Another Look At Sexual (and Non-Sexual?) HIV Risk

A recently published article finds that, out of 1834 African participants who belong to various groups thought to face high risk of being infected with HIV, incidence (the rate of new infections per year) was highest among men who had sex with men (MSM). In Western countries, MSM often have the highest rates of HIV transmission, followed by intravenous drug users (IDU). But because such a huge proportion of transmission in African countries occurs among heterosexuals who don't fall into any of the above risk groups, MSM generally account for a relatively small percentage of those infected with HIV there, as do IDUs.

It was also found that "[p]aying for sex was inversely associated with HIV infection". In Western countries, sex workers are not especially likely to be infected unless they are also IDUs. But in African countries extraordinary prevalence rates have been reported for this group, even where they are not reported to have other risks. Prevalence rates of 70 or 80% have been reported, prompting some to wonder if the women might have faced one or more non-sexual risk not examined by those doing the reporting. The alarmingly high rates reported in the 1980s and 1990s dropped rapidly, often long before the country involved made any attempts to reduce infection rates; but it's good to hear that the risks this group faces may be receding.

The study aimed to identify risk populations for HIV prevention trials. If those taking part in the trial do not face much risk it will be difficult for a trial to show an effect. But the results should also be of interest to those whose job consists of making claims such as the one about 80-90% of HIV transmission in African countries resulting from heterosexual sex. Where HIV appears to be transmitted rapidly and heterosexual sex is found to be the only significant risk, there is then a problem of explaining what is so risky about heterosexual sex between Africans, something that has eluded those working in the field so far. Some of the elusiveness may stem from the fact that heterosexual sex was assumed, rather than found to be the only risk.

One of the most surprising findings was that no HIV infections were found in over 300 women in Nairobi who identified themselves as sex workers. The authors speculate that this may be due to condom use, fewer HIV positive clients, more clients on antiretroviral drugs, etc. But hopefully the finding will prompt some reanalysis of some of the eyewatering claims made about numbers of clients per day and other speculation about unsafe sex mentioned (ad nauseum) in the past. Much of it seemed to be created to fit the rates of HIV infection found rather than to investigate if such behavior really existed or if it was common enough in high HIV prevalence areas to explain transmission rates; little effort seems to have been made to establish if sex workers faced other, non-sexual HIV risks.

The finding that pregnancy rates were higher than expected may suggest that women, even sex workers, were not using condoms particularly consistently. Extremely high rates of sexually transmitted infections in one area, and fairly high in the others, also suggest that condom use campaigns may not yet have had much impact among some high risk groups (and those thought to be high risk). If the inverse association between paying for sex and HIV prevalence among MSM is an indication that condom campaigns can work when properly targeted, that is certainly an important finding, as is the one that MSM perceive anal sex with men to be lower risk than sex with women. But some well publicized claims about female sexual behavior may have supported that perception.

One of the worrying things about this paper is that the participants are drawn from groups thought to be at high risk. However, the bulk of HIV transmission in countries where modes of transmission studies have been carried out occurs among groups of people who are not thought to be at high risk. In other words, this research excludes most of the HIV positive population in countries like Uganda and Kenya, where relatively low risk sex is said to account for over 60% of the total.

Finally, my attention has been drawn to the appendix, which I am currently unable to access, which shows that those who have received an injection in the last three months are nearly five times more likely to be infected with HIV. Those involved in clinical trials would appear to have very good reason to start looking more closely at non-sexual risks.

Turning Off the Tap: Don't Forget, There Are Two of Them

There's an article published by Peter Piot in 1987 that has had a lot of influence on the way many others have written about HIV ever since. I'd like to say it has had influence on the way people have thought, but this article seems to have been a serious obstacle to thought. Concentrating on what it has to say about women, here's how it goes: "Among 446 sera from prostitutes in Nairobi, the prevalence of antibody to human immunodeficiency virus (HIV) rose from 4% in 1981 to 61% in 1985." Also "Among pregnant women, 2.0% were seropositive in 1985 versus none of 111 in 1981."

This article and the numerous articles like it support the 'behavioral paradigm', the view that almost all HIV transmission in African countries (but not in non-African countries) is heterosexually transmitted. Why did this become the dominant paradigm and remain so to this day, despite clear evidence that it was wrong, in addition to being deeply prejudiced and stigmatizing? Well, it was concluded from the fact that "Seropositive [ie, HIV positive] prostitutes and women with sexually transmitted diseases (STDs) tended to have more sex partners and had a higher prevalence of gonorrhoea, and in women with STDs, significantly more seropositive women practiced prostitution."

Before concluding that the last statement proves, or even supports the behavioral paradigm, consider this: if someone is found to be HIV positive, it is necessary to look carefully at both sexual and non-sexual risks before concluding that they were infected sexually. while it is indeed fairly clear that people have most probably been engaging in unsafe sex if they have one or more STD, and many commercial sex workers do engage in unsafe sex, this does not mean they never face non-sexual risks. The very same sentence that identifies the sexual risks also identifies the non-sexual risks: they were probably treated for and/or vaccinated against STDs at some time in their lives, perhaps many times in their lives.

Long before HIV was recognized, sex workers were routinely rounded up for sexual health programs. In fact, the very blood samples collected in 1981 pre-date the discovery of HIV. The blood was taken at a time when injecting equipment was often reused without sterilization to an extent that has rarely been investigated. Every one of the women participating in the program faced a whole host of non-sexual HIV risks. In all probability, sex workers all over the world continue to face serious risks of being infected with HIV and other bloodborne diseases, though the risk may no longer be so high, even in African countries.

The authors can not show that the women involved were infected sexually. They wouldn't have been able to demonstrate it then and it would still be difficult to do so now. Nor can they rule out the possibility that many, if not all, were infected through the STD programs during which the blood samples were collected. But they have good reason to suspect that they are quite wrong in their conclusion about this massive rate of heterosexual transmission. And there are many other articles like this one with these exact same flaws. There is only one way that HIV prevalence can go from 4% to 61% in the space of a few years and that is through unsafe healthcare, especially that received in STD clinics.

There's a lot more that could be said about this article but let's shoot forward to the present, where the standard of analysis set by Piot and colleagues is still being rigorously maintained. As I mentioned in my last post, PEPFAR held a consultation on what they called 'mixed' HIV epidemics, those where HIV prevalence is high among those thought to be most at risk of being infected and also high among the general population, those thought (if thought is involved) to be at low or even zero risk of being infected. Remarks about Kenya's epidemic presented during this consultation show just how persistent an obstacle to thought Piot's article is.

Despite three decades of hollering about risky sex (and keeping quiet about risky healthcare), the committee accepts that 44% of HIV in Kenya is actually transmitted through heterosexual sex among couples in long term partnerships, married or otherwise; low risk sex is, according to their figures, the most risky sex of all. After low risk sex comes slightly higher risk sex, accounting for over 20% of all transmission, that between casual partners, where there is no indication that either partner is a commercial sex worker or visits commercial sex workers.

The entire contribution assumed to come from sex workers and their clients is only 14%. Note, it is no more certain that those falling into this group were infected sexually than those found to be infected in Piot's research. Sex workers and their clients, since they may often have STDs, face significant non-sexual HIV risks. But like the general population of African countries, it is mainly African sex workers who face very high HIV risks. In other countries, sex workers are unlikely to be infected with HIV unless they are also intravenous drug users. Sexual practices in some parts of some African countries may, as claimed by the HIV industry, be risky, but so are healthcare practices.

Another 15% of Kenya's HIV epidemic is said to come from men who have sex with men and prisoners. This is very ambiguous. While there may or may not be a lot of male to male sex in prisons, and anal sex is very risks, whether homosexual or heterosexual, there are also elevated non-sexual risks in prisons. Men tattoo themselves and each other, using makeshift equipment and dyes, they may take blood oaths, engage in various traditional practices, including medicine, that involves bloodletting, even take various drugs. What proportion of HIV in prisons is non-sexually transmitted?

Having inflated the figures for sexual transmission of HIV in the 'high risk' groups and claimed that low risk sex is also high risk sex, these experts conclude that all that's left for health facility related HIV transmission is 2.52%. of course, if you start off believing that 80 or 90% of HIV is transmitted through heterosexual sex, then healthcare transmission will only account for a small amount; but that's just arguing in a circle. The approximately 95% of HIV transmission that is said to be sexual needs to be re-examined. Have those producing these figures shown that all, or even most of that 95% was sexually transmitted? or, to put it another way, can they rule out non-sexual transmission in all those groups?

They are not even asking the questions. As I say above, there is an obstacle to thought here, in the form of the behavioral paradigm. Those who hold the paradigm seem unable to go beyond it. The very questions Piot should have been asking in 1987 remain unasked by most academics publishing in the field of HIV today. Papers like this one by Piot have amply fuelled prejudices ranging from those aimed at Africans and women to those aimed at men who have sex with men, drug users, prisoners, migrants, long distance drivers, religious denominations, tribal groups, nationals of various countries and others too numerous to mention.

How do we know that most people said to have been infected with HIV through heterosexual sex were really infected through sex? We don't. How can we rule out non-sexual transmission in 95% of Kenya's HIV positive people? We can't. What is the relative contribution of non-sexually transmitted HIV, such as through unsafe healthcare? We have no idea. The HIV industry likes to use the metaphor of 'closing the tap', preventing new infections; they need to see that there are two taps and both need to be closed, regardless of which one contributes most to the pandemic.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]

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.

Manufacturing Markets for Big Pharma

There’s a distinct tension between two articles I came across recently on generic antiretroviral drugs (ARV). The first, entitled ‘PEPFAR success critically dependent on use of generic ARVs, study shows’, claims that use of generic ARVs have allowed PEPFAR (the US President’s Emergency Plan for Aids Relief) to reach its target of getting 2 million people on treatment in low and middle-income countries. The article describes how use of generics has overcome various objections from some US politicians, who were well lobbied by the pharmaceutical industry and its cronies.

I would guess that what pharmaceutical companies settled for was to be in control of generics, rather than wishing their use to be banned. They would have wanted to control who produced generics, where and at what price. There’s no reason to lobby against them if they bring in a healthy profit. We are told that PEPFAR saved around 323 billion dollars by using generics. Regardless of whether they would really have spent that much money on overpriced pharmaceutical products, pharmaceutical companies still took in hundreds of millions of dollars. Anyone with shares in the industry need have no worries about that.

The article concludes that “Drugs are no longer the main driver of treatment costs”, which is good to hear. But it is interesting to note that drugs for sick people are potentially just a small part of the ARV market. A much hyped microbicide, a gel containing the ARV Tenofovir, is aimed at women who are HIV negative. And the same Tenofovir is behind the current pre-exposure prophylaxis trials (or ‘PrEP’, the process of taking antiretrovirals to reduce the likelihood of being infected with HIV), amply supported by Bill Gates’s Foundation. PrEP could potentially be used by any HIV negative person, though it may be targeted especially at men who have sex with men and perhaps commercial sex workers.

Current estimates are that in excess of 30, perhaps nearly 40 million people are HIV positive. That sounds like a vast market for ARVs when you consider that people will have to take them for the rest of their lives. But this is nothing compared to the number of people who could be customers for microbicides, PrEP and any other ways of selling ARVs that the pharmaceutical industry dream up. In Africa alone, the potential market could run into hundreds of millions of people. It is to be wondered if PEPFAR will still have the stomach for that. Gates needn’t worry, the Foundation stands to gain if microbicides and PrEP get off the ground.

In case hundreds of millions of customers doesn’t satisfy Big Pharma, and it won’t keep them happy for long, newer versions of ARVs are constantly being produced with improvements or claimed improvements. These are gradually replacing older versions. And those on ARVs, sooner or later, develop resistance to first line drugs. Second line drugs can cost many times more, but without them people will die. Third line drugs are still beyond the reach of developing countries, despite all the donor money available for treatment. It’s not clear where all the money will come from as it will exceed PEPFAR, the World Bank’s Global Fund and Bill Gate’s savings many times over. But things are going well for Big Pharma so far.

The second article is entitled ‘HIV generics under threat from tighter patenting rules’. This is about the pharmaceutical industry lobbying that is still going on to persuade governments, and anyone else who will listen, to create intellectual property laws that prevent generics from being produced. The US and the EU are the main culprits, as usual. Although generics can be produced once a ‘voluntary licence’ has been obtained, the original patent holder still gets a big say in how the drugs can be distributed, how they are priced and where they are sold.

Some object to this on the grounds that it leaves too much power in the hands of the patent holders. As I suggested above, the pharmaceutical industry likes to be able to control things and it seems unlikely that they would have conceded anything without getting their pound of flesh. Far from trying to relax intellectual property laws so that poor countries with high HIV prevalence can benefit, the US and the EU have been trying for some time to make it more difficult for countries like India, the biggest producer of generic ARVs, to produce these drugs. And there have been efforts, some of them successful, to prevent other countries from buying them. An example is Kenya, and other African countries are now trying to create similar laws.

Given the weight behind increasing the cost of ARVs, it seems very odd that PEPFAR should be fighting to reduce them. Are we supposed to believe that PEPFAR is in conflict with the government that allowed it so many billions of dollars? Could PEPFAR be a champion of fair intellectual property and trade laws that benefit poor people in poor countries? This is difficult to accept. The PEPFAR billions were unlikely to have been forthcoming in the first place unless they stood to benefit the US industry as a whole and Big Pharma in particular.

The World Trade Organization (WTO) has talked the talk of allowing developing countries access to ARVs by giving them a nominal right to produce generic ARVs under a compulsory licence. But this has had little impact in practice. And in case it should ever any impact, the US and EU are busy trying to get developing countries to sign up to Free Trade Agreements and Economic Partnership Agreements so that whatever the WTO has done is irrelevant.

Big Pharma seems to have used a classic bargaining trick; they have started the bidding at a price many times higher than would be reasonable. They have then been in a good position to accept a price a few times lower, probably set by parties who had an interest in maximizing pharmaceutical company profits. Giving the industry so much control means that they can add in the pretence that there is some level of competition, though there is unlikely to be any. A spokesperson for UNITAID, Ellen ‘t Hoen, said that “financing for HIV had to remain strong, as even the lowest-cost drugs needed an assured market”. So that’s the level of competition!

The pretence that the global pharmaceutical industry is just trying to make its way in a competitive business is sickening enough, when you consider how much effort goes into stacking the odds in their favour. But the expansion of the ARV market to include those thought to be at risk of being infected with HIV is outrageous. UNAIDS and various other commercial interests, academic institutions and the like, view almost all Africans as being at risk of infection with HIV. Yet this same group has failed adequately to describe serious HIV epidemics to the extent that they are in any position to make a useful assessment of risk.

Not only is the carefully crafted market for ARVs huge and expanding, it also enjoys the full protection of ‘global’ trade laws. And judging by the emphasis on microbicides and PrEP at the recent Vienna Aids Conference, the HIV industry appears to see its primary role as helping Big Pharma expand. The right to health has shrunk to a ‘right to treatment’ and those providing ‘the treatment’ have moved in to supply it to the healthy and the unhealthy alike. As for the HIV pandemic, Big Pharma says ‘don’t worry, we have the treatment’. But if health has been reduced to treatment, will there be any resources to ensure that healthy people stay healthy, even to reduce the spread of HIV and perhaps eventually eradicate it? Already, the HIV pandemic seems far too valuable to risk destroying.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)

Will PEPFAR Become a Fund for Health?

It sounds as if PEPFAR (President's Emergency Fund for Aids Relief) is about to change a bit under the Obama administration. These changes are all long overdue. For a start, Aids is no longer to be seen as an emergency. It wasn't an emergency before PEPFAR started, so this is good to hear.

The 'exceptionalisation' of Aids, treating it as if it is a disease that is separate from health in general, should have its own institutions and funding, is to disappear. Again, this move is long overdue, but still welcome. Hopefully, it will mean that some of the huge sums that have been raised for Aids will be spent on health services. Those who think Aids issues will lose out needn't worry, people with Aids also have general health needs. So everyone will gain.

The head of PEPFAR, Eric Goosby, is at last questioning the sustainability of putting everyone who is HIV positive on drugs that they will need for the rest of their lives. Of course, HIV positive people should be treated, but with far more people becoming newly infected for every one put on treatment, something really has to be done to reduce the number of new infections as well.

So HIV prevention should return to the agenda. The question is, what kind of prevention programmes will be funded by PEPFAR? In the past, prevention has included little but lecturing people on their sexual behaviour. There are few prevention programmes that have had much impact on HIV transmission. Of course, most well funded programmes will tell you that they have been very successful and show evidence that whatever mindless drivel they repeated to all and sundry can be trotted out at the ring of a bell, or whatever.

But rates of HIV transmission remain high in many countries, including the US, despite these questionable programmes. Does PEPFAR have anything new to bring to the table? If they don't, it would be good to hear that they are willing to talk about using condoms and employing other harm reduction approaches to HIV. For example, clean needle and syringe distribution and greater advocacy and support for sex workers, men who have sex with men and other vulnerable populations.

Another change proposed is that PEPFAR funds go to governments rather than, primarily, to NGOs. While it's true that NGOs may not have done very well in many cases, I'm not sure about the wisdom of handing large amounts of money to governments. Kenya has had a particularly bad history when it comes to administrating large amounts of money intended for HIV treatment, care and prevention (or any kind of funding). Time and time again, investigations have found administration of funds wanting, only for the money to flow in again once the row has died down. PEPFAR recently announced a doubling in Aids funding, amounting to 2.7 billion dollars over the next five years.(A Ugandan writer also worries about these changes ito PEPFAR.)

Disbursements of US aid for HIV don't relate to a country's need. The HIV epidemic in Kenya is by no means the worst in Africa, even in Sub-Saharan Africa but they are one of the top recipients of funding. No, disbursements seem to depend more on how cozy a country's relationship is with the US and for Kenya, the relationship has been very cozy since independence. Perhaps questions about how much of that money actually benefits people with HIV are irrelevant to PEPFAR, as long as cozy relationships remain, who knows? But let's hope the changes take place and my fears are not realised.

Did Someone Say 'Final Solution'?

I have read various articles about the proposal to carry out a 'gay census' in Kenya. But none of them shed any light on why the Kenyan government should suddenly be interested in identifying some of those most at risk of being infected with and of transmitting HIV. The best way to make gay people feel they are not being singled out is to make HIV and sexual health services available to all, without prejudice.

In fact, the proposal is not just to single out men who have sex with men (MSM). The proposal also aims to identify commercial sex workers (CSW) and intravenous drug users (IDU). That's hardly going to make members of these groups feel any better. They all have several things in common: they are all doing something considered to be illegal. They are also the subject of prejudice, discrimination and condemnation by political and religious leaders.

Men who have sex with men, commercial sex workers and intravenous drug users need access to sexual health services. They also need access to more general health services, the protection of the law from persecution by members of the public and by the police. But programmes involving what is often referred to as 'harm reduction' are not popular in Kenya. The possibility of decriminalising sex between people of the same gender, commercial sex work or even intravenous drug use is not even being discussed right now.

So what strikes me as most suspicious about the call to carry out this gay census, or census of people who are most at risk from HIV, is that it is being funded by the President's Emergency Plan for Aids Relief (PEPFAR). PEPFAR has always been vehemently opposed to harm reduction measures, such as the use of condoms, needle exchange programmes and other activities that are known to help reduce the spread of HIV and other diseases.

Why would PEPFAR now be interested in funding this particular approach? Are we supposed to believe that the initiative has changed to such an extent that harm reduction is no longer refused funding? And are we also supposed to believe that the Kenyan government has completely reconsidered its earlier views on gay sex, commercial sex work and intravenous drug use?

I suspect the motives behind PEPFAR's decision to fund any kind of 'survey' of some of the most vulnerable people in the country. I suspect the Kenyan government's motives, too. I have heard rumours that a number of powerful people in the US are not completely unrelated to Uganda's current discussions of an effective pogrom against gay people. This is not the way to reduce HIV transmission and it will have numerous other human rights consequences.

Unless many other things are in place that guarantee the safety of people affected by this proposed 'survey', and that will include people who don't actually fall into any of the targeted groups, the whole thing should be abandoned immediately.