According to a situation analysis of HIV in Pakistan, the country is "at high risk of HIV infection" but that presently prevalence is very low. In fact, prevalence is under .1%, which is significantly lower than in the US (estimated at .6%). Only a few thousands of HIV positive people have actually been identified.
Pakistan's epidemic is considered to be 'concentrated', that is, the majority of infections are among members of high risk groups, such as intravenous drug users and men who have sex with men. It has been suggested that the epidemic is 'in transition', but prevalence might just as easily be lower than the estimates would suggest.
There are references to "indiscriminate transfusion of unscreened blood" and "unsafe injecting practices in formal and informal healthcare settings". If these are true, then HIV can not be truly said to have penetrated the country's health services. Those types of transmission would spread the virus very quickly.
Despite the lack of conclusive evidence, it is also estimated that over 50% of HIV transmissions are through heterosexual sex. This could be compared to the 80% (sometimes 90%) estimated by UNAIDS for heterosexual transmission in African countries. The two estimates should certainly be treated with equal skepticism.
It might also be wondered how Pakistan could report indiscriminate transfusion of unscreened blood and high levels of unsafe injecting when these modes of transmission are said to be almost non-existent in African countries. Are Africa's health services so much more advanced than those available in Pakistan? And if they are, why are UN employees warned not to use them? Why do rich Africans opt for medical care in Western countries?
Transmission rates in Pakistan attributed to intravenous drug use and male to male sex are comparable to those found in African countries. But in Pakistan, 27% of transmissions are said to be due to undetermined origin. In African countries, none are so attributed. Epidemiologists much be far more efficient in African countries.
So, aside from having very low prevalence in Pakistan, another stark difference is that in Africa, far more women are infected than men. In Pakistan, it's the other way around, where "86.8 % of reported HIV positive cases are found to be men". Given that probability of transmission from women to men is said to be about half that from men to women, the contribution of heterosexual transmission should be relatively low, certainly lower than 50%.
The differences found in HIV epidemics in Pakistan and, say, South Africa (prevalence 18.1, ie, 181 times higher), are enormous. So enormous that you might ask if it is the same virus that is being referred to as 'HIV' in both countries. My suspicion is that it is the same virus, but we are being lied to about the respective contribution of non-sexual transmission in African countries. Which may be good news for Pakistan, but not for African countries.
Showing posts with label prevention of mother to child transmission. Show all posts
Showing posts with label prevention of mother to child transmission. Show all posts
Friday, May 6, 2011
Tuesday, May 3, 2011
Test and Treat Strategy Guarantees a Long and Profitable HIV Epidemic
The multi-billion dollar global HIV industry continues to edge its way towards its ideal solution to HIV: allow it to spread. Genuine prevention success would cut into the industry's profits. But fake prevention strategies, such as 'test and treat' (or 'test all, treat all' or 'treatment as (or 'is') prevention'), will guarantee increasing profits every year.
This pseudo-strategy involves testing 'all' (the figure hoped for is 80%) sexually active people about once a year, or possibly more often. But only three countries in the world have more than 20% prevalence and only 9 have more than 10%. They had better be very accurate about which 80% of the population they succeed in testing, every year.
Also, the industry usually characterizes HIV as a sexually transmitted infection, although it is not always transmitted sexually and might not even be primarily sexually transmitted. But it's the party line and it's paid off very well so far. Talk about sex will get you money, talk about non-sexual transmission, especially through unsafe healthcare, will get you branded as a denialist or some kind of crank.
But even if you accept the behavioral paradigm, the view that HIV is almost always transmitted sexually (in some developing countries, but certainly not in developed countries), you might notice that the industry has always been very bad at saying exactly who is most at risk. It might seem obvious that those who have most 'unsafe' sex are most at risk, but sex worker populations often have low HIV prevalence figures.
Indee in some countries, sex workers plus their clients plus their clients' partners make up a relatively small contribution to the country's overall epidemic. The largest contribution in many mature epidemics, such as Uganda's, appears to come from people in a stable relationship who mainly engage in low risk sex.
So the industry is in the ironic position of having to target those among whom risk of sexual transmission is low, if they are really going to have any impact through their proposed strategy. In fact, the industry will have to target pretty much all sexually active people, partly because they don't know who the people most at risk are and partly because those who are not at much risk at all appear to be contributing most to some epidemics.
There's a contradiction in there somewhere. But as long as it sells drugs and sales rise every year, the industry will not be complaining. Little attempt will need to be made to figure out how HIV is being transmitted and nothing will be done to reduce transmission by actually addressing causes.
The process will simply involve finding people already infected, putting them on treatment, going through the testing process every year and claiming that a whole lot more would have been infected if the strategy hadn't been implemented.
Oh, and don't worry about evidence: the plan is "based on mathematical modelling". "The model developed assumes a population of very high prevalence which is tested once a year and those found HIV positive started on ARVs immediately; with this early antiretroviral intervention, the model shows that in three decades the new infections would be reduced sufficiently to eliminate the epidemic."
What could disprove this model? Who is discussing the fact that epidemics are the result of conditions that themselves need to be addressed, and not just treated with drugs? And who will wish to answer these questions when there is so much money to be made from ignoring them? Test and treat strategies may seem like they are doing nothing to prevent HIV transmission, but for advocates, not preventing HIV is a form of HIV prevention.
This pseudo-strategy involves testing 'all' (the figure hoped for is 80%) sexually active people about once a year, or possibly more often. But only three countries in the world have more than 20% prevalence and only 9 have more than 10%. They had better be very accurate about which 80% of the population they succeed in testing, every year.
Also, the industry usually characterizes HIV as a sexually transmitted infection, although it is not always transmitted sexually and might not even be primarily sexually transmitted. But it's the party line and it's paid off very well so far. Talk about sex will get you money, talk about non-sexual transmission, especially through unsafe healthcare, will get you branded as a denialist or some kind of crank.
But even if you accept the behavioral paradigm, the view that HIV is almost always transmitted sexually (in some developing countries, but certainly not in developed countries), you might notice that the industry has always been very bad at saying exactly who is most at risk. It might seem obvious that those who have most 'unsafe' sex are most at risk, but sex worker populations often have low HIV prevalence figures.
Indee in some countries, sex workers plus their clients plus their clients' partners make up a relatively small contribution to the country's overall epidemic. The largest contribution in many mature epidemics, such as Uganda's, appears to come from people in a stable relationship who mainly engage in low risk sex.
So the industry is in the ironic position of having to target those among whom risk of sexual transmission is low, if they are really going to have any impact through their proposed strategy. In fact, the industry will have to target pretty much all sexually active people, partly because they don't know who the people most at risk are and partly because those who are not at much risk at all appear to be contributing most to some epidemics.
There's a contradiction in there somewhere. But as long as it sells drugs and sales rise every year, the industry will not be complaining. Little attempt will need to be made to figure out how HIV is being transmitted and nothing will be done to reduce transmission by actually addressing causes.
The process will simply involve finding people already infected, putting them on treatment, going through the testing process every year and claiming that a whole lot more would have been infected if the strategy hadn't been implemented.
Oh, and don't worry about evidence: the plan is "based on mathematical modelling". "The model developed assumes a population of very high prevalence which is tested once a year and those found HIV positive started on ARVs immediately; with this early antiretroviral intervention, the model shows that in three decades the new infections would be reduced sufficiently to eliminate the epidemic."
What could disprove this model? Who is discussing the fact that epidemics are the result of conditions that themselves need to be addressed, and not just treated with drugs? And who will wish to answer these questions when there is so much money to be made from ignoring them? Test and treat strategies may seem like they are doing nothing to prevent HIV transmission, but for advocates, not preventing HIV is a form of HIV prevention.
Wednesday, April 27, 2011
Unsafe Injections Are Common, Especially in Poor Countries
The weekly Safe Injection Global Network newsletter has arrived in my inbox. As always, I'm stunned by how many new incidents are uncovered every week that demonstrate how dangerous lapses of safety can be in hospitals, even in countries with very well funded health services.
A survey of 87 facilities in the US found that hemodialysis patients were twice as likely to be infected with hepatitis C virus (HCV) as non-hemodialysis patients.
222 endoscopy patients in New Orleans are being contacted because they may have been exposed to HIV, hepatitis or other diseases through unsterile equipment. This is the second such incident this year. The last time, 360 patients were contacted. The period covered this time is over 7 months. The risk may be small, but it was a long lapse, and the hospital is rightly taking no chances.
In Alberta, 226 patients are being screened HIV and HCV because a care worker was found to be positive for both viruses. Again, the risk to patients is low, but these things can't be left to chance. Apparently, the investigation revealed no breaches of infection control practices.
A report suggests that thousands of patients who have attended a certain Veterans' Affairs dentist need to be screened. This is not the first article about the same dentist, but the dentist in question was working for 18 years in the clinic and failed to change gloves and to sterilize equipment between patients.
The problem might even date back to the mid 1970s. Two patients have already been identified as having hepatitis B virus (HBV), but only a few hundred have been screened so far. This whole episode is in need of clarification. Former patients must now be wondering if other practitioners could have done the same, and how long it will take before they are informed.
The use of multi-dose flasks of vitamin C in an Australian health facility has been demonstrated to have resulted in at least three people being infected with HCV. Inadequate infection control was 'apparent'.
The point I am making is that health facility acquired infections occur, there are lapses in procedures, mistakes made and what not. But in Western countries, where such occurrences often don't represent a very high risk to patient safety anyway, an investigation is carried out. Sometimes people are disciplined, controls are tightened up, effort is made to ensure that adverse events don't happen again.
In developing countries, where health facilities are in short supply, underfunded, understaffed, underequipped, lacking in written procedures and trained personnel who can (and do) follow them, the risk that people could be infected with a serious disease is very high when adverse events occur.
The fact that there are very few articles about such events in developing countries, and even fewer about investigations and patients being contacted to be screened, is very suspicious indeed. Only an idiot would conclude that such events never occur. So the question arises as to whether anyone is even checking for them, if they are recognized, if they are reported and if anything can be done, or if anything is done, when these breaches occur.
Another recent article finds that patient safety incidents are underreported and, as a result, policy is biased. In other words, the extent of patient safety issues is not even well established in Western countries, let alone in developing countries.
Finally, an article looks at 'deliberate, extreme' underreporting of hospital acquired infections in Mongolia and the strategies that health personnel use to avoid accurate reporting.
Unsafe injections occur everywhere, but in some countries, effort is made to establish to what extent and to identify remedial action that can be taken. But in many countries, no such effort is made. On the contrary, the whole issue is ignored, denied or swept under the carpet.
In some countries, unsafe injections are very common and are known to cause tens of millions of serious infections, such as HIV, HBV and HCV. But in these countries, no remedial action is taken and, worse than that, UNAIDS and other institutions simply deny that unsafe injections is a problem.
How, in the light of so much evidence that unsafe injections are very common, especially in poor countries, UNAIDS can claim that as little as 2-2.5% of HIV is transmitted by this route, I can not understand. But this bias results in biased policy, policy that concentrates on sexual transmission. And biased policy results in biased spending, with hardly anything going towards non-sexual HIV transmission.
Unsafe injections and other forms of non-sexual HIV transmission clearly make a considerable contribution to HIV transmission in high prevalence countries. It is the job of UNAIDS to work out the exact extent of this contribution and ensure that funding for adequate prevention measures is provided to countries. Otherwise, high HIV transmission rates will continue to destroy the lives of millions of people every year.
A survey of 87 facilities in the US found that hemodialysis patients were twice as likely to be infected with hepatitis C virus (HCV) as non-hemodialysis patients.
222 endoscopy patients in New Orleans are being contacted because they may have been exposed to HIV, hepatitis or other diseases through unsterile equipment. This is the second such incident this year. The last time, 360 patients were contacted. The period covered this time is over 7 months. The risk may be small, but it was a long lapse, and the hospital is rightly taking no chances.
In Alberta, 226 patients are being screened HIV and HCV because a care worker was found to be positive for both viruses. Again, the risk to patients is low, but these things can't be left to chance. Apparently, the investigation revealed no breaches of infection control practices.
A report suggests that thousands of patients who have attended a certain Veterans' Affairs dentist need to be screened. This is not the first article about the same dentist, but the dentist in question was working for 18 years in the clinic and failed to change gloves and to sterilize equipment between patients.
The problem might even date back to the mid 1970s. Two patients have already been identified as having hepatitis B virus (HBV), but only a few hundred have been screened so far. This whole episode is in need of clarification. Former patients must now be wondering if other practitioners could have done the same, and how long it will take before they are informed.
The use of multi-dose flasks of vitamin C in an Australian health facility has been demonstrated to have resulted in at least three people being infected with HCV. Inadequate infection control was 'apparent'.
The point I am making is that health facility acquired infections occur, there are lapses in procedures, mistakes made and what not. But in Western countries, where such occurrences often don't represent a very high risk to patient safety anyway, an investigation is carried out. Sometimes people are disciplined, controls are tightened up, effort is made to ensure that adverse events don't happen again.
In developing countries, where health facilities are in short supply, underfunded, understaffed, underequipped, lacking in written procedures and trained personnel who can (and do) follow them, the risk that people could be infected with a serious disease is very high when adverse events occur.
The fact that there are very few articles about such events in developing countries, and even fewer about investigations and patients being contacted to be screened, is very suspicious indeed. Only an idiot would conclude that such events never occur. So the question arises as to whether anyone is even checking for them, if they are recognized, if they are reported and if anything can be done, or if anything is done, when these breaches occur.
Another recent article finds that patient safety incidents are underreported and, as a result, policy is biased. In other words, the extent of patient safety issues is not even well established in Western countries, let alone in developing countries.
Finally, an article looks at 'deliberate, extreme' underreporting of hospital acquired infections in Mongolia and the strategies that health personnel use to avoid accurate reporting.
Unsafe injections occur everywhere, but in some countries, effort is made to establish to what extent and to identify remedial action that can be taken. But in many countries, no such effort is made. On the contrary, the whole issue is ignored, denied or swept under the carpet.
In some countries, unsafe injections are very common and are known to cause tens of millions of serious infections, such as HIV, HBV and HCV. But in these countries, no remedial action is taken and, worse than that, UNAIDS and other institutions simply deny that unsafe injections is a problem.
How, in the light of so much evidence that unsafe injections are very common, especially in poor countries, UNAIDS can claim that as little as 2-2.5% of HIV is transmitted by this route, I can not understand. But this bias results in biased policy, policy that concentrates on sexual transmission. And biased policy results in biased spending, with hardly anything going towards non-sexual HIV transmission.
Unsafe injections and other forms of non-sexual HIV transmission clearly make a considerable contribution to HIV transmission in high prevalence countries. It is the job of UNAIDS to work out the exact extent of this contribution and ensure that funding for adequate prevention measures is provided to countries. Otherwise, high HIV transmission rates will continue to destroy the lives of millions of people every year.
Tuesday, April 26, 2011
Blinded by Influence: the 'Rightness' of Big Funding
Matthew Black has raised some issues in response to my last post, which I would like to answer in detail. It appears that his opinion is based to some extent on a very brief article which denies, but doesn't adequately refute, some of the most pressing arguments against the behavioral paradigm, the view that HIV is almost always transmitted sexually in African countries.
Firstly, in saying that I don't believe all HIV is transmitted sexually, I am not claiming that it is never transmitted sexually. Nor am I saying that it is mostly transmitted non-sexually, by unsafe health care or any other non-sexual modes.
What I am saying is that we do not know the extent of non-sexual transmission and that it is vital to address this lack of knowledge in order to judge how much time, effort and resources are spent on each mode of transmission.
Aside from lack of thorough research into non-sexual transmission, particularly through unsafe injections, but by no means limited to that, no adequate explanation has ever been given as to why heterosexual transmision of HIV is realatively uncommon outside of a few high prevalence countries, mostly in sub-Saharan Africa.
People all over the world have sex, some of them have a lot of sex and it is often 'unsafe'. But rates of sexual transmission appear to be hundreds of times higher in a few African countries, if UNAIDS and the AIDS orthodoxy are to be believed.
Another anomaly is what is known about non-sexual HIV transmission: not only is it far more efficient than heterosexual transmission (regardless of which sets of figures you actually use) but it is also the commonest form of transmission in most Western countries and other countries where prevalence is not excessively high.
Indeed, aside from men who have sex with men, the only high prevalence group in Western countries is intravenous drug users. Even sex workers who are not intravenous drug users are very unlikely to be infected with HIV.
The Service Provision Assessment data I refer to in my previous posting is the latest available from Measure DHS and this kind of survey only takes place about every five years, the same as most demographic and health data relating to HIV (an assessment was carried out last year but the data is not yet publicly available).
But health services are not receiving anything like the sort of resources that are being thrown at antiretroviral drugs. If anything, as populations increase, services are less and less able to cope with demand.
But we don't need to ask if health facilities in high HIV prevalence countries are risky places for those who wish to avoid HIV, hepatitis and other blood borne viruses. The UN itself bears witnes to the fact that they are not trustworthy. The UN warns its own personnel to avoid health facilities that are not approved by the UN itself because of the known risks.
But when it comes to advising African countries about HIV risks, the UN changes its story and says that HIV is unlikely to be transmitted non-sexually, particularly through unsafe injections. Why there is this discrepancy in their advice, we are not told.
But despite the WHO claims in the brief Continuing Medical Education Journal document mentioned above, the WHO has also published material which accepts that 70% of injections globally are unsafe and an unknown percentage, perhaps as high as 15 or 20%, may be contaminated with HIV. Huge percentages of hepatitis B and C are transmitted by unsafe injections. And the WHO is part of the UN.
Mr Black may be interested to know what happens in Western countries when there has been a suspected case of unsterile equipment being used on patients in health facilities. Hundreds, thousands, even tens of thousands of people are contacted and advised to be tested for HIV and other viruses. I cite just one example here, but new ones are reported every month. But I have cited others in the past.
On many occasions in rich countries, nosocomial transmissions have been identified and treated, where possible. Such investigations do not take place in countries that have very poor health facilities, and that's what I and Gisselquist, Brody, Potterat and a number of other people are questioning.
People in Western countries do not tolerate such outbreaks occurring. When they do occur an investigation follows. As a result of the investigation, procedures are improved accordingly. Why are the authors of this CMEJ article prepared to tolerate conditions in African countries, where health facilities are so lacking in every way, that would be unthinkable in Western countries?
And more importantly, how can UNAIDS and others deny that non-sexual HIV transmission is worth investigating in countries where they have not even bothered to investigate it?
The issue, Mr Black, is not just about whether sexual transmission is or isn't responsible for most HIV infections in a handful of high prevalence countries: the issue is that the contribution of non-sexual transmission, especially through unsafe healthcare, has never been properly evaluated in those countries. And just as UNAIDS seem afraid to use African health facilities themselves, they also seem afraid to investigate them.
Firstly, in saying that I don't believe all HIV is transmitted sexually, I am not claiming that it is never transmitted sexually. Nor am I saying that it is mostly transmitted non-sexually, by unsafe health care or any other non-sexual modes.
What I am saying is that we do not know the extent of non-sexual transmission and that it is vital to address this lack of knowledge in order to judge how much time, effort and resources are spent on each mode of transmission.
Aside from lack of thorough research into non-sexual transmission, particularly through unsafe injections, but by no means limited to that, no adequate explanation has ever been given as to why heterosexual transmision of HIV is realatively uncommon outside of a few high prevalence countries, mostly in sub-Saharan Africa.
People all over the world have sex, some of them have a lot of sex and it is often 'unsafe'. But rates of sexual transmission appear to be hundreds of times higher in a few African countries, if UNAIDS and the AIDS orthodoxy are to be believed.
Another anomaly is what is known about non-sexual HIV transmission: not only is it far more efficient than heterosexual transmission (regardless of which sets of figures you actually use) but it is also the commonest form of transmission in most Western countries and other countries where prevalence is not excessively high.
Indeed, aside from men who have sex with men, the only high prevalence group in Western countries is intravenous drug users. Even sex workers who are not intravenous drug users are very unlikely to be infected with HIV.
The Service Provision Assessment data I refer to in my previous posting is the latest available from Measure DHS and this kind of survey only takes place about every five years, the same as most demographic and health data relating to HIV (an assessment was carried out last year but the data is not yet publicly available).
But health services are not receiving anything like the sort of resources that are being thrown at antiretroviral drugs. If anything, as populations increase, services are less and less able to cope with demand.
But we don't need to ask if health facilities in high HIV prevalence countries are risky places for those who wish to avoid HIV, hepatitis and other blood borne viruses. The UN itself bears witnes to the fact that they are not trustworthy. The UN warns its own personnel to avoid health facilities that are not approved by the UN itself because of the known risks.
But when it comes to advising African countries about HIV risks, the UN changes its story and says that HIV is unlikely to be transmitted non-sexually, particularly through unsafe injections. Why there is this discrepancy in their advice, we are not told.
But despite the WHO claims in the brief Continuing Medical Education Journal document mentioned above, the WHO has also published material which accepts that 70% of injections globally are unsafe and an unknown percentage, perhaps as high as 15 or 20%, may be contaminated with HIV. Huge percentages of hepatitis B and C are transmitted by unsafe injections. And the WHO is part of the UN.
Mr Black may be interested to know what happens in Western countries when there has been a suspected case of unsterile equipment being used on patients in health facilities. Hundreds, thousands, even tens of thousands of people are contacted and advised to be tested for HIV and other viruses. I cite just one example here, but new ones are reported every month. But I have cited others in the past.
On many occasions in rich countries, nosocomial transmissions have been identified and treated, where possible. Such investigations do not take place in countries that have very poor health facilities, and that's what I and Gisselquist, Brody, Potterat and a number of other people are questioning.
People in Western countries do not tolerate such outbreaks occurring. When they do occur an investigation follows. As a result of the investigation, procedures are improved accordingly. Why are the authors of this CMEJ article prepared to tolerate conditions in African countries, where health facilities are so lacking in every way, that would be unthinkable in Western countries?
And more importantly, how can UNAIDS and others deny that non-sexual HIV transmission is worth investigating in countries where they have not even bothered to investigate it?
The issue, Mr Black, is not just about whether sexual transmission is or isn't responsible for most HIV infections in a handful of high prevalence countries: the issue is that the contribution of non-sexual transmission, especially through unsafe healthcare, has never been properly evaluated in those countries. And just as UNAIDS seem afraid to use African health facilities themselves, they also seem afraid to investigate them.
Sunday, April 24, 2011
Public Money Pays the Piper, So Why Do Big Pharma Call the Tune?
Every now and again I read UNAIDS' publications. Not just for the pretty pictures and diagrams, but because I hope that some day they will play a different tune. Mainly, I want to hear that they have modified their claim that 90% of HIV is transmitted through heterosexual sex. That was the figure that appeared in a draft of their 'Getting to Zero' 2011-2015 Strategic plan. In the published version, the figure is 80%.
But that's not really a modification. They just got it wrong. The official line has for a long time been that 80% of transmission is from heterosexual sex and almost 20% is through mother to child transmission (MTCT). Men having sex with men and intravenous drug users, it appears, make a negligible contribution to high prevalence epidemics. In fact, most HIV transmission is said to result from what is essentially low risk sexual behavior. Which is strange, for a virus that is difficult to transmit through penile-vaginal sex.
UNAIDS' claim to use a 'Know your Epidemic, Know your Response' methodology is flatly contradicted by their claims about heterosexual and other modes of transmission. They don't know their epidemics and nor, we can safely conclude, do they know their response. That's why they have failed to have much impact on transmission rates.
Oddly enough, the plan doesn't mention abstinence, ABC or any of the other rubbish that has filled so much of the official literature. In fact, prevention by useless strategies appears to have been replaced with prevention by wishful thinking. Instead of admitting that hardly anything has been spent effectively on prevention since UNAIDS was established, they are implying that treating people is preventing HIV transmission.
In truth, antiretroviral treatment can reduce transmission, but on its own it is unlikely to reduce it very much. Indeed, many of the figures that 'support' various claims made by UNAIDS about heterosexual transmission are years out of date and are assumed or modeled figures, they are not drawn from empirical research. Therefore, UNAIDS also undermines its many claims that their strategic plan is 'evidence-based' or 'evidence informed'.
One area of HIV transmission that presumably fits into the 2% category is non-sexual transmission, through unsafe healthcare, unsafe cosmetic practices, etc. The WHO, in the last year or so, has admitted that an estimated 40% of injections in African countries are unsafe and the organization accepts that at least 5% of HIV infections could come from such unsafe injections. This estimate is for a region, not for any particular country. The figure for some countries is likely to be a lot higher.
Despite claiming that HIV transmission from unsafe injections is very low, UNAIDS warns its employees and those of the UN as a whole to avoid medical facilities that are not UN approved, as I mentioned yesterday (and on other occasions). If there is a risk for UN employees, there is a risk for non-UN employees. So why the discrepancy between the WHO's figures and those of UNAIDS, and why the warning for UN employees but not for ordinary people?
The whole Strategic Plan is similarly biased towards a behavioral view of HIV, whereby it is depicted as overwhelmingly a matter of individual sexual behavior. This is a dated view, it hasn't worked in the past and it is not going to work in the future. It is difficult to see how this Strategic Plan differs materially from anything UNAIDS has published in the past. Most of the references seem to be to UNAIDS publications or similar.
Finally (although there is little positive that one could say about the Plan), it states that "investment in HIV is critical for the strengthening of health systems and achievement of the MDGs." On the contrary, investment in health systems is critical for the treatment and prevention of HIV. Claiming that money spent on HIV is money spent on health systems is neither honest nor based on empirical evidence.
One only need take a cursory look at Kenya's Service Provision Assessment (or the SPA for any other high prevalence country) to see how unprepared they are to play any part in preventing HIV transmission, especially nosocomially transmitted HIV. And they are equally unprepared to treat or care for HIV positive people adequately.
UNAIDS need to pay a little less attention to what politicians, religious leaders and industrialists think they should do and pay a bit more attention to HIV, a blood-borne virus that is sometimes transmitted sexually, especially through anal sex. They have sold enough drugs for the friends in the pharmaceutical industry and it's time to address the one disease they were established to eradicate.
But that's not really a modification. They just got it wrong. The official line has for a long time been that 80% of transmission is from heterosexual sex and almost 20% is through mother to child transmission (MTCT). Men having sex with men and intravenous drug users, it appears, make a negligible contribution to high prevalence epidemics. In fact, most HIV transmission is said to result from what is essentially low risk sexual behavior. Which is strange, for a virus that is difficult to transmit through penile-vaginal sex.
UNAIDS' claim to use a 'Know your Epidemic, Know your Response' methodology is flatly contradicted by their claims about heterosexual and other modes of transmission. They don't know their epidemics and nor, we can safely conclude, do they know their response. That's why they have failed to have much impact on transmission rates.
Oddly enough, the plan doesn't mention abstinence, ABC or any of the other rubbish that has filled so much of the official literature. In fact, prevention by useless strategies appears to have been replaced with prevention by wishful thinking. Instead of admitting that hardly anything has been spent effectively on prevention since UNAIDS was established, they are implying that treating people is preventing HIV transmission.
In truth, antiretroviral treatment can reduce transmission, but on its own it is unlikely to reduce it very much. Indeed, many of the figures that 'support' various claims made by UNAIDS about heterosexual transmission are years out of date and are assumed or modeled figures, they are not drawn from empirical research. Therefore, UNAIDS also undermines its many claims that their strategic plan is 'evidence-based' or 'evidence informed'.
One area of HIV transmission that presumably fits into the 2% category is non-sexual transmission, through unsafe healthcare, unsafe cosmetic practices, etc. The WHO, in the last year or so, has admitted that an estimated 40% of injections in African countries are unsafe and the organization accepts that at least 5% of HIV infections could come from such unsafe injections. This estimate is for a region, not for any particular country. The figure for some countries is likely to be a lot higher.
Despite claiming that HIV transmission from unsafe injections is very low, UNAIDS warns its employees and those of the UN as a whole to avoid medical facilities that are not UN approved, as I mentioned yesterday (and on other occasions). If there is a risk for UN employees, there is a risk for non-UN employees. So why the discrepancy between the WHO's figures and those of UNAIDS, and why the warning for UN employees but not for ordinary people?
The whole Strategic Plan is similarly biased towards a behavioral view of HIV, whereby it is depicted as overwhelmingly a matter of individual sexual behavior. This is a dated view, it hasn't worked in the past and it is not going to work in the future. It is difficult to see how this Strategic Plan differs materially from anything UNAIDS has published in the past. Most of the references seem to be to UNAIDS publications or similar.
Finally (although there is little positive that one could say about the Plan), it states that "investment in HIV is critical for the strengthening of health systems and achievement of the MDGs." On the contrary, investment in health systems is critical for the treatment and prevention of HIV. Claiming that money spent on HIV is money spent on health systems is neither honest nor based on empirical evidence.
One only need take a cursory look at Kenya's Service Provision Assessment (or the SPA for any other high prevalence country) to see how unprepared they are to play any part in preventing HIV transmission, especially nosocomially transmitted HIV. And they are equally unprepared to treat or care for HIV positive people adequately.
UNAIDS need to pay a little less attention to what politicians, religious leaders and industrialists think they should do and pay a bit more attention to HIV, a blood-borne virus that is sometimes transmitted sexually, especially through anal sex. They have sold enough drugs for the friends in the pharmaceutical industry and it's time to address the one disease they were established to eradicate.
Saturday, April 23, 2011
Comfortable With High Rates of Mother to Child HIV Transmission?
According to the UN, "Extra precautions should be taken...when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere." This excellent advice is given to UN employees. But it is not given to people who don't have the benefit of access to 'UN approved' medical facilities.
Is everyone comfortable with this? UNAIDS say that only around 2.5% of HIV transmission results from unsafe medical practices in high prevalence countries. But they think it necessary to warn UN personnel working in high prevalence countries to avoid the health facilities that people in developing countries have to put up with, if they actually have access to health facilities at all.
Sometimes you read about how awful it is that large numbers of infants are still born HIV positive or go on to be infected by their mother (mother to child transmission or MTCT). And it is horrific, but it is preventable. The problem with worrying mainly about the infants is that they are infected by someone else who is already infected, possibly their mother. And their mother's infection was probably also preventable.
So why does UNAIDS not worry about the person who infects the infant? And why is the person who infects the infant possibly their mother? I can't answer the first question but I know UNAIDS don't worry about it because they deny that unsafe health care plays a significant part in HIV transmission, and therefore refuse to investigate possible instances of it and they refuse to give proper estimates for its extent.
And the reason I say the person who infects the infant is only possibly their mother is that many infants have been identified whose mother is HIV negative (for instance in Mozambique and Swaziland). UNAIDS has tied itself in knots trying to argue that many babies are breastfed by a HIV positive person who is not the child's mother, etc. And while that might be a possiblity sometimes, it is unlikely to explain away all such instances.
Many women are known to become infected with HIV when they are already pregnant. Many are infected in the second or third trimester, even in the few months after they give birth. Now, I can't prove that women abstain from sex during and just after pregnancy. But nor do I think UNAIDS can demonstrate that most women don't abstain or, at least, reduce their coital frequency.
Nor can I prove that women don't have large numbers of unprotected sexual experiences with people who are not their partner during and just after pregnancy. But nor can UNAIDS demonstrate that they do. Indeed, the belief that African women, from a handful of African countries, sometimes from limited regions in those countries, engage in reckless sexually behavior ragardless of their own personal risk or circumstances, sounds to me like pure prejudice.
Sarah Boseley of the UK Guardian reports on a study questioning the suitability of antiretroviral treatment for young sufferers, a study which finds that very high rates of resistance result when people born with HIV are still young. And continued incidence of resistance is just a matter of time.
There is good and bad news for Sarah Boseley and for others who think that HIV rates in people born with HIV or who convert in their first few months or years is totally unacceptable: it is very likely that most mother to child transmission is preventable. And most of it is not just preventable in the way such transmissions are preventable in Western medical contexts, through careful support, treatment and medication.
It is very likely that a large percentage, perhaps the majority of transmissions, are a result of unsafe health care practices, injections, transfusions, intravenous drips and various other invasive procedures. After all, who believes that health facilities in high HIV prevalence countries are able to guarantee safety from transmission of HIV and other blood borne conditions? UNAIDS certainly doesn't.
The bad news is that little is likely to be done to reduce this kind of transmission because UNAIDS and other institutions who decide how HIV is transmitted (no, establishing how it is transmitted is not an empirical matter, don't be silly) have failed to investigate non-sexual transmission of this kind. In fact, they have refused to investigate, despite plenty of evidence that there is a case to be answered.
Is everyone comfortable with this? What makes the behavior of UNAIDS and those who follow their directives so despicable is that UNAIDS and other parties are well aware that a lot, perhaps a majority of HIV transmission, is a result of unsafe medical practices. It is not just a matter of sexual behavior. Africans do not have weired sex lives and they do care about their children, sexual partners, families and compatriots. Africans do not want their children to be born with HIV. But UNAIDS don't seem to mind.
Is everyone comfortable with this? UNAIDS say that only around 2.5% of HIV transmission results from unsafe medical practices in high prevalence countries. But they think it necessary to warn UN personnel working in high prevalence countries to avoid the health facilities that people in developing countries have to put up with, if they actually have access to health facilities at all.
Sometimes you read about how awful it is that large numbers of infants are still born HIV positive or go on to be infected by their mother (mother to child transmission or MTCT). And it is horrific, but it is preventable. The problem with worrying mainly about the infants is that they are infected by someone else who is already infected, possibly their mother. And their mother's infection was probably also preventable.
So why does UNAIDS not worry about the person who infects the infant? And why is the person who infects the infant possibly their mother? I can't answer the first question but I know UNAIDS don't worry about it because they deny that unsafe health care plays a significant part in HIV transmission, and therefore refuse to investigate possible instances of it and they refuse to give proper estimates for its extent.
And the reason I say the person who infects the infant is only possibly their mother is that many infants have been identified whose mother is HIV negative (for instance in Mozambique and Swaziland). UNAIDS has tied itself in knots trying to argue that many babies are breastfed by a HIV positive person who is not the child's mother, etc. And while that might be a possiblity sometimes, it is unlikely to explain away all such instances.
Many women are known to become infected with HIV when they are already pregnant. Many are infected in the second or third trimester, even in the few months after they give birth. Now, I can't prove that women abstain from sex during and just after pregnancy. But nor do I think UNAIDS can demonstrate that most women don't abstain or, at least, reduce their coital frequency.
Nor can I prove that women don't have large numbers of unprotected sexual experiences with people who are not their partner during and just after pregnancy. But nor can UNAIDS demonstrate that they do. Indeed, the belief that African women, from a handful of African countries, sometimes from limited regions in those countries, engage in reckless sexually behavior ragardless of their own personal risk or circumstances, sounds to me like pure prejudice.
Sarah Boseley of the UK Guardian reports on a study questioning the suitability of antiretroviral treatment for young sufferers, a study which finds that very high rates of resistance result when people born with HIV are still young. And continued incidence of resistance is just a matter of time.
There is good and bad news for Sarah Boseley and for others who think that HIV rates in people born with HIV or who convert in their first few months or years is totally unacceptable: it is very likely that most mother to child transmission is preventable. And most of it is not just preventable in the way such transmissions are preventable in Western medical contexts, through careful support, treatment and medication.
It is very likely that a large percentage, perhaps the majority of transmissions, are a result of unsafe health care practices, injections, transfusions, intravenous drips and various other invasive procedures. After all, who believes that health facilities in high HIV prevalence countries are able to guarantee safety from transmission of HIV and other blood borne conditions? UNAIDS certainly doesn't.
The bad news is that little is likely to be done to reduce this kind of transmission because UNAIDS and other institutions who decide how HIV is transmitted (no, establishing how it is transmitted is not an empirical matter, don't be silly) have failed to investigate non-sexual transmission of this kind. In fact, they have refused to investigate, despite plenty of evidence that there is a case to be answered.
Is everyone comfortable with this? What makes the behavior of UNAIDS and those who follow their directives so despicable is that UNAIDS and other parties are well aware that a lot, perhaps a majority of HIV transmission, is a result of unsafe medical practices. It is not just a matter of sexual behavior. Africans do not have weired sex lives and they do care about their children, sexual partners, families and compatriots. Africans do not want their children to be born with HIV. But UNAIDS don't seem to mind.
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