Maternal Health Care a Significant HIV Risk in Ethiopia

[Cross-posted from the Don't Get Stuck With HIV site.]

A young doctor who had been working for 26-28 hours was taking blood from a baby born to a HIV positive mother and accidentally pricked himself with the needle. He reported the incident and got some kind of treatment in the same hospital, but he had to drive himself to another hospital 45 minutes away to get the drugs he needed after being awake for 29 hours. There are several issues here but I'd like to concentrate on the fact that a hospital that had a HIV positive female patient did not have the drugs required to administer post-exposure prophylaxis. Thankfully the doctor in question was OK, but he had to wait six months to have that confirmed.

An accident like this could occur in any country in the world. In this instance it happened in Ireland, where HIV prevalence is very low, around 0.2%. The mother was known to be HIV positive, whereas the HIV status of a significant proportion of people in many countries, perhaps the majority of people in high prevalence countries, would not be known. Needlestick injuries are more common in places where there are fewer staff, less well trained staff and where access to supplies and equipment are poor. But even in countries where conditions for infection control are probably good there can be slips, such as the one described above.

Of course, the fact that conditions for infection control are not good in developing countries does not mean HIV is frequently transmitted through unsafe medical procedures. UNAIDS, WHO and the rest may be right in their claim that only 2-2.5% of HIV transmission is accounted for by unsafe injections, contaminated blood transfusions and other health care risks. But it would be comforting to hear that unexplained HIV outbreaks are investigated. It's not as if there are no such unexplained outbreaks; many infants are found to be HIV positive even though their mother is negative; many adults are infected even though they have no identifiable sexual risk, etc.

One of the oldest high prevalence HIV epidemics in Africa, that in Uganda, should have taught us a lot. It is now obvious that at least some of the rapid drop in prevalence after its peak in the late 80s must have been a result of high death rates. Some of the drop in incidence, the rate of new infections, must have been a result of improvements in infection control practices in health facilities. Very little of the drop in infections can clearly be associated with various 'initiatives' aiming to address sexual behavior, which (much) later became known as ABC (Abstain, Be faithful and use Condoms). So why is there now so much emphasis on sexual behavior when we know that many of those approaches have had very little impact, in Uganda or anywhere else?

According to an article from IRIN news, Uganda is targeting 'cheaters'. This is an extremely inept piece of campaigning (and reporting). Knowing that someone is HIV positive is not the same as knowing how they became infected. The data itself even suggests that most of the people considered to be 'cheaters' could not have been infected through sexual behavior because their behavior is classified as low risk. Some of them may have been infected sexually, but it is unlikely that they all were. Yet this group, people who are in long-term relationships, often married, makes up the biggest group of HIV positive people, 43% of all new infections. To establish how they became infected it is first necessary to do some investigating.

Another group of unexplained infections can be found among women of child-bearing age. Some may well be infected sexually, but some may not. It's certainly not a foregone conclusion that all of them must have been infected sexually just because they have had sex. The group that is especially in need of investigation is those who have given birth with the assistance of a health care professional. The 2005 Demographic and Health Survey for Ethiopia shows that HIV prevalence is eight times higher for this group (prevalence is 9.9% for those who received assistance from a health professional and 1.2% for those who gave birth without assistance from a health professional). In addition, HIV prevalence is a lot lower among men. HIV in Ethiopia is very low in rural areas and appears to be higher among employed, better educated, wealthier people who live in urban areas. A more recent Demographic and Health Survey for Ethiopia was published in 2011, but there is no figure cited for this group.

There are so many ways HIV can be transmitted, especially in countries where HIV prevalence is high and most people don't know they are infected. It must also be remembered that most people don't realize that there are significant non-sexual risks; if they don't know about the risks they will not know anything about protecting themselves and their families. There are health care risks, such as operations, vaccinations and dental care, traditional practices, such as circumcision, scarification and traditional medicine and cosmetic risks, such as manicures, pedicures, tattoos and piercing.

Rather than continuing to waste money on sexual behavior interventions, many of which have been largely unsuccessful and all of which fuel the stigma that attaches to HIV infection in African countries, it is time to investigate non-sexual transmission in all its forms. If there is any shortage of evidence that non-sexual HIV transmission makes a significant and underestimated contribution to serious HIV epidemics, that can only be because of a lack of research and a lack of investigation where levels of HIV transmission are unexplained by sexual behavior alone.

Donor countries, including Ireland, are keen to get women in developing countries to use ante-natal care clinics and other health facilities. Far more important than providing people with health care is providing people with safe health care; otherwise we could be increasing risk of transmission of HIV and other infectious diseases rather than reducing risk. Needlestick incidents are probably the least of people's worries in countries like Ethiopia, but only because many people don't attend health facilities most of the time. If our aim is to increase access to health care we had better ensure that health facilities are also safe.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

PrePex at Loggerheads with Main Recipients of Circumcision Funding?

Only a few weeks ago, the owners of the company that makes PrePex 'bloodless' circumcision devices (effectively, a plastic ring and a rubber band) were happily plugging their ware, a difficult process of persuading journalists to regurgitate an entire press release without any research or criticism. This time, the press release was set in Uganda and a researcher, presumably one not versed in the skills of PR, claimed that "We have so far tested it on about 50 clients but we need 250 more to confirm its acceptability but so far it has worked properly with those who used it". No need for any Ugandans to worry, then.

But alas, some of the main proponents of circumcision, who are also some of the main recipients of the copious millions of dollars available for the mass male circumcision programs in Africa, have announced that "The PrePex Device Is Unlikely to Achieve Cost-Savings Compared to the Forceps-Guided Method in Male Circumcision Programs in Sub-Saharan Africa". They were even generous enough to make the findings available in a free peer-reviewed source. This is all the more remarkable when you consider how most research relating to mass male circumcision is made available: selectively, at the convenience of those who collected the data, rather than that of anyone who may wish to scrutinize it.

Of course, this may be just a bit of a spat between those who prefer to know that scalpels are used (who currently receive the lion's share of funding) and those who don't give a toss how the operation is carried out as long as they make lots of money out of it. The paper by Walter Obiero, Marisa Young and Robert Bailey claims that at $45-50, the PrePex method is "unlikely to result in significant cost-savings". The authors declare no competing interest, unless the fact that at least one of them is a founder of the Nyanza Reproductive Health Society, which provided some of the funding for the research, represents some kind of competing interest.

The $45-50 figure is interesting. According to an article from the UK's National Secular Society, hospitals in Sheffield are going to start charging for non-medical circumcision. They carry out fewer than 200 per year, which is surprising enough, but they expect to save nearly $1,600 per operation. Could it really cost 32 times more to carry out a circumcision in an English hospital? I can imagine costs are lower in African countries, for lots of reasons, but I wonder what, exactly, will be excluded from the mass circumcision campaigns to keep the costs so low. I wonder also if Sheffield could be induced to reconsider their decision if they could offer the operation so cheaply, and how many people would then take them up on it.

One person commenting on Sheffield's decision feels that this may give rise to 'backstreet operations'. But in African countries where circumcision is already carried out for tribal reasons, almost all circumcisions are 'backstreet operations', carried out by someone with no medical training, often without sterile instruments. The several billion dollars on offer for mass male circumcision programs in African countries are mainly available in areas where circumcision is not routinely carried out already.

A spokesperson for the National Health Service said: "Non-therapeutic circumcisions are not clinical interventions and as a group, we would not want anybody to undergo a medical procedure if there was no specific clinical need." A spokesperson for the National Secular Society said "We believe that non-therapeutic circumcision should not be permitted until the boy is old enough to give informed consent." These guys have evidently never heard about the US government's plans for African males.

Most articles promoting mass male circumcision for high HIV prevalence African countries claim that "results from three trials in sub-Saharan Africa, including one from Rakai, Uganda, showed that circumcision could reduce HIV transmission from positive women to negative male partners by up to 60 percent". This is not what the trials showed. HIV transmission was lower in the group that was circumcised than in the group that was not. But the trial did not show that all transmission was a result of sexual contact. Some may have been through unsterile healthcare, reused medical equipment, etc. Perhaps more importantly, at least one of the trials suggests that HIV transmission increased in the control group, rather than decreasing in the intervention group.

It seems hard to believe that current interest in promoting mass male circumcision to reduce HIV transmission from females to males could be based entirely on the evidence for the effectiveness of such a strategy, because the evidence is extremely mixed so far. It seems equally hard to believe that the whole thing is just a money earner for those competing for funding. But there is a lot of money involved. You might expect the Nyanza Reproductive Health Society to be unworried about whether PrePex is used, or some other method. But the difference in cost could be about 10%, some $100,000,000. So how much does something have to be worth to be a 'competing interest'?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Mass Male Circumcision: it's Not Done in Europe, So Why do we Tolerate it in Africa?

The current plan to circumcise 20 million African adults and countless millions of African infants arose purely from the prevailing view that HIV is almost always transmitted sexually in African countries. If we had tested that view years ago and modified it appropriately in the light of available evidence, the issue of aggressively promoting circumcision and spending billions of dollars of 'aid' money on it would never have arisen. It would have been clear that HIV is not exclusively transmitted through sexual contact, that it is also transmitted through unsafe healthcare, cosmetic and traditional practices.

If circumcision reduces HIV transmission, it could only reduce sexual transmission, not transmission through other modes. It is also only claimed to reduce sexual transmission from females to males; it may increase transmission from males to females and, given that prevalence is higher, often much higher among females in African countries, this may result in circumcision programs increasing HIV transmission overall. In addition, African countries' crumbling health systems would not be able to provide tens of millions of safe male circumcisions; the most basic health services are denied to most people and available services are known to be very unsafe.

We have privileged HIV above all other diseases and we have privileged sexual transmission above all other modes of transmission. By doing this, we have stigmatized every African as sexually promiscuous and every HIV positive African as paying the price for their own behavior; yet we fail to acknowledge that HIV is not always transmitted sexually. So why are circumcisions now carried out so readily in countries where most other kinds of operation and medical procedure are unavailable? Even where other procedures may save people's lives, disproportionate amounts of money are spent on sexually transmitted HIV, including in areas where HIV is certainly not the highest priority, sometimes not even a low priority.

Therefore, in the interest of safe healthcare for all, it is necessary to oppose mass male circumcision programs. They will not reduce HIV transmission much, if at all; they will not be carried out in contexts where safe healthcare is generally available; and they will be carried out in countries where the most common causes of illness and death are generally ignored, despite being far higher priorities than HIV or sexual health. For example, there is an urgent need to address reproductive health more broadly, the overall health of women, infants and children and the health of men who are not HIV positive, nor at risk of being infected through their sexual behavior. Diseases that relate to living conditions, such as TB, that infect far more people than in countries where living conditions are better, also need to be addressed. There are also water-borne diseases that infect, debilitate and kill millions because of lack of access to clean water and sanitation.

HIV needs to be put in perspective; it is a virus, one of many, sometimes sexually transmitted, sometimes non-sexually transmitted. We don't even have any idea of the extent of non-sexual transmission, so we can neither tell how much transmission mass male circumcision could avert, if any, nor can we tell how many people are likely to be infected and/or to infect others as a result of the circumcision programs. Mass male circumcision is part of a much bigger picture, and it's because the bigger picture of HIV is distorted by Western obsession with 'African' sexual behavior that we've ended up with something as stupid as mass male circumcision. People are being denied their right to health care, to safe healthcare, to bodily integrity and to many other things. Circumcision is just one problem and the mass male circumcision problem grew out of our failure to address non-sexually transmitted HIV, safe healthcare and all the more important development areas in developing countries.

I am not an 'intactivist' and I don't advocate for 'intactivism', not because genital integrity is too small or too unimportant an issue; it's because it is just a part of a much bigger picture. Most human rights are being denied in some developing countries, not just a handful of rights. Genital integrity is just a part of something that is too big to ignore: bodily integrity and the other human rights that are being denied to those who are denied their right to bodily integrity. Circumcision itself may do harm, it may do good, it may do nothing. But it is the aggressive promotion of mass male circumcision programs in places where most forms of healthcare are unavailable and most available healthcare is not safe that is most objectionable.

If anyone tells you that healthcare services fail people in high HIV prevalence countries because of stigma, health seeking behaviors, culture, education, tradition, or anything else, remember that healthcare services are far more likely to fail because they are not available to most people; where they are available, they are likely to be unsafe. This is not to say that stigma is not an issue, but it is one that arises from the view, mentioned above, that HIV is almost always transmitted through heterosexual sex in African countries. Education also fails people, and not just in relation to health. Health seeking behaviors, culture, tradition and other issues may well be important issues. But they are of less importance where access to healthcare is poor and where that healthcare is not safe.

Despite lengthy (and lucrative) campaigns telling us that everyone is at equal risk of being infected with HIV, that HIV is an 'equal opportunities' virus, that it's all about sexual behavior, etc, it has long been clear that risk is most definitely not 'equal'. Both men and women who are receptive sexual partners face a very high sexual risk. Men who only engage in insertive sex (i.e. most heterosexual men) and who have no other risks are very unlikely to become infected, so women face higher sexual risks than men. Intravenous drug use is the second biggest risk in most rich countries. But the extent of non-sexual infection through unsafe healthcare, cosmetic and traditional practices in high HIV prevalence countries is not well known and is often not even acknowledged.

In wealthy countries circumcision stands out as an anomaly, where female genital mutilation (FGM) is viewed as a denial of the right to bodily integrity. We don't need to argue against FGM on the grounds that it causes physical (and psychological) damage, or that it may present problems later on in life. The fact that there is a right to bodily integrity is enough, but the anomaly stems from the fact that male circumcision is not seen as a denial of the right to bodily integrity. Some argue for male circumcision as a religious or cultural right, and that is not a problem, as long as it is the adult individual who makes the decision, not the parent.

But in developing countries, there is nothing anomalous about programs funded by Western governments telling people what is good for their health, regardless of broken down and unsafe health facilities, cultural and religious practices, or even human rights. FGM is opposed on grounds that should also be used to argue against male circumcision, yet male circumcision is promoted with the claim that it reduces sexual transmission of a virus, in the full knowledge that the virus is not always transmitted sexually and that it may be transmitted through circumcision itself. Western countries were once opposed to breastfeeding. Indeed, it may have been Western churches that once opposed circumcision in parts of Africa, or at least deemed it unnecessary for people who had been converted to Western religions. Claimed health benefits do not justify mass male circumcision programs.

In developing countries, circumcision is just one issue out of many, the tip of the iceberg. If we were to forget circumcision and concentrate all our attention on some other issue tomorrow no one would be any worse off. Singling out HIV, circumcision or any other issue, divorced from the context that gives rise to the issue, is part of the problem. If we didn't believe the lie that HIV is almost always transmitted sexually in African countries, we wouldn't even be questioning the wisdom of mass male circumcision, and those promoting it would not have received billions of dollars to ride roughshod over African people.

If it was decided that some other kind of intervention reduced HIV transmission, such as giving HIV positive people ARVs long before there is a clinical benefit (it's called Treatment as Prevention) or giving HIV negative people ARVs because they have or may have a HIV positive partner (it's called PrEP, pre-exposure prophylaxis) or give lifelong ARV treatment to pregnant women, rather than a short course of ARVs (it's called B+), those may become as aggressively promoted as circumcision. Sadly, all three of these are already being aggressively promoted even though the net benefit may be low and there may be very serious consequences in terms of transmission rates and health more broadly.

We don't have to do research to know that people need safe healthcare, education, infrastructure and the like, but we seem to avoid getting involved in these basic human rights and instead allude to things like corruption and culture and whatever else journalists and academics tell us is pertinent. Mass male circumcision programs are not wrong because they won't work or because circumcision reduces sensitivity or has anything else to do with sex or the penis. They are wrong because people have a right to bodily integrity, to safe healthcare and to many other things that are currently denied to them.

This is not merely a logical or academic argument against circumcision; we know that we couldn't carry out such programs on our own fellow country people, regardless of any claimed benefits, public health or otherwise; so why are we even discussing doing so in African countries? Aggressive promotion of mass male circumcision programs in African countries, mainly funded and carried out using US money, has got to stop.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

TB and Gold Mining: Sending Them Home To Die

A message from the director of the film 'They Go to Die' (YouTube video).


Jonathan P Smith, an American epidemiologist, is making a film about the kind of scenario mentioned in yesterday's blog post: South African miners and their families being infected with TB as a result of living and working in appalling conditions, and the failure of crumbling health services to offer the level of treatment that would cure people of the disease, prevent it from spreading and avoid drug resistant strains developing.

Smith follows four former gold miners who have contracted resistant TB while working at a gold mine. The gold mine's hospital has failed to treat the men and they are now being sent home. It is likely they will die from TB, but also that they will infect a number of other people first. As they have a resistant strain, they can also transmit this resistance. Treatment will therefore be difficult, very expensive and unlikely to be available. Their immediate family will probably be most at risk.

Mine owners are under no obligation to treat miners infected with TB. But government programs to eradicate the disease are unable to influence the working and living conditions that result in TB spreading rapidly and resistant strains of TB from developing and spreading. Eradication programs are often separate from other health services, because health services are unable to cope even with far less threatening diseases, and funding levels mean that TB eradication often amounts to little more than free drugs.

Squalid living and working conditions ensure that a disease like TB will remain endemic, and that people will remain highly susceptible. Circular migration from home to work and back ensure that TB will be spread widely. Intermittent health services ensure that resistant strains will develop and be spread, to infect and reinfect people of all ages. Add to this a high disease burden and an underfunded health sector, and you have a production line of sick people, packaged up to receive whatever pharmaceutical companies have to offer.

The figures Smith cites are staggering: TB rates among South African gold miners are 1,400 times rates in western countries. Western countries may be willing to send money and drugs for TB eradication programs, but we also enjoy cheap consumer goods, which depend on costs for raw materials being kept as low as possible. As a result, conditions in mines remain hazardous and miners and their families suffer the consequences. Even HIV, which attracts more funding than any other disease, is rampant in mining areas.

Smith notes that those infected with HIV are very vulnerable to TB but he doesn't mention if those with TB are more likely to be infected with HIV. TB has always infected poorer people in higher numbers whereas HIV has often been more closely associated with wealthier, better educated people. But HIV prevalence also tends to be higher among employed people, especially those in formal employment, such as mining. The received view of HIV transmission, that it is mainly a result of unsafe heterosexual sex, would suggest that employed people take more sexual risks. But perhaps employment related health facility conditions may play a role here?

People working in mines do have access to health services, but those services tend to be basic. It is unlikely that safe healthcare is a high priority. Miners suffering from diseases that are common in terrible living and working conditions, such as TB, respiratory infections, intestinal parasites, nutritional deficiencies, water-borne diseases and sexually transmitted infections (STI), may face additional risks in health facilities. Do those facilities have enough basic supplies, such as gloves, injecting equipment, sterilizing fluid, gauze, etc? Are there enough well-trained personnel? Can safety be guaranteed? Or are mining hospitals as unsafe as most hospitals in high HIV prevalence countries?

Some of the highest TB figures are found in countries that have significant mining interests, and in countries that supply the migrant labor. But some of the highest HIV figures are also found in these countries. Much has been written about the role of sexual behavior in an effort to explain these epidemics. But a lot less has been written about the possible role of unsafe healthcare. There is a great fondness for writing about and reading about sexual behavior, but this could mask the elevated levels of non-sexual risk that miners and others must face.

TB spreads easily among people who live together, especially in overcrowded slums. It also spreads easily among people who work in badly ventilated mines. But HIV does not spread so readily through unsafe sex alone. Perhaps transmission through unsafe healthcare could help to account for some of the worst epidemics in the world? Perhaps unsafe healthcare could explain why many infants are infected when their mother is not and why so many people with a HIV negative partner become infected where there is no obvious sexual risk?

Smith writes: “What is the point of public health research if there is no public health benefit? We, as researchers, have an ethical obligation to not simply perform epidemiological research, but advocate a positive change in our research population... [T]o conduct research without the intention of betterment within that population makes a mockery of our public health researches.” This could equally be applied to all research, such as human rights, development, anthropology, even industry related research.

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

TB: the Emergency is that We Have Failed, Time for a Different Approach

The English Daily Mail is not a source I would usually turn to for articles about global health issues, but the English MP Peter Hain does have some interesting remarks to make about TB. Following the government's decision to postpone mass culling of badgers to cut transmission of bovine TB to cattle, Hain reminds us that human TB kills about 1.4 million people every year.

Hain also mentions the issue that excites the pharmaceutical industry the most: drug-resistant strains of TB, which are developing and spreading rapidly. If ever there were a demonstration of the foolishness of believing that health was just a matter of fighting disease and that fighting disease is just a matter of throwing drugs at a handful of headline-grabbing diseases, TB is one.

There have been TB eradication programs around for decades and it is the failure of these programs to do any more than throw drugs at people that allows resistance to develop so readily. TB could have been contained a long time ago. But health is not just a matter of fighting disease and TB eradication (or HIV eradication, or any other disease) is not just a matter of drugs.

For a start, people live in appalling conditions. TB spreads rapidly in appalling living conditions, just as water-borne diseases spread rapidly among people who have little or no access to clean water and good sanitation. As long as people live in such conditions, they will continue to suffer from and die from diseases, many of which are preventable and/or treatable. Leaving people in their current conditions means that throwing drugs at them will be of little benefit; for every vaccine they receive, there are hundreds, perhaps thousands of other diseases they can suffer and die from.

Then there are people's working conditions. Hain notes that some of the worst TB epidemics are in South Africa's gold, diamond and coal mining areas, which are said to be responsible for 760,000 new cases of TB every year and the highest death rates for TB in the world. The conditions in which miners work are ideal for the spread of TB. As migrant laborers, most of them return to their families frequently, and they risk spreading TB to anyone with whom they come into contact.

According to Hain, a "migrant worker with TB will typically spread the infection to 10 to 15 other people each year that he’s sick". (Compare this to the 1.2-1.4 people to whom a HIV positive person will typically transmit the virus.) Worse still, "When he returns to his home community, he may not have access to health services capable of putting patients through the necessary six months of TB treatment". Though TB sometimes attracts enough funding for 'treatment' to be free to many people, drugs alone are generally not enough.

The living and working conditions people experience are not conducive to lengthy and expensive drug regimes. Treatment interruptions and treatment failures can quickly give rise to resistant strains of TB developing, which can also be transmitted to others. As resistant TB can be up to 100 times more expensive to treat than non-resistant strains, many will die of the disease. And because it is so readily transmitted, others will be infected with this resistant strain, also.

That's the bit that makes pharmaceutical companies so happy. There's no doubt that they will make a lot more money out of resistant TB. But one of the reasons throwing drugs at the problem does not work is because living and working conditions are not generally addressed by TB eradication programs. Most people don't have access to the sort of health services that will ensure they receive everything they need to clear them of TB. But most also live in conditions where they are highly susceptible to transmitting TB and to being infected, or reinfected, with TB and resistant TB.

Mine owners are not called upon to make conditions healthier. Western buyers of South African raw materials are not keen to increase their costs. The 'economy' of South Africa may depend on mining revenue, but unless that is translated into better living and working conditions for miners, TB and other diseases are not just going to disappear. Good for Big Pharma, not so bad for wealthy South Africans, but not so good for ordinary South Africans.

Hain is incorrect if he assumes that a thriving mining sector results in a stronger economy and that this results in better healthcare systems. The TB epidemic is costing the country a lot of money. So it may seem like a good investment to throw drugs at those with TB. But it's not just healthcare systems that are lacking, it's also education, water and sanitation, habitation and working conditions that are making and keeping people sick.

Hain's suggested approach sounds good, but it is inaccurate to say that an emergency response is needed. Poor living and working conditions mean that emergencies frequently arise, do a lot of damage and can not easily be remedied. But lack of health structures, health personnel, infrastructure and other things mean that TB and other diseases can not be eradicated.

Even ridiculous programs that consist of little more than showering people with drugs could do a lot of good, but not if other conditions are not improved first. There's little to be gained from eradicating one disease only for people to suffer from and die from other diseases, particularly resistant versions of more easily eradicated diseases.

TB, like HIV, is not an emergency in the way that a hurricane or tsunami is. These epidemics result from the conditions in which people live. Massive epidemics are a consequence of most people living in terrible conditions. These are long term trends, many people have never experienced anything but poverty and struggle. Perhaps an emergency can be declared in response to endemic diseases, one by one, as seems to be the favored approach by international institutions. But why not address the conditions in which people live and work, the rights they are denied, the determinants of health and the rest?

The emergency is that we have tried and failed to eradicate some of the most serious diseases by addressing them one by one and merely throwing drugs at them. The emergency is that realizing there is a problem and setting up institutions in wealthy countries is not enough. Countries like South Africa need health systems, education, infrastructure and decent living and working conditions. Addressing TB on its own will continue to fail unless other development areas are also addressed. If there is an emergency, it is that we have known all this for decades and have systematically failed to act on that information.

Peter Hain is not wrong, but we don't need to address basic health and social services and various other problems in order to eradicate TB, we need to do all these to eradicate any disease. We also need to address these issues to ensure that people enjoy good health, which is not merely the absence of disease. Of course, these are also conditions under which diseases can be controlled, and that includes TB. Throwing drugs at people and sending them back to the conditions in which diseases thrive, what we are doing right now, is clearly not the right approach.


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

Circumcision: a Case of Retributive Healthcare?

There are many objections to mass male circumcision, but only a few of them should be required to convince someone that the vast majority of operations should never have been carried out, and that infant circumcision should not be routine anywhere. I would attach most weight to the argument that infant circumcision is a denial of the right to bodily integrity and follow that up with the consideration that it is done without consent, and can easily be postponed until the infant grows up. Where consent can truly be claimed to be informed, adult circumcision should not be so problematic. Current mass male circumcision programs in African countries are demonstrating clearly that most adult men do not choose to be circumcised; whether those who have consented are appropriately informed is open to question.

But the most important objection against mass male circumcision as a HIV transmission reduction intervention is, in my view, that not all HIV transmission is a result of sexual intercourse. Circumcision does not reduce non-sexual HIV transmission, for example, that which is a result of unsafe healthcare, cosmetic or traditional practices. The majority of circumcisions in Africa are carried out in traditional, non-sterile conditions. But even conditions in hospitals and clinics are well known to be unsafe. The UN are very clear on this point, issuing its employees with their own injecting equipment when they are in developing countries because "there is no guarantee of the proper sterilization of such materials." UN employees are also reassured that "We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment."

The US Centers for Disease Control (CDC) states that "Injection safety is part of the minimum expectation for safe care anywhere healthcare is delivered; yet, CDC has had to investigate outbreak after outbreak of life-threatening infections caused by injection errors.  How can this completely preventable problem continue to go unchecked?  Lack of initial and continued infection control training, denial of the problem, reimbursement pressures, drug shortages, and lack of appreciation for the consequences have all been used as excuses; but in 2012 there is no acceptable excuse for an unsafe injection in the United States."

But what about safe healthcare in developing countries? The Safepoint Trust finds that each and every year due to unsafe injections there are:

• 230,000 HIV Infections
• 1,000,000 Hepatitis C Infections
• 21,000,000 Hepatitis B Infections
• The above resulting in 1,300,000 deaths each year (WHO figures)
• Syringe re-use kills more people than Malaria a year which the WHO estimate kills 1,000,000 a year (WHO)
• At least 50% of injections given were unsafe (WHO)

Safepoint only reports on injections. What about other healthcare procedures that may spread diseases, especially deadly ones? Many health facilities lack basic infection control capabilities and supplies, such as clean water, soap, gloves, disinfectant and much else. There are also the risks people face as a result of cosmetic procedures, such as pedicures and tattoos, and traditional procedures, such as scarification, male and female genital mutilation and traditional medicine.

Why are we even talking about something as invasive as circumcision, involving tens of millions of men and possibly hundreds of millions of infants? So many medical procedures are already carried out in unsterile conditions and can expose patients to risks of infection with HIV, hepatitis and perhaps other diseases. The circumcision operation itself is a risk for HIV and unless the risk of hospital transmitted HIV infection is acknowledged, it is not acceptable to carry out these mass male circumcision programs. It is not possible to claim that people can give their informed consent where they are unaware of the risk of infection through non-sexual routes.

A third important objection to mass male circumcision is that people in developing countries, particularly the high HIV prevalence African countries where all these mass male circumcision programs are taking place, are denied many of the most basic types of treatment. How can we propose universal infant circumcision where half of all infant deaths and a massive percentage of serious infant sickness is a result of systematic denial of basic human rights, such as access to clean water and sanitation, adequate levels of nutrition, decent living conditions, basic health services, an acceptable level of literacy and education, employment, infrastructure and a lot more?

To force 'healthcare' in the form of mass male circumcision programs on people who are lacking so many more important things is extremely patronizing, at best. But to force unsafe healthcare on people who have little access to the kind of information they need to be sure that they are protecting themselves against infection with HIV and other diseases, and against all the threats of unsafe healthcare, would be criminal behavior in western countries. Why are western countries silent about this treatment of people in developing countries? Are we punishing Africans for their poverty and lack of development, or just for their perceived sexual behavior? Mass male circumcision programs do seem very much like a form of 'retributive healthcare'.


[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

A Vagina is Not a Penis, But Mutilation is Always Mutilation

Those opposing female genital mutilation (FGM) often claim that male circumcision is a completely different thing, and many have no objection to it. To the extent that a vagina is not a penis, FGM and male circumcision are quite different. But they both involve mutilation. It is not the seriousness of the mutilation of a vagina that is objected to. If it was, some forms of FGM would certainly be more objectionable than male circumcision; but some forms would be a lot less objectionable.

FGM is opposed, and rightly so, because it is mutilation, and is generally carried out without consent. It also tends to be carried out in non-sterile conditions and can lead to very serious consequences in later life. But even if it were a mild operation (for example, the American Pediatric Society's 'nick') with no long term consequences whatsoever, carried out in clinical conditions by a trained surgeon, and with parental consent, most people would still object to it.

There have been calls in the UK to make 'home circumcision' (for males) illegal, following several infant deaths as a result of the operation being carried out by unqualified people in unsterile conditions. But why should serious injury or death be required before the legitimacy of male circumcision is questioned? By what reasoning is male circumcision an elective operation that parents can legally choose on behalf of their children, but female genital mutilation an outrage?

The American Academy of Pediatrics is often cited on the subject of infant male circumcision, but they do not suggest that parents should choose circumcision for their children. They say that "the health benefits of newborn male circumcision outweigh the risks, but the benefits are not great enough to recommend universal newborn circumcision" and that "the final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs". The academy was a bit hesitant about FGM for a while but they later expressed their opposition to all forms of mutilation, even forms that do no permanent damage.

I'm not sure what kind of ethical belief could lead one to choose circumcision for an infant. But why should religious and cultural beliefs be a reason for parents being allowed to choose an unnecessary operation for their children, one that leaves permanent damage? Surely your membership of that religion doesn't depend on your being circumcised as an infant, does it? Does it depend on the operation being carried out against ones will, or can one choose it later in life?

FGM sometimes involves removal of flesh, though it need not do so to be considered mutilation. Male circumcision always involves removal of flesh. Is it really possible that the former is mutilation and the latter is an elective operation just because of the differing gender? And what about the claim that infant male circumcision is 'easier', 'causes less pain', or is in any way preferable to adult circumcision? Is there any basis for the claim, or is it only made to justify the lack of consent involved in infant male circumcision? Would anyone make the same claim about FGM (which is not generally practiced on infants)?

My view of the right to bodily integrity is that it applies equally to males and females, infants and adults, and to people of all religions and cultural groups. FGM constitutes a denial of the right to bodily integrity and ignores the principle of informed consent, but so does male circumcision (excepting cases where there is a medical need). A tolerant society would allow people their religious beliefs, but it would at the same time protect all people from injury. Nobody is being denied their "right to freedom of thought, conscience and religion" as a result of the right of all, male and female, to be protected from bodily harm.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

Safe Healthcare and Bodily Integrity For All

Opposition to male circumcision need not be based on the claim that the operation is harmful, nor on the claim that it is more or less harmful than female genital mutilation (FGM), or various other processes. The facts that it is harmful, and can be more harmful than certain instances of FGM and other processes are important, but not as important as the fact that infant circumcision, like infant FGM, is a denial of the right to bodily integrity. Therefore it is no good claiming that it is cleaner, looks better, protects from diseases, etc. Those considerations, even if true, can not be used to deny the right to bodily integrity.

Many things are good for people's health and far fewer are campaigning for them, such as safe healthcare in developing countries. This is also a human right; hopefully safe healthcare rather than just any old healthcare. There is a lot of evidence that it is unsafe healthcare that causes much of the mortality and morbidity in countries with a high disease burden. We don't even need to carry out expensive research to show that safe healthcare improves health. So why the billions for circumcision, and the heavy handed campaigning, when there are more obvious and more urgent things that need to be addressed?

When it comes to the claim that circumcision reduces HIV transmission, there are several serious problems. For a start, it reinforces the view that most HIV transmission is sexual transmission, even though none of the randomized controlled trials excluded the possibility that some of the people who were infected were not infected through sex. If most HIV transmission is sexual it is unlikely circumcision will have much net benefit, especially when you consider that it is thought to increase transmission from men to women. But if most HIV transmission is not sexual, circumcision will very likely increase the risks that men face, given the conditions in healthcare facilities in high HIV prevalence countries.

Where FGM is banned, it is not permitted just as long as the conditions under which it is carried out are hygienic; it is not allowed if it is a cultural practice; the possibility that it might have some health benefits is not generally even discussed, except to deny that it has any health benefits. But mass male circumcision is aggressively promoted where many women can not even give birth in safe conditions, where people donating blood risk infection with HIV and hepatitis, where the majority of HIV infections occur in long term, monogamous relationships for which no serious sexual risks can be identified.

According to the arguments of the circumcision enthusiasts, every man in the world should be practicing male circumcision. But it's not much practiced in Ireland, or anywhere else in Europe. So why is it acceptable for rich countries to use foreign aid money to carry out mass male circumcision programs in African countries? Is it because we believe that, while HIV is mostly transmitted through male to male sex and intravenous drug use in rich countries, that it is mostly transmitted through unsafe heterosexual sex in African countries? Why do we believe that?

But if we even do a little superficial research, or read UN information leaflets, we must also know that conditions in health facilities in developing countries are unsafe, that blood and skin piercing instruments can be contaminated with HIV and other diseases; isn't it fairly telling that UN employees are issued with their own injecting equipment when going to developing countries? So how can we not believe than some HIV transmission occurs in African hospitals? And how can we believe that only about 2.5% of all HIV transmission in African countries is a result of unsafe healthcare, when the UN warns its own employees about these risks?

Even if the figure is as low as 2.5%, if health facilities are dangerous then half a million Africans could be infected from mass male circumcision programs alone. And it would be difficult to estimate how many infants and boys might be infected with HIV and other diseases through non-medical circumcision, which is what the majority receive. Are we so obsessed with 'African' sexuality that we think there are no other important HIV risks but sexual? The best way to reduce HIV transmission would be to prevent all risks, not just sexual risks. The UN has made a start in reducing the risk of infection among UN employees working in developing countries, but Africans would be wise to note the advice that is given out to non-Africans.

The problem is, of course, that health facilities have been all but ignored since the World Bank and IMF's 'structural adjustment policies' of the 1980s insisted that African countries needed fewer facilities, fewer health professionals, less money spent on training and lower salaries. There is vague talk about 'health systems strengthening' and other nice-sounding programs. But big donors still seem to favor vertical health programs, where separate, parallel health structures need to be set up for each initiative, whether it's polio, cholera, TB, lymphatic filariasis, onchocerciasis, HIV or whatever. Mass male circumcision is just another vertical program, each one destined to cost perhaps as much as real health systems, that people urgently need. And as for safe healthcare? No, that would be too much like development.

The UN is in an odd position because they claim that health facilities are safe enough for Africans as only 2.5% or less of all HIV transmission is a result of unsafe healthcare, but these facilities are not safe enough for their own employees. Even tourists going to African countries can purchase supplies of needles and syringes and they will find warnings about using health facilities in many countries in their guidebooks. It's no secret, just as long as you are from a wealthy country. Can we conclude that, not only are Africans almost uniquely susceptible to sexually transmitted HIV, even where conditions in health facilities are appalling, but also, foreigners from rich countries are uniquely susceptible to healthcare transmitted HIV? If so, then HIV is indeed anomalous.

My guess would be that the UN is telling the truth to its own employees about the dangers of health facilities in developing countries. Therefore, they must be lying when they claim that 80% of HIV transmission is a result of unsafe sex and about 18% is a result of mother to child transmission. So mass male circumcision programs will not reduce HIV transmission via sexual intercourse. On the contrary, they will probably result in increased HIV transmission through unsafe healthcare.

This is not entirely bad news. Since infant circumcision is a denial of the right to bodily integrity, will probably not result in a net reduction in HIV transmission and will cost a lot of money that could better spent on other diseases, mass male circumcision programs will clearly have to be stopped immediately. And that should free up scarce resources for more urgent issues, which should not be very difficult to identify.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

FGM and Circumcision: Rights for the Goose & Rites for the Gander

Things seemed to be looking up in Germany a few months ago when a court ruled that circumcision constituted bodily injury. But Muslims and Jews protested and the country passed a law protecting circumcision, as long as parents were informed about the risks. In the interest of protecting religious freedom, the right to bodily integrity has been denied. Perhaps male circumcision is being viewed as being no more serious an injury than ear piercing. But it is a lot more serious, which is why the question about it arose in the first place; a baby boy's genitals had been mutilated, and this is just one of the risks.

Certain forms of female genital mutilation (FGM) are undoubtedly a far more serious bodily injury. But others may be little more serious than ear piercing. None are, apparently, sanctioned by any religion. One might expect that it is not the level of injury that is involved that makes FGM an offence in countries where it is forbidden by law. Ireland has passed such a law: female genital mutilation "means any act the purpose of which, or the effect of which, is the excision, infibulation or other mutilation of the whole or any part of the labia majora, labia minora, prepuce of the clitoris, clitoris or vagina of a girl or woman". But I'm not sure about any kind of mutilation that is not permanent, such as nicking or pricking.

However, male circumcision unambiguously involves excision, permanent and irreversible damage, indeed, mutilation. If the issue ever arose in Ireland we may take the German option of hiding behind religious freedoms. But couldn't the FGM act then be challenged on the grounds of cultural freedoms? Perhaps not. But male circumcision can not generally be claimed to be "necessary for the protection of [a man or boy's] physical or mental health". Neither consent nor parental consent can be accepted as a defence for FGM, so why should they be for male circumcision? The same goes for being required or permitted for customary or ritual reasons. Even taking someone out of the country for the operation is not permitted.

In the UK, a circumcision that was carried out by a midwife using a pair of scissors on a 27 day old boy went wrong and the boy died. There is more than one offense there, but should a circumcision carried out by a qualified surgeon in a clinical setting with the consent of the parents be any more acceptable? If the operation is being carried out for religious or cultural reasons, surely it can wait until the child grows up? Maybe it is easier, cheaper or whatever is claimed by those who want it done to infants (thought I doubt if these claims are in any useful sense true), but it is a clear denial of a boy's right to bodily integrity.

Of course, many people may grow up not at all bothered whether they are circumcised or not. But if there is a right to bodily integrity, it also exists when people have no objection to what may be seen as infringements of that right. Thus, FGM is not permitted even if the person (who must be over 18) gives their consent, unless there is 'no resultant permanent bodily harm'. If a law were to protect people against infringements such as infant circumcision, it would not be an objection to the law that they may want to be circumcised, or that many people have grown up having been circumcised as an infant and are happy with that.

What bothers me is that male circumcision is not generally required or permitted for 'customary or religious reasons' in Ireland, Germany or the UK, yet none of these countries, or any other European country, appears to have any objection to mass male circumcision campaigns being aggressively promoted in African countries. These campaigns involve misinformation, political arm twisting, deceit and downright lies. But they are being carried out, supposedly in the name of HIV prevention, where they may do a lot of harm, and even in countries where HIV prevalence is higher among circumcised than uncircumcised men. Why are Ireland and other Western countries not objecting to this?

The mass male circumcision programs in African countries appear to be entirely funded by the US. But countries that would not consider such programs themselves, even for the 'public health' benefits claimed for the operation, should be questioning the right of the US to take such action. Male circumcision is itself a bodily injury, I would argue, but the risks of additional serious injury involved, on such a scale, should be enough to make people question these programs. Denial of the right to bodily integrity on such a massive scale, carried out by a wealthy and powerful country, in poor countries where inequalities are so high and healthcare is so inaccessible and unsafe, is an extremely destructive and divisive form of cultural imperialism.

It's something of a truism that male circumcision is not the same thing as FGM; but on a continuum from, say, ear piercing to FGM, male circumcision is a lot more serious than ear piercing. While ear piercing may not generally be seen to constitute an infringement of the right to bodily integrity, male circumcision, I would argue, always does. It is an infringement whether people who have been circumcised think so or not. Even if they have no objection to circumcision, they could still have been allowed them to make the decision to be circumcised for themselves.

Some countries see fit to permit infant male circumcision, but what right does the US have to aggressively promote such a practice in African countries, regardless of whether HIV prevalence is higher or lower among uncircumcised men? Ireland and other countries have taken a commendable stand against FGM, so why not infant male circumcision? Perhaps Germany has its reasons for avoiding a confrontation with Jews and Muslims. But if Jews and Muslims are not confronted about infant male circumcision, how can we justify confronting cultures where FGM is (or was) permitted? Indeed, the contradictory stances make objections to FGM sound like just another instance of cultural imperialism, which is not a conclusion we would like to come to, is it?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

HIV: We May Not Know Best, But We Know Better Than You

My blog posts are a response to people I've met, things I've read, thoughts I've had and the like. The following post is partly inspired by, and wholly dedicated to, someone I met today. I hope it is the beginning of a fruitful exchange of thoughts.

If someone decides that they are not going to take medication and you want to reassure them that the drugs are safe, or that they are for the best, what do you tell them? While arguing that the fact that some drugs have turned out to be unsafe doesn't mean all drugs are unsafe sounds logical enough, would this change someone's mind? Surely the fact that some widely used drugs have serious side effects and can be prescribed to people to whom they do more harm than good would only increase their concern. And if you conclude that their concerns are legitimate, what if they also decided that they would not allow their child to have medication that had known side effects, and perhaps were not even specifically recommended for children?

I'm not opposed to the use of medicines myself; I would go to a doctor if I felt I needed to and I would bring a child to a doctor if I felt I needed to. I would also strive to take the doctor's advice. But there could be instances where I disagreed with the doctor. An example could be a urinary infection, for which the doctor recommended (male) circumcision (not that I think this would generally happy, just that it is sometimes cited as an argument for circumcision). Kids get all kinds of infections; some just disappear and others can be treated with drugs. The fact that the doctor recommended circumcision would not persuade me to have the child circumcised. If the condition was clearly caused by lack of circumcision and would be likely to persist or recur without circumcision, then I might consider it.

Mass drug administration (MDA) in countries where there is little modern healthcare is very difficult. People don't come running to the clinics just because they don't normally have access to free healthcare. Rather, MDA programs take a long time to prepare and involve a lot of work, and still often result in most people either not receiving the drug or not taking it. Rigorous programs to eradicate serious conditions such as lymphatic filiarisis (LF) do not always produce good results quickly. LF can lead to elephantiasis, causing grotesque swelling of the legs and scrotum. It is very visible. But people who do not have it, or have no symptoms, do not necessarily see the point in taking drugs.

It's quite natural to question the use of some drug or procedure, whether it is supposed to prevent or treat something. It may not work or it may have side effects, maybe even side effects that are more serious than the condition to be treated or prevented. In countries where healthcare is rare and safe healthcare is even rarer, questioning the need for or safety of the drug or procedure may be even more important. For the very reason that the threat is greater, the need for questioning is also greater. And yet, in places where healthcare is scarce and not too safe, MDA and other blanket programs tend to be paid for and implemented by outsiders, people whom those receiving the drug or procedure have no reason to trust or obey (because it is obedience that seems to be expected).

So what can we make of these figures in the Washington Times that show that 1.5 million Africans have been circumcised, or have given consent for their children to be circumcised? If it is difficult to persuade people to take drugs how could it be so easy to persuade them to be circumcised, or to allow their children to be? It is thought that adults who decide not to take drugs, such as those for LF, don't give them to their children either. That also strikes me as being quite natural. If it's not good for you why should it be good for your children? So why have 1.5 million people agreed, or agreed on behalf of someone else to be circumcised?

It may seem shocking that someone would refuse medication, and even more shocking that they would refuse medication for their children. But it seems even more shocking that some people don't have the option to refuse drugs or procedures that they believe to be either unnecessary or harmful. If the Washington Times figures are correct, how was this brought about? Were people put under pressure? Were they lied to? Were they made to think that their children would benefit from the treatment, or that their lives or their children's lives would suffer serious consequences if they did not comply (or obey)? It's shocking enough that "leading public health and anti-AIDS groups have set a goal of circumcising some 20 million men in 14 Africa countries by 2015", but why have 1.5 million people already given in and been circumcised?

Were they told they would be infected with HIV (or a host of other diseases the circumcision campaigners have added in), or that their children would be infected? Were they told that everyone is doing it, that women also like men to be circumcised, that it is hygienic, etc? It seems that many of these claims are being made, but none of them are completely true; none of them, on their own or together, constitute good or legitimate reasons for being circumcised or for having a child circumcised. Adults can quite safely decide to be circumcised or not. But why should they be persuaded to make that decision for their children? Are they told it's less painful, less difficult, safer or whatever else? Because none of these claims are true in any useful sense.

I am happy to accept that there is a virus called HIV and that it generally causes AIDS, but there are many questions about HIV transmission, such as why the most serious epidemics are in a few parts of some countries. I also do not accept that HIV is mainly sexually transmitted, nor even that sexual behavior among people in places where HIV prevalence is high is significantly different from other places, where HIV prevalence is low. Therefore, I can not accept that circumcision will reduce HIV transmission significantly; and I certainly don't think reducing HIV transmission could be a reason for deciding to have infants and children circumcised when they can easily be allowed to grow up and make this decision for themselves. As for the drugs, if I was very sick I would hope to find something to make me better, and I would hope for the same for my children.

But there is little I can say to reassure someone who refuses drugs, for HIV or any other disease, for themselves or for their children. Even if 99% of advice that our healthcare experts give us is good advice, how can we tell which is the 1% (although I'm pretty sure the figure is not as high as 99%)? Public health programs seem to require high levels of adherence (or obedience), but is adherence more important than benefit? It seems that public health programs may place a higher emphasis on everyone doing what they are told, for their sake or for the sake of someone else, or everyone else, regardless of whether they benefit, or even if they suffer undesirable consequences.

While we might wish to think we have some autonomy when it comes to public health for ourselves and our children in Western countries such as Ireland, compared to people in developing countries anyhow, maybe we don't always have as much choice as we think. Perhaps that needs to be put to the test. This is true of HIV, especially, because it's often presented to us as a matter of individual responsibility and individual behavior. If that's true, why should we make a decision about whether to take or refuse a drug or procedure, for ourselves or for our children, for the greater good of the population as a whole? I know I have a choice about certain things relating to health, but I know I don't have a choice about others; if I were to be HIV positive, or if my child were thought to be positive or at risk of being infected, decisions would not be entirely in my hands. If 'reassurance' were enough to persuade someone to avail of a drug or procedure, for themselves or their child, I'm not yet in a position to give them that reassurance.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

It's Good to Ask Questions, Even Stupid Ones Sometimes

There's an article in the UK's Argus newspaper about a professor in Brighton University who is being criticized for denying that HIV causes AIDS. He plans to screen a film called House of Numbers, which uses typical journalistic sleight of hand to argue the its case. But why are people so worried about students being subjected to this film? The arguments in the film are so pathetic that secondary school students could easily see through them. So university students should be well able to deal with the issues, but only if they see the film. Protesting about the screening before it happens makes it sound as if they might all run the risk of being convinced that HIV does not cause AIDS just by watching it.

The problem with arguments such as those used in the film is that the HIV industry and those upholding mainstream views about the virus tend to over simplify things. If someone suggests anything they don't agree with, they brand them as a denialist. If someone questions the extent to which HIV is sexually transmitted in African countries, for example, their views are quickly dismissed. I have been called a denialist myself; it's far easier than arguing against the evidence that a substantial proportion of HIV transmission may not be sexual. However, it is perfectly consistent to dismiss denialist arguments while continuing to question the view that 80% of HIV transmission in African countries is a result of heterosexual sex.

Those making the film were easily able to find people who disagreed with various aspects of the mainstream view of HIV. But not all of those people would also deny that HIV causes AIDS. I certainly don't deny that HIV causes AIDS, but I do think HIV figures are frequently massaged by various parties for financial or other reasons. This is not something that only happens with HIV, the entire pharmaceutical industry runs on presenting dubious figures, partial findings or downright lies to maximize their profits. Views such as mine don't even sound like a denial that HIV causes AIDS. But it is useful for both sides of the argument to conflate denial with simply questioning certain aspects of the mainstream view for which there is little evidence.

I don't agree with the professor in question, but that's because I have seen the film. How can anyone claim to disagree with a film that they haven't seen? In order to disagree with something, you need to understand what it is first. The nature of HIV and its modes of transmission is not a matter of aligning yourself with a particular political view, or at least, it shouldn't be seen that way. Hearing what your opponent has to say is not something you should shy away from, not if you want to demonstrate why their view is wrong. House of Numbers is a good example of a piece of pseudo-scientific tosh put together to suit the interests of those involved in making the film. It is important for people to know that just because something is published in the mainstream media, a scientific journal or made into a film, that doesn't make it fact.

Sadly, a lot of articles published in peer reviewed scientific publications depend on assumptions that are completely unfounded, but are often unstated. House of Numbers places several arguments in a context where people can judge them for what they are. Most scientific publications are inaccessible in various ways; they are expensive to people from outside the scientific community, and also, scientific papers tend to be constructed in a way that excludes most people because it takes years to learn how to understand them. A film about how the scientific community view HIV transmission and HIV epidemics might allow far more people to raise questions about what kind of unspoken assumptions must lie behind the lofty pronouncements of people who speak in shibboleths and rarely deign to talk to those who are not also scientists.

Let everyone that wants watch House of Numbers; those with a questioning mind will refuse to accept the message that the film tries to spoonfeed us with. But let's also question other views about HIV. Mainstream views about HIV transmission also need to be scrutinized: how are we to understand it when we are told that the same virus that mostly infects men who have sex with men and intravenous drug users in Western countries mostly infects heterosexuals, in huge numbers, in certain parts of certain African countries? We are told that HIV is hardly ever transmitted through unsafe healthcare in these same African countries, yet it transmitted in this way in several non-African countries, such as China, Kazakhstan and Kyrgyzstan.

Most of us don't even need to think about whether we believe that Africans have weird sex lives, that they don't care whether they infect their partner or their children with an incurable virus; we reject the view immediately. But mainstream views of HIV transmission assume that sexual behavior is completely different in areas where HIV prevalence is high, and it is highest in a few African countries. HIV policy is based on such mainstream views and billions of dollars have been spent on implementing programs based on these policies. So if we don't think such terrible things about Africans, we need to question why policies, programs and funding are the way they are.

The good thing about House of Numbers is that it asks questions that need to be asked. The fact that the film gives implausible answers means that the whole exercise backfires on itself. If the mainstream view of HIV were to be similarly scrutinized, with questions being asked and answers being constructed to suit the interests of those answering, and transparently so, people might know a lot more about the HIV industry than they do now. They should be able to see that the mainstream view of HIV is entirely self serving. And it should be very clear how thoroughly racist it is to point the finger at the sexual behavior of African people when there is evidence that a large proportion of HIV transmission is not a result of sexual behavior; we just don't yet know how much.

[For more about non-sexual HIV transmission, see the Don't Get Stuck With HIV site.]

Mass Male Circumcision Recommended Even Where it Increases HIV Transmission

I commend The Guardian (UK) for covering the issue of circumcision from the point of view of those who are opposed to it. It's in their Science section, though it is also an important issue for development, given that it is being marketed aggressively in developing countries as a HIV intervention, and given the billions of dollars of 'aid' money that have been earmarked for these idiotic campaigns. However, the development section in The Guardian is sponsored by the Gates Foundation, which funds circumcision in high HIV prevalence countries and doesn't appreciate dissenting views. Anyhow, the fact that serious opposition to circumcision is being raised in a relatively open-minded newspaper is very heartening.

The campaigns in African countries are doing a lot of damage in the sense that hundreds of thousands of people have already agreed to be circumcised and many people seem to believe the pro-circumcision propaganda. But nowhere near the number expected are agreeing to the operation. And the majority of those being circumcised are not adults, the very people who are most at risk from sexual transmission of HIV, if the propagandists are to be believed. It's mostly teenagers that have been persuaded that the operation will be more difficult or more painful if they wait till they are adults. I'm not sure if that's what they have been told or if it is what they are allowed to believe; either way, what does it mean? Cutting off a healthy piece of flesh is the same whether you are an infant, child, teenager or adult.

Adverse events may be less frequent during infant circumcisions, but that is not a reason to make a decision that could easily be left to the person when they are an adult. After all, the majority of men will probably decide not to be circumcised, which is the best way of eliminating adverse events altogether. It may be objected that circumcision is said to give some protection against some fairly easily avoidable conditions, many of which will not be a risk till adulthood anyway. But this still doesn't make circumcision sound like something that obviously needs to be carried out universally. There doesn't seem to be anything about circumcision that makes it urgent, something that needs to be done to infants or children, or people who have not reached a stage where they can make up their own minds.

One of the most pathetic arguments is that the child should 'look like their father', which doesn't hold much sway in countries where the operation is not yet common. But I've never heard of anyone refusing to circumcise a child whose father was not circumcised just so the child can look like their father. Their father may have a tattoo or a pierced penis, but this would not be permitted on an infant just so he could resemble his father. The argument about resemblance may be more popular in Western countries anyway. But what about the claim that circumcision is 'cleaner'? Dirty finger nails are unhygienic but we don't remove finger nails. Instead, we wash our hands and use a nailbrush. Not that I'm suggesting people use a nailbrush on their penis, but if they have difficulty washing themselves, it's hard to see circumcision alone helping them much.

Of course, there is nothing that could be called debate in countries where people are simply bombarded with publicity; campaigns exhort men to 'stand proud' and that 'wise men make smart choices' (even though the main targets are teenagers; men tend to choose not to be circumcised), etc. The effectiveness of circumcision, and not just against HIV, is presented to people in Kenya and other African countries as if there is no room for doubt, as if it is just another aspect of modern healthcare, like vaccination, giving birth in health facilities and going to a hospital when you are sick. But with infant circumcision there isn't even the pretense of making a choice; the choice is made for you by a parent or by both parents.

The vast majority of males, even in high HIV prevalence countries, do not face much risk of being infected until they are well into their twenties. So there is no excuse for circumcising infants and claiming that it reduces sexual transmission of HIV and other sexually transmitted infections. Even if it can do so in theory, it will not prevent infections among those who are not sexually active. The fact that the majority of men may choose to remain uncircumcised may worry those who think public health is something that should be imposed on Africans whether they agree or not. But most of us would claim to be against imposing 'public health' measures, whether through lies, trickery, force or by any other means. We would expect informed choice to be involved, even where the intervention has been shown to be beneficial.

So much for the pretense of legitimacy. But what about the 'science'. HIV prevalence is higher among uncircumcised men in some countries (such as Kenya) and higher among circumcised men in other countries (such as Zimbabwe). If HIV is 'scientifically proven', does that mean it should only be introduced in Kenya and other countries where HIV prevalence is lower among circumcised men? And in countries like Zimbabwe, where HIV prevalence is higher among circumcised men, what would the public health experts recommend? They seem to be recommending circumcision, and hence increased HIV transmission. Imposing a public health measure for which there is weak evidence of benefit, without informed consent, is bad enough, but what about imposing a public health measure which the evidence suggests will do harm?

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

WHO to Continue Dithering Over Depo Provera Risks?

Lest we forget what HIV related institutional racism looks like, there are frequent reminders. The UN's IRIN/PlusNews runs a good example this week, entitled 'Uganda: Profiles of infidelity, HIV vulnerability'. If you formulate your favorite prejudice so that it looks superficially like a hypothesis, it's not very difficult to find anecdotes that seem to supply superficial evidence. The authors interview four African women who obligingly illustrate the 'all women are victims; all men are promiscuous' prejudice.

According to the article, "Married or cohabiting couples are at a higher risk of HIV infection in Uganda than their single counterparts, with some studies finding that as many as 65 percent of new infections occur in long-term relationships." What they don't mention is that they have no idea what proportion of that 65% of infections are sexually transmitted and what proportion are non-sexually transmitted. But of course: "The prevailing culture, a hybrid of traditional mores and more modern, western values, accepts - even expects - men, and increasingly women, to have a "side dish" - a euphemism for a sexual affair." So we can just guess.

It's easy enough for us to accept the above because mainstream and specialized media sources generally say the same sort of thing, though their remarks may be couched in different terms. We are not encouraged to question the underlying views about women or Africans, nor even to suggest that you could find people in any country who would talk similarly about their experiences of sex, gender, relationships and many other matters. This is not to cast doubt on any of the anecdotes, nor of all the stories we hear about gender inequalities, gender based violence, promiscuity and the like. But these issues prevail everywhere, not just where HIV prevalence is high.

None of these stories explain why HIV prevalence is so high in some parts of Uganda. But nor do they address any of the social issues mentioned, which tend to be alluded to most when they can be associated with HIV. Gender based violence, for example, is abhorrent, occurs everywhere, and needs to be addressed whether HIV infection is involved or not. But to address HIV transmission, it needs to be clearer exactly how it is being transmitted in order to even know who is most at risk. Knowing that most of the people infected are married or are in long term relationships does not tell us how the virus is being transmitted.

I don't wish to single out IRIN/PlusNews as if they are the only biased and prejudiced news outlet. And, rather surprisingly, they also have an article this week giving some recognition to the fact that injectable hormonal contraceptives, such as Depo Provera, have been associated with a doubling of transmission from HIV positive women to men, and a doubling of transmission from HIV positive men to women. The article fails to point out that WHO simply did not warn people, but it goes further towards warning people than WHO themselves have done. Of course, it doesn't sound obviously racist to fail to warn women about these risks, until you find out that most users of injectable hormonal contraceptives are Africans and African-Americans.

Apparently WHO are going to discuss the issue this week, after making such a mess of it in May and January of this year. Even if they do make the risks clear this time, it is not at all certain that this will have any impact on the organizations that have been ruthlessly pushing these products, despite knowing the dangers. The best WHO have come up with is to warn people who are HIV positive, or who are considered to be at risk of being infected, to also use condoms. That's bad enough considering those pushing the method say injectables are a useful option where condoms are not used much, for whatever reason. But who is at risk? According to the article about infidelity in Uganda, almost everyone is at risk. Branding everyone as promiscuous renders targeting impossible.

Several people mentioned in the article said that WHO have, so far, tried to muddy the waters as much as possible and control what is said about Depo Provera and other such products. But a representative of AVAC tries to muddle out of the mess by claiming that they are "fundamentally communicating uncertainty". In fact, they are demonstrating how easy it is to lie and to deceive people whose risk of being infected with or of transmitting HIV is high (or is perceived as being high). WHO and the rest of the HIV industry are continuing to stigmatize African people for what is said to be their promiscuous sexual behavior; they want injectable contraceptive use to continue to rise so that organizations and businesses can realize their own goals, ideological, financial and whatever other form they may take.

Incidentally, AVAC calls itself a "non-profit organization that uses education, policy analysis, advocacy and a network of global collaborations to accelerate the ethical development and global delivery of AIDS vaccines, male circumcision, microbicides, PrEP and other emerging HIV prevention options as part of a comprehensive response to the pandemic". This is a long and tortuous way of saying they are a pharmaceutical industry front group; rampant institutional sexism and racism are not going to get in their way and an increase in transmission of HIV is but a small price to pay.

As part of his continued pursuit of philanthropy at all costs, Bill Gates has adopted population control (to put it mildly) as his development paradigm. His wife has argued that Depo Provera and similar products are popular in African countries without mentioning how aggressively marketed they are. The Gates Foundation has partnered up with Pfizer, who make Depo Provera, just in case anyone should doubt the place of injectable contraceptives in Gates' plans for Africa, however destructive they may be.

Assuming that HIV is almost always transmitted through heterosexual behavior in African countries (though not elsewhere) is not only highly insulting to Africans, and especially to African women; it also results in other factors that facilitate HIV transmission being ignored, such as use of Depo Provera and other injectable hormonal contraceptives, unsafe healthcare and various co-factor diseases (for example urogenital schistosomiasis, which may quadruple the risk of HIV infection for women living in certain areas). WHO need to lose their role as lackey to Big Pharma and return to thinking of health as a right, not a commodity.

[For more about non-sexual HIV transmission and injectable hormonal contraceptives like Depo Provera, see the Don't Get Stuck With HIV site.]

HIV and Prevention: Where There's Money, There's a Way?

The WHO (World Health Organization) finds that Pakistan has "high rates of unscreened blood transfusions and a very high demand for therapeutic injections and poor infection control practices in hospitals and clinics nationwide", which can lead to transmission of HIV and other diseases. It's a big step for the WHO to talk about non-sexually transmitted HIV in this way, and I hope their 'concern' also extends one day to sub-Saharan African countries. Because, even if infection control practices are a lot better in African countries than they are in Pakistan, and that's a very big if, the risk of healthcare transmitted HIV is still high in Africa because of the huge numbers of HIV positive people in some populations.

UNAIDS once pooled together some available figures on HIV and unsafe medical injections in a group of African countries, but they came to some fairly half-hearted conclusions about the issue. They found that "receiving multiple medical injections is significantly positively associated with being HIV-infected, for both women and men. Ever having received a blood transfusion also tends to be positively associated with being HIV-Infected". They further find that "few adults perceive the risk of HIV infection from having injections or blood transfusion". After many years and hundreds of millions of dollars of HIV education, it seems hard to believe that people are not aware of non-sexual risks, especially from contaminated blood and unsafe healthcare.

The UN itself is so acutely aware of the risks of hospital transmitted HIV that they have issued a booklet for their own employees, warning that "Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere." The problem is that UNAIDS' HIV prevention interventions do not warn Africans about these risks. Instead, Africans are told that 80% of HIV transmission is a result of unsafe sex (and about 18% is a result of mother to child transmission).

The totally misguided mass male circumcision programs (also called 'safe' male circumcision or 'voluntary' medical male circumcision) have a particularly nasty sting in the light of the above considerations. If HIV is not almost always transmitted sexually, circumcision will not prevent as many infections as enthusiasts are projecting. But also, conditions in sub-Saharan African health facilities are poor enough to warn UN employees against, so how can they provide in excess of 20 million circumcisions safely? The simple answer is that they can't, the UN can not ensure that the operations will be safe, not safe enough for their own employees, anyhow.

The oft-cited randomized controlled trials of mass male circumcision have already made it clear that it is not circumcision on its own that explains differences in transmission rates in circumcised and uncircumcised populations because HIV prevalence is as often higher among circumcised men as it is among uncircumcised men. If it protects against sexual transmission of HIV, it only does so sometimes. Apparently (Hillary) Clinton has a "blueprint for reaching an AIDS-free generation which includes throwing more drugs at the problem and circumcising men.

Making antiretroviral drugs available to everyone who has a clinical need for them is vitally important, and it has proved its worth by keeping millions alive who would otherwise have died; it has also ensured that most HIV positive women in rich countries and a majority of women in poor countries can give birth to HIV negative babies; some of them even live to raise their own children. But if we are to make drugs more widely available in order to reduce HIV transmission, we need to know which people to target. Assuming that HIV is almost sexually transmitted, as mass male circumcision programs do, will not work. But perhaps now that there is so much money tied up in reducing HIV transmission through mass antiretroviral drug administration, we will acknowledge that not all Africans are sexually promiscuous and that a substantial proportion of HIV transmission can be cut by improving conditions in health facilities.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]

HIV and the Open Secret of Mass Male Circumcision

An article that begins "[The Zimbabwean] government is considering making neo-natal male circumcision compulsory as a long-term strategy for HIV prevention" may not raise an eyebrow if you have been subjected to the biased coverage in the mainstream press about mass male circumcision programs. The fact that some randomized controlled trials have shown that circumcision may reduce HIV transmission has certainly convinced a lot of people. The problem is that circumcision clearly doesn't always protect against HIV transmission and one of the countries where it does not is Zimbabwe (others are Cameroon, Malawi, Burundi, Ethiopia, Ghana, etc).

Another problem is that the randomized controlled trials did not show that circumcision protects against sexual transmission of HIV. Some people on the trial may have been infected through unsafe healthcare, or one of several other routes. This could mean that circumcision is even more effective than previously thought, of course. But it also means that we don't have a clue why or how circumcision may protect against the virus. What we do know is that the operation is unlikely to reduce transmission from HIV positive men to women, and that it probably even increases transmission. HIV positive men may already be circumcised. If they are not, they are eligible for the mass circumcision programs; so the net benefit may be negative.

But back to Zimbabwe, where HIV prevalence is higher among circumcised men. Why would circumcising anyone be beneficial? If 'the science' is behind circumcision in Kenya, Uganda and South Africa, where the randomized controlled trials suggest that the operation may be beneficial, shouldn't Zimbabwe recommend that parents do not allow their infant boys to be circumcised? Shouldn't plans to circumcise millions of Zimbabwean people, at a cost of hundreds of millions of dollars, be shelved? A spokesperson said infant circumcision was 'more sustainable' than adult circumcision. But does that mean it's cheaper? Because that is not the same things as sustainability.

The HIV industry finds Zimbabwe's HIV epidemic quite mystifying anyhow. HIV prevalence figures were estimated to be among the highest in the world in the late 90s, at almost 30%, but dropped to half that in the following 10 years. Of course, much of that drop could probably be explained by massive death rates. But it is likely that incidence, the annual rate of new infections, also dropped. The industry claims that almost all transmission is a result of 'unsafe' sexual behavior. Therefore, they are forced to believe that levels of 'unsafe' sexual behavior were reduced radically at a time when the country was experiencing political, social and economic turbulence.

There are probably several reasons why incidence declined. Radical changes in sexual behavior seem unlikely to be a result of the HIV industry's interventions because the same interventions have never been shown to have had much impact elsewhere (though the industry is loath to admit that), also because there is little evidence that Zimbabwe (or any other country) ever followed the industry's 'advice' particularly faithfully. The puzzled authors of the PLOS Medicine article above can do little but scratch their heads, but they don't even mention the possibility that health facilities may have been responsible for a significant proportion of transmission at one time in Zimbabwe and that this reduced as health facilities became less accessible.

That may be unfair to Zimbabwe health services. After all, transmission in health facilities may have reduced because conditions were improved. These are empirical questions, and ones unlikely to be answered by the HIV industry because they simply refuse to ask them, or to allow others to do so. Perhaps we'll never know. But it would seem like a smart question to ask. If HIV transmission is sometimes a result of unsafe healthcare, and it may almost never be, as UNAIDS claim, will circumcising adults make any difference? Will circumcising infants? Wouldn't it be better to reduce unnecessary operations in health facilities and concentrate on more urgent matters?

Tomorrow is World AIDS Day and one of the industry's offerings is a rather sickening song from 'Champions for an HIV-Free Generation'. It asks us what we are waiting for, tells us that circumcision is cool and clean and protects lives, that it's what the smarter generation does and advises us that if we are champions we should get circumcised. The song even mentions Zimbabwe and several other countries where HIV prevalence is higher among circumcised than uncircumcised men. This is not about whether people should or should not circumcise for religious or any other reasons, it's about the ethics of aggressively marketing circumcision for its protective benefits against HIV in countries where HIV prevalence is higher among circumcised men.

[For more about non-sexual HIV transmission and mass male circumcision, see the Don't Get Stuck With HIV site.]