue a few months ago. The first was about how unconvincing the whole trial was, along with the media coverage it received. The second was about how the trial was likely to be both invalid and unethical.

None of the worries that I and others have expressed about the trial, known as CAPRISA, have been answered by any subsequent publications. But now the gel has been 'fast-tracked' by the FDA.

The most worrying statement in this article about the 'fast-tracking' is: "most new cases are among women infected during sex with men". Most new cases are among women, but there is little evidence that most of them result from sex with men.

The CAPRISA trial itself gives numerous indications that HIV is not spread solely by sex. Most of the participants didn't engage in much sex and most of them used condoms most of the time. In other words, the sex involved was not predominantly 'unsafe' sex. But, despite this, HIV transmission rates were appallingly high. Why? The trial did not attempt to establish why.

This trial was indifferent as to whether people were infected sexually or non-sexually. Data about how many male partners were HIV positive, and how many had the same viral strain as their female partner, were not collected.

The assumption that HIV is almost always transmitted sexually (in African countries, not in non-African countries) informs most HIV prevention programming. Evidence of non-sexually transmitted HIV is often ignored or even suppressed. It is never investigated.

But even though the CAPRISA trial demonstrated the irrelevance of sexual behavior in very high transmission scenarios, apparently trials are going to continue. Worse still, all sorts of plans are being made about commercial production of the gel, as if its effectiveness has been demonstrated!

Almost all the money currently being spent on HIV prevention (as opposed to treatment, which receives far more funding) goes to programs that assume that sex is the problem. The result is that hardly any money goes into preventing HIV transmission that doesn't result from sex. Yet, medical services in African countries are of such low quality that UNAIDS warns UN employees about the risk of being infected with HIV from medical treatment.

If there are risks of medical transmission of HIV for UN employees, there are medical risks for everyone. The refusal of the CAPRISA trial to warn participants about non-sexual risks renders the trial unethical. The failure to investigate how participants were infected renders it invalid. This vaginal gel is just one more travesty being committed by the HIV industry.

(For discussion of pre-exposure prophylaxis (PrEP), see my other blog.)

Could a Nosocomial HIV Outbreak Occur in Kenya?

One of the most horrifying examples of a nosocomial HIV outbreak occurred in Romania in the 1980s. According to a recent article in Time:

"Unlike in the rest of Eastern Europe, the majority of people living with HIV in Romania did not become infected as adult drug users or sex workers, but as children living in orphanages. In 1987, nurses hoping to cure Romania's orphans of their anemia started injecting them with whole-blood transfusions daily, reusing syringes on multiple children. Some of the blood turned out to be contaminated and at least 10,000 orphans contracted HIV. By 2000, Romania claimed 60% of all the pediatric HIV infections registered in Europe."

There have been many other nosocomial outbreaks, before and since, the majority of them remaining relatively undocumented. However, the basic details of some of the worst are listed in various places on the web, in particular, in David Gisselquist's book 'Points to Consider', available online, free of charge.

In many countries where nosocomial HIV (and other blood-borne diseases, such as hepatitis) outbreaks occurred, they were related to blood transfusions and the use of other blood products. Such occurrences in Western countries are now far less likely to happen, perhaps extremely unlikely. And even in developing countries there is greater awareness of the risks associated with blood transfusions. Most blood is screened, but it is unlikely that all countries take all precautions necessary to ensure that these risks are completely eliminated, especially developing countries.

And when it comes to unsafe injections, it is particularly difficult to quantify the risk. The WHO estimates that about 70% of injections are unnecessary and that a high percentage are unsafe, maybe close to 20%, maybe higher. The figures they cite usually lump countries together in regions and sub regions, so it's hard to know what figures apply to which countries.

UNAIDS is usually silent on the issue of non-sexual transmission of HIV, and nosocomial transmission of HIV, in particular. There are two notable exceptions; the first is when they publish figures denying that nosocomial transmission contribute more than about 2.5% of infections to epidemics in countries such as Kenya; the second is when they warn UN employees to avoid medical facilities in countries such as Kenya because of the risk of nosocomial infection with HIV or other blood borne diseases. It would be truly a medical miracle if only non-Kenyans (and non-Africans) were susceptible to such risks.

Evidence that HIV has been transmitted in African countries is  not hard to find and 'Points to Consider' is a good place to start. But the HIV orthodoxy remains, that HIV transmission is almost all heterosexual in African countries. It appears that evidence to the contrary is being systematically ignored. Why this is so is very unclear.

But rather than constantly drawing together the evidence (a quick search for 'nosocomial' on my blog links to plenty of citations where evidence can be evaluated), it is time for the issue to be investigated. The investigation needs to assess how much HIV has been transmitted nosocomially in the past and to ensure that it no longer happens in the future. At present, most 'official' figures, are modeled. These models first assume, without adequate evidence, that almost all HIV transmission is through heterosexual sex. Then these 'officials', in their infinite wisdom, allocate a small percentage that is nosocomial.

Given what is known about probabilities of heterosexual HIV transmission, it is not possible for the virus to spread as quickly as it has in some African countries (though not all). But given what is known about nosocomial infections, the Romanian instance being just one, it is possible for HIV to spread rapidly in countries that have very poor health services.

Kenya has very poor health services but a lot of people don't have access to health facilities. However, many of the countries with the highest rates of HIV transmission have poor health services to which a large percentage of the population have access. There is an opportunity to investigate and possibly eliminate a substantial percentage of HIV transmission.

Perhaps it's a matter of professional pride or academic pigheadedness that prevents UNAIDS and other parties from even admitting the possibility that they are wrong. But, whatever the reason, the possibility must be acknowledged. Otherwise, many more people will be infected with HIV and other viruses, leading to a lot of unnecessary and preventable suffering and death. What happened in Romania in the 1980s could happen in many African countries in the 2000s. It could happen in Kenya.

(To read about pre-exposure prophylaxis (PrEP), see you other blog.)

Kenyan Health Care Suffers From Underfunding and Corruption

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

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

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

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

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

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

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

Testing the HIV 'Test and Treat' Strategy

A 'Test and Treat' strategy, also referred to as 'Treatment as (or 'is') Prevention', has not shown very good results in a study in China. Such strategies were the most hyped item on the agenda just under two years ago in the HIV/AIDS world. The claim was that HIV positive people responding to treatment usually have a very low viral load so they are far less likely to transmit the virus to their sexual partners; therefore everyone in a population could be tested regularly, perhaps every year, and immediately put on antiretroviral (ARV) treatment if found to be positive.

The study in China looked at discordant couples, couples where only one partner is HIV positive. HIV transmission rates were relatively low, at 4.3% over a three year period (a seroconversation rate of 1.7 per 100 person years), though the rate increased over time.

Risk was higher where sexual activity was higher and where condoms were not always used. Risk was also higher among those who had lower scores in a psychological test. But the ARV treatment itself did not lower the risk of transmission.

Another piece of research could lend some corroboration to the Chinese research. Though not looking at Test and Treat specifically, it does suggests that such strategies may not be very effective outside of the very closely monitored trial conditions that applied to earlier randomized controlled trials.

This piece of research investigated the effects of $6 billion of PEPFAR funding (President's Emergency Plan For Aids Relief) on AIDS related deaths and prevalence in recipient countries. While the fund may have had some success in lowering death rates from AIDS, it did not significantly lower prevalence over its first four years in operation. The authors and speculate that four years may be too short a period.

It is estimated that death rates were reduced by 10.5% (an estimated 1.2 million deaths). However, the number of people put on treatment could be as much as 100 times higher than in the Chinese research. If mass treatment had much effect on transmission, one would expect some detectable effect on prevalence, even after just four years.

But unless you believe the UNAIDS orthodoxy about HIV being mainly transmitted sexually in African countries, the low rates of sexual transmission found in the Chinese research will not be very surprising. The area where the research took place, Zhumadian, has higher than average HIV prevalence because of the use of infected blood products from paid plasma donors in the 1990s.

Perhaps the investigators in the PEPFAR research should not have been so surprised that the $1.2 billion allocated to prevention, about one fifth of the total, had little impact. Because most PEPFAR prevention 'strategies' assume the truth of the UNAIDS orthodoxy, that most HIV transmission in African countries is sexual. Maybe they will now start to see that the orthodoxy needs to be challenged.

In addition to casting doubt on the completely untenable and highly racist assumptions that make up the orthodox view of HIV transmission in African countries, the above research could also question the medicalization of HIV and other diseases. This is the implicit assumption that health is just a matter of treating diseases with drugs, as opposed to ensuring that the conditions under which diseases spread are dealt with.

If high rates of non-sexual HIV transmission can occur in China, they can occur in African countries. And if low rates of sexual transmission can occur in China, they may also be occurring in Africa. Low rates of sexual transmission may be the norm in Africa and it is late in the day to start investigating the contribution that non-sexual transmission plays. But we have a duty to investigate this if we want to have any impact on African epidemics. We can no longer allow prejudices to determine what should and should not be asked about the massive rates of HIV transmission found in a handful of countries in Africa.

Nosocomial and Iatrogenic HIV Transmission in Kenya

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

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

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

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

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

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

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

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

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

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

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

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

Will Kenya Challenge UNAIDS Over Health Care Transmitted HIV?

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

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

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

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

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

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

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

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

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

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

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

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

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

The Limits of Human Promiscuity

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

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

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

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

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

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

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

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

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

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

The ‘Unknown Knowns’ of HIV Epidemiology

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Unsafe Health Care and Risk of HIV Transmission

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

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

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

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

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

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

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

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

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

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

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

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

HIV Incidence Has Been Declining Since Before UNAIDS Was Established

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIV Has Always Been Good News for Ambulance Chasers

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

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

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

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

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

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

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

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

Concentration Clinics for the Usual Suspects

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

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

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

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

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

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

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

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

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

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

Idle Arguments Support Blinkered Policy

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

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

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

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

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

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

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

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

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.

Harm Reduction Needs to Start in Health Facilities

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

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

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

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

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

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

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

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

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

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

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

Prejudice Wins Over the HIV Industry

It has been well established that HIV is transmitted through sexual contact, through contaminated blood and other bodily fluids and from mother to child. However, UNAIDS and the HIV industry have a rather anomalous view of the disease. They have decided (or decreed?) that HIV is primarily spread through heterosexual sex in African countries (and from mother to child). But in other countries, so the story goes, HIV is primarily spread through contaminated blood, by intravenous drug users and unsafe medical practices, through men having sex with men and among commercial sex workers and perhaps their clients.

If HIV is mainly spread through blood-borne transmission, one would expect it to follow a similar pattern to other blood-borne diseases, such as hepatitis C virus (HCV). Two researchers have found that to be the case in a number of Asian countries. Countries with low HIV prevalence also have low HCV prevalence and countries with high HIV prevalence have high HCV prevalence. This means that countries with low HIV prevalence might see rates increasing at some stage in the future.

If HIV is mainly spread through heterosexual sex, as it is said to be in African countries, one would expect it to follow a similar pattern to other sexually transmitted infections. But this is not the case. Sexually transmitted infections are very high in many countries where HIV prevalence is not very high. Also, sexual behaviour that is said to increase the risk of HIV transmission tends to be a lot more common in countries that have relatively low HIV prevalence.

Differences between male and female sexual behaviour are also telling, where such differences have been detected by empirical enquiry, as opposed to speculation and assumption. Whereas males are more likely to engage in unsafe sexual practices, females are more likely to be infected with HIV. Men also tend to have more partners than women. But there is nothing to suggest that what is mainly a blood-borne disease in some countries should be mainly sexually transmitted, and rarely blood-borne, in others.

So, UNAIDS and the HIV industry are wrong in (at least) two important respects: firstly, it is unlikely that HIV is transmitted primarily through unsafe heterosexual sex in African countries because there is no evidence that levels of unsafe heterosexual sex there are high enough; and secondly, it is unlikely that HIV is rarely transmitted through unsafe medical procedures and other possible blood-borne routes. Conditions in African medical facilities are poor, just as they are in many Asian medical facilities.

In fact, in African countries where many people have (or at one time had) access to medical facilities, HIV rates are the highest in the world: South Africa, Zimbabwe, Swaziland, Lesotho, Botswana and others. In countries where many people have little or no access to medical facilities, HIV rates are far lower. For example, Kenya, Uganda and Tanzania, especially the rural parts of these countries. And in almost all areas with high HIV prevalence, more women than men are infected, often far more women.

So UNAIDS and the HIV industry have spent years tying themselves in knots trying to explain why a disease that is both sexually transmitted and blood-borne is mainly sexually transmitted in some countries and mainly blood-borne in others. This is especially difficult when neither levels of sexual behaviour nor conditions in medical facilities bear out such a conclusion. But if you supplant evidence with prejudice in developing a health strategy, you are bound to end up with such anomalies.

This sort of institutional racism results in the rather obtuse view that Africans engage in inordinately high levels of sexual activity, despite evidence to the contrary. HIV prevalence has reached hyperendemic levels in many Southern African countries, so the HIV industry insists on sexual behaviour change. Why these racists have also concluded that virtually no HIV transmission occurs as a result of unsafe medical practices is a complete mystery. But as a result, the industry feels that no effort need be made to improve conditions in medical facilities.

HIV, which is difficult to spread sexually, quickly spread to every country in the world throughout the 80s and 90s. In most countries, prevalence has remained below 1%. But in some countries, over 25% of sexually active adults are infected. No adequate explanation has been given as to how this could happen if HIV is mainly sexually transmitted. On the other hand, there have been several outbreaks of medically transmitted HIV (that have been properly investigated. In addition to Romania, there were also outbreaks in Libya, Kazakhstan and Russia that were caused by unsafe healthcare). The combination of sexual and blood-borne infection could help explain how these hyperendemics occurred.

This is not a conclusion. All we can conclude is that non-sexually transmitted HIV plays some part in countries with high HIV prevalence. The part that non-sexual transmission plays may have been more significant in the past, certainly in countries that have had the capacity to improve medical and other facilities. But rates of HIV transmission in some hyperendemic countries are still too high to be explained by sexual transmission alone. This means that a lot of work needs to be done to ensure that medical facilities and other places where blood-borne risks exist are made safe.

But first, UNAIDS and the rest of the HIV industry need to agree to investigate the extent of non-sexual HIV transmission. They need to agree to prevention programs that target non-sexual transmission, in all its forms. Unless people are aware of the risks they face, they will not know that they need to avoid these risks, let alone know how to avoid them. Surely levels of institutional racism and sexism that allow millions of people to become infected with HIV and to die of Aids are serious enough to deserve the world’s attention?