Mix Vaccine With Contaminated Water and Swallow

I've ceased to expect much from the English Guardian on the subject of development now that their development section is "in partnership with the Bill and Melinda Gates Foundation". But a recent blog post from the section takes pretty much the opposite stance to that of the Gates Politbureau when it comes to the question of basic water, sanitation and hygiene over vaccination.

The Gates publicity machine tends to gush about vaccines, about how they are the future of health and development, about how they are investing $10 billion in them, advocating for a 'decade of vaccines', etc. This flies in the face of public health experience over many decades. For Gates, public health means giving people some drugs and letting them swallow them with contaminated water.

But according to the Guardian article, the World Health Organization estimates that 10% of global disease could be prevented through the provision of safe water, sanitation and hygiene facilities. That estimate sounds rather low, especially for infant and childhood diseases. But at least it is recongized that conditions such as cholera and guinea worm can not be eradicated without providing people with the basics.

Gates, on the other hand, wishes to sink much of his Foundation's money into a vaccine for cholera and polio, with only dribs and drabs going to WASH. And it's not just the Foundation's money that is involved here. It seems that when the Foundation makes a pronouncement about anything, regardless of its serious lack of understanding of the issues, global policy does likewise.

The massive cholera epidemic currently raging in Haiti is a result of a lack of water, sanitation and hygiene services in the country. This lack is not purely a result of some recent disasters, either. The country has been left dangerously underdeveloped as a result of numerous factors, many of them political. Even if a vaccine was available, people would be unlikely to have received it in Haiti and they would likely have been infected with many of the other water borne diseases that are as debilitating and deadly as cholera.

The author of the Guardian article, Yael Velleman, is a policy analyst at WaterAid. The article also calls for closer cooperation between government departments responsible for health, on the one hand, and water, sanitation and hygiene, on the other. This means that donors and those working in development need to connect these two development themes and recognize that they are interdependent.

So, yes to vaccines and other medical technologies. But without better living conditions, they will make little or no difference to people's lives. WASH must come first because without it vaccines will be useless. If you don't believe me, carry out this quick thought experiment: mix vaccine with water drawn from the nearest source of contaminated water and swallow.

These are excellent and sobering insights from WaterAid and Yael Velleman, in particular. There is more on the above issues on their website, including some clarification of the Gates Foundation's stance on immunization and how inimical it is to development (my words, not hers!). The issue is covered in pictures in another Guardian article.

Why is HIV Prevalence So Low in Cuba? (Hint: Health Services)

Last October Esther Murugi, Kenyan minister for special programs, called for greater acceptance of gay people in society. Her call was met with predictable righteous indignation from most politicians and church leaders. And her call stirred up a bit of debate, a small amount of which may have been constructive.

In the last few days, Murugi called for isolation of HIV positive people as a means of eradicating the disease. Does she mean Kenya should isolate all 1.5 million HIV positive people for up to ten years and longer? Isolate them where? There are not enough schools for all the country's children nor hospitals for the country's sick people.

I'm inclined to give Murugi the benefit of the doubt. After all, she is willing to stand up for one of the most reviled groups in East Africa, gay people. And I don't think she can be held responsible for believing rubbish about HIV, given that global HIV policy is governed by a bunch of racist, sexist quacks.

Ok, she thinks that Cuba has one of the best controlled HIV epidemics in the world because they isolated HIV positive people. What she is probably not aware of is that Cuba has the highest number of doctors per head of population in the world. HIV positive people were actually treated, counseled and supported in Cuba, long before they were in most other countries.

Cuba, like many other countries (the US only recently dropped its travel ban on HIV positive people), panicked a bit at first. But they had one thing that most Western countries have and most African countries do not: good health services. And they took action to make sure that HIV transmission was reduced, both sexual and non-sexual transmission.

Murugi may also be confused because at one time Cuba didn't have access to antiretroviral drugs. That was because of US trade sanctions, not because those cruel Cuban leaders didn't care about HIV positive people. In fact, Cuba is probably one of the few countries in the world that acted decisively, quickly and effectively to limit the damage that HIV caused in most other countries, rich and poor.

Indeed, Cuba still manages to keep HIV transmission low, which is more than can be said for several Western, Eastern European, Asian, African and other countries. Cuba is fortunate in enjoying relative autonomy from UNAIDS and other institutions that seem to exert such a negative influence on HIV prevention and treatment policies around the world.

The minister is seriously misinformed, but misinformation about HIV is not uncommon, rather, it's the norm. And if any Kenyans happen to agree with Murugi, the answer is no, it's not going to happen. The country hasn't even tested the majority of HIV positive people yet or got the majority of people who need antiretroviral drugs on treatment. The country's health services do not have the capacity to even account for all HIV positive people, let alone isolate them, in any sense of the word.

If the minister wishes to make herself useful, she could raise the issue of gays again and perhaps take other measures to reduce HIV related stigma, rather than increase it. For instance, she could point to the evidence from WHO that a significant percentage of HIV comes from unsterile injections (and probably from other unsafe medical procedures).

The extremely low levels of HIV transmission in Cuba, from before HIV was identified, through the earliest days of the pandemic, right up to the present, probably have a lot more to do with the quality of their health services than with the amount of sex Cubans have or the types sexual practices most commonly found there. Levels of transmission in every country probably relates to quality of and access to health services and certainly doesn't relate to sexual behavior. But only Cuba seems to have noticed that.

And if Minister Murugi wants more Kenyan people to be tested, more HIV positive people to receive treatment and more HIV negative people to be protected, she needs to ensure than health services are cleaned up first. The last thing Kenya needs is for everyone to rush to their collapsing health services in the state they are in right now. That's only likely to increase transmission.

When Will UNAIDS Be Abolished?

When people find used hypodermic needles in areas where children play in Western countries, they are upset. Quite rightly so. They don't like the thought that their children are being exposed to injury and diseases, possibly even serious or deadly diseases.

But even many Westerners seem to believe that HIV 'dies' within seconds, minutes or some fairly short period, outside of the body. This is not what the US Center for Disease Control (CDC) says on the subject, although it may have said that at one time. Their current answer to the question 'How well does HIV survive outside the body?' is difficult to interpret.

But no matter how you interpret the risk, no one wants a possibly contaminated needle piercing their skin or that of their children. As well as the physical injury, there is also a risk that the needle is contaminated with hepatitis and it is almost certainly contaminated with bacteria.

So the CDC's comment about 'incorrect interpretations' of risk causing 'unnecessary alarm' seems injudicious. I know the question is about HIV but the answer really needs to address risk as a whole. Potentially, HIV can survive for days and even weeks, under the right conditions. Contact with contaminated needles and other instruments should be avoided and where this is not possible, medical advice is required.

However, the idea that the HIV does not live outside the body is widely held, by professionals and lay people. And in countries like Kenya, Tanzania and Uganda, it is far more dangerous to be unaware of the risks. The chances of medical or cosmetic equipment being contaminated in countries with high prevalence of HIV, hepatitis and other diseases can be very high.

You might think that there would be a lot of awareness of these risks and how to avoid them but I have rarely spoken to anyone who has considered the risks they face from contaminated instruments in health or cosmetic facilities.

UNAIDS dismisses the importance of any form of non-sexual HIV transmission, let alone transmission in health facilities. They grudgingly accept that a few percentage points of HIV transmission in East African countries may come from such routes. But they hardly mention cosmetic instruments, razors, tattooing equipment and the like, at all.

As a result, such transmission may be occurring at high rates and people are doing nothing about it. When they take their child to the hairdresser, or go themselves, they could be picking up scabies, hepatitis, HIV or some kind of bacterial infection. To help people avoid these risks, the best thing to do would be to inform them.

Risks in health facilities are more difficult to handle. Doctors, nurses and other health personnel can be pressed for time and it is not easy for patients, or those accompanying patients, to intervene. At best, personnel will be annoyed, at worst, they will refuse to treat the patient, give them poorer quality treatment or make them wait a long time.

The WHO has published data showing that as much as 14% of injections in developing countries are contaminated with HIV and they have unpublished data showing that this figure can be a lot higher. A large proportion of hepatitis B and C is transmitted through contaminted needles. And an estimated 70% of all injections are not even necessary.

When there is even the hint that someone in a Western country may have come into contact with contaminated equipment, there is an investigation to establish how procedures could have resulted in such a risk. And anyone who may have been affected, even going back years, and through thousands of records, is contacted and screened.

Not only does this sort of investigation and screening of possible use of contaminated equipment not take place in developing countries but UNAIDS and others seem keen to deny that such things, which happen in the best resourced health systems in the world, could possibly happen in the worst resourced health systems in the world.

After Decades of Torpor, Is WHO Waking Up to the Problem of Unsafe Injections?

Recently, I wrote about condom manufacturers' apparent lack of concern that their products seem to get such bad press where clinical trials of HIV related medicines are concerned. I also linked to an article about a group of Nigerians  taking their government and various other state and non-state institutions to court because they used condoms correctly and consistently but still became infected with HIV. Several non-Nigerian institutions are also involved, including Family Health International (FHI).

Granted, numerous institutions have conspired to blame HIV transmission in Africa almost entirely on sexual behavior, when this is clearly not the whole story. But plaintiffs argue that they were used to test the efficiency of a particular brand of condoms, which were substandard. Perhaps there is evidence that this particular brand of condoms was faulty, in which case, they should indeed be withdrawn.

But the plaintiffs appear to want all condoms to be withdrawn from the market. It would be very surprising of it turned out that all condoms were faulty, despite the claims of the Catholic and other churches that this is so. There is plenty of evidence that condoms are effective in preventing the transmission of HIV and various other sexually transmitted infections. Condoms remain the most effective protection against sexual transmission of HIV.

What condoms don't do is protect people from non-sexual HIV transmission. This may sound too obvious a point to make, but there have been constant claims that abstaining from sex, only having sex with one, faithful partner and using condoms, are the only strategies for avoiding HIV transmission. Worse still, some claim that abstinence from sex is the only way. None of these claims are true.

Abstaining, being faithful and even using condoms will only protect from sexual transmission of HIV. They will not protect from non-sexual transmission, such as through intravenous drug use, unsafe medical practices or unsafe cosmetic practices.

Rather than admitting that they are wrong, the HIV hierarchy also claim that non-sexual HIV transmission is very rare in African countries. Such transmission happens in other countries, poor Asian countries, rich Western countries, Eastern European countries and everywhere else. But, it is claimed, it is too rare in African countries to merit more than about 1% of prevention funding. Never mind that health services range from appalling to non-existent in most African countries.

The WHO is relatively unenlightened when it comes to admitting that HIV prevention strategies are in need of review, given their almost total lack of success over the past few decades. But they do accept that unsafe injections are extremely common. Syringes and other injecting equipment are unsafe because single use equipment are being reused, without adequate (or perhaps any) sterilization.

According to the WHO, "in Africa alone, 20 million medical injections contaminated with blood from patients with HIV are administered every year". How they can also estimate that this results in only 23,000 HIV infections (also, a million hepatitis C and 21 million hepatitis B infections) every year is a mystery, given the efficiency of HIV infection through reused injecting equipment. But it gives an indication of the scale of the problem.

Apparently there is a campaign in Tanzania to have all single use injection equipment phased out and replaced with 'auto-disable' equipment, which breaks after use and therefore can't be reused. The sooner the better.

However, Tanzania's problem is not just with single use injection equipment being reused. They also have too few medical facilities, too few trained healthcare staff, too little equipment and various other things. It remains to be seen if the introduction of auto-disable syringes will be accompanied by improvements in supplies and all the other lacks. After all, there must be some reason why the health and lives of so many people are being put at risk for want of cheap equipment.

The Nigerian case is somewhat different because it appears to claim that a particular brand of condoms do not adequately protect against HIV infection. But the WHO findings, which probably seriously underestimate the problem, make it quite clear that sex alone is not responsible for HIV transmission in countries with sub-standard health services. Therefore, HIV prevention strategies should be extended to include the prevention of non-sexually transmitted HIV, especially nosocomial infections, those occurring in hospitals as a result of medical treatment.

[If you are interested in the question of whether people will be prepared to combine strategies, such as male circumcision, mcirobicides and pre-exposure prophylaxis with continued condom use, see my other blog.]

UNAIDS Suppresses Revolution in HIV Prevention

In 2002, a number of articles were published in the International Journal of STD and AIDS (IJSA) that questioned the contribution of sexual transmission to HIV epidemics in African countries. They raised the possibility that non-sexual transmission, especially unsafe medical injections, contributed a far higher percentage of HIV transmission than previously recognised.

Given the amount of evidence presented in these articles, one might expect HIV epidemiologists and infection control experts all around the world to sit up and take note, broaden their research interests or even rethink some of the current ideology.

But very little indeed happened. An improbable number of people put their names to a short article denying that non-sexual HIV transmission plays a significant part in African countries' HIV epidemics. The authors reasserted that sexual transmission 'continues to be by far the major mode of spread of HIV-1 in the region'. Worse still, they reassert the need to increase efforts to reduce sexual transmission of HIV.

Almost a decade has passed since these IJSA articles were published and quite a number of additional articles have appeared, also casting doubt on the 'behavioral paradigm', the view that HIV is almost always transmitted sexually in African countries. These have been almost entirely ignored.

If the view of UNAIDS and the HIV industry is that HIV is mostly transmitted sexually, per se, that it is primarily a sexually transmitted infection (STI) which may sometimes be transmitted non-sexually, that would be easier to deal with. They would be quite wrong and the evidence against their claim would be undeniable (which is not to say they wouldn't deny it).

But things are not that simple. UNAIDS and the HIV industry claim that HIV is mostly sexually transmitted in African countries. They accept that non-sexual transmission occurs in non-African countries, especially among intravenous drug users. Contaminated blood is one of the most efficient routes for HIV transmission, so it is obvious that HIV positive people sharing injecting equipment run a very high risk of transmitting the virus or being infected with it.

Yet again, though, while going with the argument that transmission occurs when drug users share injecting equipment, the HIV industry does not accept that HIV transmission through reuse of contaminated medical equipment occurs to any great extent in Africa.

The WHO (World Health Organization) admits that up to 10% of blood transfusions in developing countries may be contaminated, and therefore be responsible for transmitting HIV and other pathogens. The WHO also accepts that as many as 17% of injections may be unsafe and they even estimate that about 70% of injections in developing countries are unnecessary.

Now, I'm not saying that the HIV industry believe that unsafe medical practices don't occur. They are so worried about unsafe medical practices in developing countries that they warn their own employees and associates against using medical facilities unless they are UN approved.

This is why I accuse UNAIDS and the HIV industry of institutional racism: they believe that non-sexual HIV transmission occurs but they won't accept that it's a problem for Africans. This is an important distinction because they accept that medical practices are so unsafe in African countries that they won't allow their employees and associates to risk using them. But these same medical facilities, they claim, pose little or no risk to Africans; at least, not to the extent that they or anyone else should do anything about it.

No matter how you look at it, that is institutional racism. Evidence that should give rise to a revolution in HIV prevention programmes in African countries has been ignored. Instead of targeting risks, such as those that could be found in plenty in medical facilities, UNAIDS and the HIV industry have chosen to ignore anything that doesn't relate to sexual transmission of HIV, in Africa.

The majority of HIV positive people globally are from Africa and most of them live in Africa. Medical standards are so low in many African countries that a lot of people receive little or no health care, good or bad. Ironically, this may protect a lot of people from HIV and other viruses, such as hepatitis C virus. Certainly in Kenya, HIV is lowest where health care coverage is lowest and the virus tends to spread very slowly to places where people have little or no access to medical facilities.

The majority of HIV positive people in African countries are women. This is why I accuse UNAIDS and the HIV industry of institutional sexism. The view that HIV is almost always spread sexually (in African countries) is translated into the view that women spread HIV. The stigma that HIV inevitably brings with it derives from the behavioral paradigm. If most HIV is transmitted by unsafe sex, it follows that most HIV positive Africans have a lot of unsafe sex (there has to be a lot of unsafe sex because HIV is not easy to transmit sexually). If most HIV positive people are women (and the ratio of infected females to males is usually very high), HIV is mostly transmitted by women.

Of course, most women have sex with men and they are unlikely to transmit HIV to other women directly. And the many men these women do not transmit HIV to can not go on to transmit it to others. But questions about why so many more women are infected, why so few men in some areas are infected (if they are so sexually irresponsible, etc), why some infants and children are infected when their mother is not, any questions that make the behavioral paradigm seem less tenable, are either dismissed by the HIV industry or just not raised.

Instead of a revolution in HIV prevention, we now have reaction, a refusal to consider the role of non-sexual HIV transmission in African countries. We are left with a preponderance of 'prevention' programs that don't work, not because they are inherently ineffective (though they are) but because they bear little relation to how HIV is being transmitted. I accept that I don't know what proportion of HIV is transmitted non-sexually. But nor do UNAIDS or the rest of the HIV industry. I am asking that they deal with the evidence that has been presented to them, rather than sweeping it under the carpet.

In 2002, a new form of HIV denialism was institutionalized by UNAIDS. It was based on prejudices relating to race and gender. According to the institution and its followers, HIV is an STI; but only in African countries. HIV can also be transmitted by unsafe medical treatment; but only to non-Africans. The earlier denial of the connection between HIV and AIDS was bad enough, but the UNAIDS brand of denialism is internally contradictory. You can't even articulate it without being struck by the crudeness of its logic. However, if the rantings of the recent Vienna AIDS conference are anything to go by, this denialism is the state of the art.

Deal With Your Anger Wisely, Obama

Obama is 'angry' over the spread of HIV/Aids. It appears he's angry with African governments for not doing anything about the epidemic and perhaps with Africans for doing the spreading. That seems to be the direction his thinking takes. He says "treating patients while others are catching the virus is untenable."

"We are never going to have enough money to simply treat people who are constantly getting infected," he said. "We've got to have a mechanism to stop the transmission rate."

I couldn't agree more. That's why I believe some of the main actors in the HIV industry should find out why HIV transmission is so high in some African countries and in some sectors in some African countries, yet it is low in other countries and other sectors. These actors include UNAIDS, the WHO, the UN as a whole, the US Center for Disease Control, universities such as Johns Hopkins and various other extremely well funded institutions. I assume Obama has some influence with them. (That he has influence in Africa is not in question but how that influence works or how legitimate it is are less clear.)

And while we're on the subject of money, my guess is that the amount of money made out of HIV dwarfs the amount spent on it, it's a good investment. Institutions like the ones mentioned, various commercial interests and other big NGOs have done very well out of funding over the years. So let's not pretend that money is leaking out of the US and the country gets nothing in return. And the absolute amount of HIV money coming from the US may be high, as Obama claims, but as a percentage of GDP, the US is nowhere near the highest contributor.

The “retrogressive culture that makes females satisfy the pleasure of men” that Obama says is responsible for the “upswing in new HIV/Aids infections in Africa” is, presumably, the same culture that gave rise to a Black American politician who won the last US presidential elections. Has he anything to say about the retrogressive culture that allows billions of dollars to be spent enriching rich people and institutions while Africans die?

"In Africa, empowering women is going to be critical to reducing the transmission rate because so often women, not having any control over sexual practices and their own body, end up having extremely high transmission rates”.

Women all over the world have little control over sexual practices and their own body but nowhere in the world are HIV rates as high as they are in some Southern African countries. The entire cash-rich industry has failed to explain what is behind the source of their wealth and power: HIV epidemics in certain African countries.

It's great to hear that the "US has a huge interest in public health systems in Africa" because health systems have been ignored for several decades, with all the attention being concentrated on a handful of diseases considered newsworthy enough to attract funding. Let’s get on with it.

It's hard to believe that such statements as the ones found in this article could really emanate from one of the most powerful politicians in the world. Doesn't he have anyone to do his publicity or to provide him with up to date information? It is not true that in Uganda "infection rate was about 30 per cent in the late 1980s". Prevalence in certain sectors of the population may have reached that level but there was never a time when 30% of sexually active people in Uganda were HIV positive. HIV prevalence did reach such levels some time later, but not in Uganda.

There was no "politically-led three-themed campaign - for Abstinence, Being faithful and Condom use or ABC model - [that] helped drive down the rate to an average six per cent." ABC didn't exist till the late 1990s and it was not dreamed up in Uganda. The abstinence only campaigns imposed by his predecessor on Africa in the early 2000s have had little or no effect in Uganda, just as they had little or no effect in the US. They may have been confusing but most behavior change programs failed, so any damage they could have done may have been similarly limited.

If Obama wants to "explore workable preventive programmes" he needs to challenge the behavioral paradigm, the view that most HIV is transmitted sexually in African countries. He needs to question the view that Africans have unbelievable amounts of ('unsafe')sex with incredible numbers of partners.

If he wants to "build greater public health infrastructure", he needs to be informed about basic distinctions between vertical approaches to health, which target individual diseases and horizontal approaches, which concentrate more on primary healthcare. And he shouldn't be distracted by nice distinctions like 'diagonal' approaches, which claim to be some kind of 'third way'.

And if he wants to "institutionalise country-specific interventions", he needs to campaign for the abolition of UNAIDS and perhaps other big players in the HIV industry. Their programs to date have painted whole continents with the same brush, failing to identify all the ways that HIV is being transmitted and ignoring some of the most vulnerable groups. Buzzwords like 'global health' seem to lead, inexorably, to this sort of broad brush policy.

Massive rates of HIV transmission in African countries can not be explained by resort to myths about the great sexual appetite Africans have. And no research has yet demonstrated that Africans have more appetite for sex than people who live in other continents.

Rapid rates of HIV transmission can partly be explained by very low standards of healthcare, where the majority of injections given in healthcare settings are not necessary and are unsafe, very likely to transmit HIV, hepatitis and various other infections. The extent to which unsafe healthcare could explain high rates of HIV transmission in African countries is unclear, because the HIV industry, in all its splendor, wealth, power and wisdom, has never seen fit to investigate.

Please Mr Obama, before you consider punishing anyone, try to establish what wrong has been perpetrated and who has perpetrated it. The important thing is to reduce HIV transmission, not to apportion blame, despite what the Christian Right may tell you. But unless we are clear about how HIV is being transmitted, and you seem very unclear, we will never reduce transmission enough to eradicate the disease.

You've Been Bad: No Sex for a Month

One of the noticeable characteristics of many HIV researchers is that they seem to have a liking for telling people how to run their sex lives, who to have and not to have sex with, when to have sex, where to have sex and what sorts of sex to have. Crucially, they feel the need to tell people in developing countries these things. They certainly don't tell people in rich countries, unless they are men who have sex with men (MSM) or commercial sex workers.

This is because, typically, HIV researchers toe the line on HIV transmission: that in high prevalence countries, it is almost all transmitted through heterosexual sex but in low prevalence countries, it is mainly transmitted by MSM, intravenous drug users and perhaps commercial sex workers. These researchers seem to see themselves as arbiters of good sexual behaviour and they can even threaten to come along and circumcise anyone who misbehaves, as long as they are not already circumcised, of course. If they are circumcised they are considered to be better behaved than the uncircumcised, anyhow.

So two of these intrepid researchers have come up with a plan to have an official 'no sex month'. The thinking behind this is that HIV positive people are most infectious when they have just been infected. At this stage, they will probably not know they have been infected and even if they test, they will probably not receive a positive result. Anyone going through this stage of HIV infection during a no sex month will avoid transmitting the virus, at least for a while. Once they have gone through to the next stage, they will be far less infectious and, hopefully, they will be tested before they reach the third stage, during which they will be highly infectious again.

There are people to whom this proposal will not appeal, specific groups that these researchers will probably want to include. Commercial sex workers will be unlikely to forgo a month of earnings, for example. (And intravenous drug users could be relatively unaffected by the cunning plan.) But the researchers point to the Muslim month of Ramadan, where Muslims abstain from sex during daylight hours. I wonder if they have done any research into whether this has had any impact on HIV transmission, aside from their assumption that because HIV is often lower among Muslims, Ramadan could the the key. And is daytime sex more likely to result in HIV transmission than nighttime sex? Or perhaps daytime sex is seen as more in need of censure.

Well, because we are talking mainly about African countries, it will probably be seen as perfectly reasonable to 'test their hypothesis' on the people. After all, they clearly have too much sex, of the wrong kind and possibly even during the day. Why these researchers see their proposal as a one off is not clear. But they are wrong in saying that it 'does not create additional stigma'.

The behavioural paradigm, which says that HIV is mainly transmitted heterosexually in developing countries, is what causes the main stigma that attaches to HIV. It is because people in developing countries are being told that they have too much sex, and sex of the wrong kind, that HIV is stigmatized, that people are made to feel that they are bad people, who must be censured and punished, if necessary.

More importantly, the behavioural paradigm is completely unfounded. HIV is not mainly transmitted by heterosexual sex in developing countries. The extent to which HIV is transmitted non-sexually is not clear precisely because researchers like the two in question refuse to consider non-sexual transmission as being important enough to research.

If, as a result of this 'experiment', HIV rates are found to have dropped, this will not necessarily mean that sexual transmission will have been cut. Non-sexual transmission, for example, through unsafe medical practices, could also go down during the no sex month. Sex workers and MSM, if they do give up sex, will have less need to visit sexually transmitted infection clinics to receive jabs and contraceptive injections (very popular among sex workers). These are likely routes to HIV infection through unsafe injections. Will the research take such circumstances into consideration?

Perhaps the researchers would like to carry out another experiment on this obliging and convenient population of human beings: perhaps they would like to have a medical safety month. During this month, it would be ensured, not just that every health care worker takes the utmost care during every procedure, but that there are enough health care workers everywhere and all of them have enough equipment so that they don't need to reuse anything or do anything that could put their patients at risk. During this month, Everyone in the country would have access to safe health care, no one would have to resort to some quack wielding a much reused needle and no one in the health care industry would have to take any risks because of lack of resources.

Apart from seeing how this affects HIV transmission, it would be interesting to see what sort of demand there was for treatment and what levels of diseases and other health conditions would be revealed. But if no sex months provide a 'potential strategy', then so do medical safety months. Indeed, medical safety months would have benefits that go far beyond HIV transmission. Perhaps we could have clean water and sanitation months, where people are provided with enough water and sanitation facilities to reduce some of the biggest killers in the developing world. The possibilities are endless, we could have infrastructure months, electricity and lighting months, connectivity months and many other types of month.

The researchers assure us that a no sex month would produce "easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign". And I'm sure all the other types of month would also supply vast quantities of data, such as maternal health figures, infant mortality figures, child mortality health figures, nutrition figures, disease mortality figures, more data than you could shake a circumciser's scalpel at. In fact, I don't think you would need to threaten people at all, I really think they would go for these dedicated months without any incentive. They may even demand that such benefits be granted to them all the time, not just for a month.

Even the researchers themselves warm to their theme and suggest that such months could be adapted for different populations "depending on what is driving the epidemic". So, among miners in South Africa they suggest a 'no commercial sex' month. But how about a no mining month? Then they could have a significant impact on the TB epidemic, which is driven by the mining industry and is said to spread hand in hand with HIV.

The researchers conclude that "In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic". But are these researchers open to new ideas? Are UNAIDS and CDC open to new ideas? The biggest new idea, which is only new in the sense that it has been ignored by those who are best placed to apprehend it, is that HIV is not only transmitted sexually, that the behavioural paradigm is wrong. No new discovery needs to be made: these people and institutions simply need to tell the truth. A 'no lies' month from UNAIDS would do more to reduce HIV transmission than all their HIV 'prevention' programs, past, present or future.

Even WHO Admits Unsafe Injections are Ubiquitous

The dental unit of a hospital in Missouri has realised that 1,800 of its clients may have been exposed to diseases such as HIV and hepatitis B and C as a result of poor hygiene. All the people, apparently all war veterans, who may have been exposed, are being contacted and an investigation has been called for to find out how such an incident could occur. A political spokesperson has said that this is unacceptable for veterans. Whether he thinks it would be equally unacceptable for people who have spent no time in military service is unclear.

Still, it’s good to hear that there is a protocol, there is sterilization equipment and that someone is checking to see that the protocol is adhered to. It’s also reassuring that there are people who know that lack of care in using such equipment can give rise to infection risks and that if there is any possibility that clients are at risk, they can be and will be contacted and given a full check-up. Presumably, the staff involved will be retrained and those found to be responsible will be disciplined appropriately.

A similar occurrence in California resulted in 3,400 patients being contacted because they underwent a colonoscopy and it was found that correct hygiene precautions may not have been followed. And in the UK, 519 people have been contacted because a healthcare worker who may have treated them was found to be HIV positive. The worker, who has worked in a number of hospitals, has been moved to a role where there is no risk of blood contact.

The two American incidents are probably more worrying than the UK incident because patients are unlikely to be infected by HIV positive healthcare workers, in practice. But infections from unsafe medical procedures are thought to be common, especially in countries where there are low levels of training, staffing, safety and funding. The World Health Organisation (WHO) estimates that in some regions, up to 70% of the 16 billion injections given in transitional and developing countries are unnecessary. They estimate that up to 40% of injections worldwide are given with syringes or needles reused without sterilization and this could be as high as 70% in some countries.

One doctor in Kenya relates how he has stuck himself with needles on several occasions. He also says this is common among healthcare workers. However, the likelihood of a healthcare worker becoming infected is quite low, in practice. The biggest worry is of patients being infected by contaminated equipment. And this doctor says that they don’t always have enough needles, for children in particular. He describes how they improvise to get around this problem but also admits that this means the patient can be infected with hepatitis. He doesn’t mention HIV but presumably they are at risk from any blood borne disease.

This one medic can see up to 100 patients a day, as can many practicing healthcare workers in other facilities all over Kenya and East Africa. Doctors and other healthcare practitioners receive a lot of training but if they don’t have the equipment, they either need to ‘improvise’ or refuse to treat people. But what of all the other people who give injections and carry out other procedures that involve potential blood exposure? The risks may be lower but some of them only receive a few weeks training. And there are those with no training at all who also give injections, informal practitioners and the like.

UNAIDS ‘estimate’ that unsafe healthcare results in around 0.6% to 2.5% of HIV infections in Kenya. Yet the WHO estimate that globally, 2% of HIV infections are caused by unsafe injections. Is it really credible that countries with high prevalence of blood borne diseases and low levels of safety in healthcare settings could have such low transmission rates through unsafe medical procedures? WHO estimates that up to 9% of HIV infections may come from unsafe injections in South Asia. How could the figure be so much lower in African countries, where healthcare is known to be of a very low standard and prevalence of HIV is so much higher than it is anywhere in Asia?

In the US and the UK, where there is a relatively small risk that people will be infected with HIV as a result of medical procedures, hundreds, even thousands of people are screened to make sure that they were not infected. But in developing countries, where HIV prevalence is high, we are told that most HIV transmission is through heterosexual sex and therefore transmission through unsafe medical procedures cannot be high. Where there is doubt, people are not recalled and screened. Potential nosocomial cases (ones that occurred in healthcare settings) are not investigated. There is overwhelming evidence that heterosexual behaviour in African countries does not explain high levels of HIV, but because they are African countries, it is accepted that they have lots of sex, that they should stop doing so and when they do, everything will be ok.

Health facilities in African countries lack adequate drug supplies, have chronic shortages of trained personnel and do not even have enough condoms at a time when they are faced with rising HIV prevalence. It is not credible that, at the same time, there is a very low risk of HIV infection through unsafe medical practices. Global HIV policy is obsessed with sexual HIV transmission to the extent that non-sexual transmission is being completely ignored, especially in developing countries. Informing people of the non-sexual risks of HIV transmission, and how to avoid them, is just as important as informing them of the sexual risks. People have a right to the information they need to protect themselves.

HIV Industry Admits They Got it Wrong? Sort of!

The US has launched a new grant to help developing countries to strengthen their health systems. The term 'health system strengthening' has become quite fashionable recently. But it's usually used by defenders of the likes of PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global fund, who argue that their funds do not target HIV at the expense of other diseases or of health systems strengthening. Remarkably, the article about this new fund, the Global Health Initiative, flatly contradicts these claims and even reads like an admission that mistakes have been made. Such admissions are rare, but vital if serious diseases such as HIV are to be controlled.

In another article, it is noted that the amount of money spent on HIV in Tanzania has risen by over 2000% between 2001 and 2007, from 17 to 381 billion Tanzanian shillings (11.5M to 259M USD). And the author is encouraged that in the same period, prevalence has dropped by 1%, from 6.7% to 5.7%. Is that encouraging? Hard to say, but apparently "Some of the biggest challenges in the fight against HIV/Aids are embezzlement and mismanagement of funds." One wonders where prevalence would stand if the money hadn't been embezzled and mismanaged. In some sectors of the Tanzanian population prevalence has been increasing.

The article ends with the conclusion that HIV was not adequately addressed because the focus was on the health sector, whereas this disease in particular is not simply a health problem. But you could argue that diarrhoeal diseases and intestinal parasites are a matter of water and sanitation, respiratory diseases are a matter of environment and housing and malaria is a combination of all of these factors and perhaps some others. None of them are 'simply' health problems.

Yet, it is true to say that you can't just reduce HIV transmission by sending everyone to a clinic and giving them counselling and drugs if they are infected and lecturing everyone who is not infected about safe sex and perhaps giving them condoms. This has been tried and has failed. Amazing amounts of money have been thrown at HIV and the result has been a continuation of very high levels of transmission and a distinct lack of understanding of why some countries and parts of countries have such profound HIV epidemics and why some do not.

So, like other diseases, HIV epidemics are not just a matter of dealing with a particular pathogen, you must also consider the host and the environment. Looking at it (and other diseases) from this point of view, there are a lot of ways of spending 381 billion Tanzanian shillings aside from on health aspects alone. Many people are said to be more susceptible to HIV infection because they don't have a choice about when, how often or with whom they have sex. Others are susceptible because they have various health conditions that make them so, for example, malnutrition, intestinal parasites, sexually transmitted infections, TB, malaria, etc.

As well as dealing with host factors, then, money could be spent on environmental factors, water and sanitation, infrastructure, gender relations, equality, poverty and many other things. But anyhow, the claim is that the money was spent on the health sector, not on health systems (supply chain management, health worker retention, information management, etc). And it seems fairly clear that money has not been spent on health systems, pace the argument for the Global Health Initiative and contra the unconvincing arguments of Global Fund and PEPFAR proponents.

But here's a thing, you could argue that those tenets of epidemiology leave out something very important, perhaps most important when the epidemic is HIV: nosocomial infections. This is where the disease is spread by medical procedures. The pathogen is clearly being introduced into a host, but artificially so and the environment is a rarefied but highly risky one. Do nosocomial infections, to some extent, elude epidemiologists altogether (or just those who work for UNAIDS, WHO or CDC and a few other institutions that have a lot of influence in the HIV industry)?

Following the pronouncements of those august institutions, you would think that nosocomial infections hardly infect anyone in developing countries, with the rare exception of some of their own employees who happen to be working in those countries and have to use the same medical facilities as the natives. Don't worry, that has probably never happened, though that doesn't stop them from warning their employees.

Ignoring other diseases, health in general, water and sanitation, nutrition, environmental conditions and structural conditions in the fight against HIV has been unbelievably stupid. Equally stupid is the failure to ensure that there were adequate health structures in place to implement various HIV prevention and treatment initiatives, however misguided some of these may have been. In fact, in countries like Kenya, health structures were being dismantled from the 1980s onwards at the instigation of institutions like the World Bank (yes, the one that came up with the Global Fund!).

In admitting that health systems have been ignored, the HIV aristocracy may be getting just a little closer to admitting that their view of HIV transmission in developing countries is in bad need of reconsideration. They still tell us that HIV is almost entirely transmitted through heterosexual intercourse in developing countries. But it would seem very hard to maintain this view when the Global Health Initiative is admitting that health systems have been ignored and this has done a lot of damage and has wasted much of the money that has been poured into HIV so far.

Huge amounts of money have been and still are being spent on trying to get people into medical facilities, to be tested and/or treated for HIV and many other diseases. Pregnant mothers are encouraged to go to clinics and to bring their babies and infants to be vaccinated. Men are being encouraged to go to clinics to be tested and/or treated for HIV and sexually transmitted diseases and even non-communicable diseases. But if health advocates want people to go to health facilities, they would need to make sure those health facilities are safe enough that people do not become infected with something as life-threatening as HIV. People need to be made aware of the risks they face in health facilities and those health facilities had better be improved quickly and thoroughly. I don’t think the admission that grotesque mistakes have been made was intended but it has certainly let the genie out of the bottle, well, one of them.

Facts, Facts, Facts, Just Not That One

In an article entitled ‘Aids and Evidence: Interrogating Some Ugandan Myths’, Tim Allen concludes something that others have also concluded about HIV, in relation to Uganda, in particular: ‘Much less is known about the epidemic than is asserted’. We don’t know why prevalence and even incidence in Uganda dropped from very high rates in the 1980s to far lower rates in the 2000s. There is a lot of speculation about why this happened, but it remains speculation. It is possible that much of the apparent improvement in Uganda’s epidemic was a result of the disease taking its natural course. And it is fairly clear that many of the things that are said to have contributed to the epidemic’s decline either didn’t occur or didn’t have much effect.

It was established quite early on that HIV could be transmitted through blood and other bodily fluids, not just through sexual contact. This meant that people could be infected through medical procedures such as injections and blood transfusions, intravenous drug users could be infected, HIV positive mothers could pass on the infection to their babies, either in the womb, during delivery or through breastfeeding and people might even be infected by their hairdresser or manicurist, if they didn't take proper precautions. Early on in the epidemic, these considerations probably influenced the measures that countries such as Uganda took to reduce the spread of HIV. But later, as HIV became more dominated by political and religious leaders, it was treated as if it was almost entirely sexually transmitted. According to the official view, this is only true of developing countries, though.

For me, the thing that doesn’t ring true in the many allusions to Uganda’s great success in fighting HIV is that they all assume the truth of the behavioural paradigm. They all assume that because HIV is mainly sexually transmitted, what a country needs to do is tell people everything about ‘safe sex’, give them some condoms and everything will be ok. When Uganda first started putting in place measures to reduce the spread of HIV, they probably didn’t subscribe to what became the enduring fiction that drives HIV policy, national and international. But later, when donors, politicians, religious prognosticators and commercial interests become involved, Uganda said whatever was required to get the money flowing and to keep it flowing.

Because the most prominent people in the industry so much want everyone to believe that HIV is primarily sexually transmitted, they even want to believe it themselves, they have rewritten everything that happened before the fiction was created. They so much want this fiction to be true that they refuse to countenance the possibility that a certain amount of HIV, perhaps a very large amount, comes from non-sexual processes. Even though there are measures that can be taken to prevent non-sexual HIV transmission, these measures are generally not taken in developing countries. Even though we know that it is not possible to significantly influence people’s sexual behaviour just by telling them what they should and shouldn’t do, that’s what most HIV prevention programmes consist of.

Given that those who control the HIV industry and its considerable wealth base all their decisions on a fiction, it’s not surprising that others, who don’t have access to the same levels of data, expertise and other resources, weave their own fictions. A man calling himself ‘Dr’ Ayiko, seems to accept the fiction based on the behavioural paradigm. He therefore also accepts the story about Uganda reducing HIV prevalence by exhorting people to abstain from sex, be faithful to one partner and use condoms. But he feels that this approach no longer works and that one of the main reasons for the continued spread of HIV is ‘intentional’ transmission.

I assume he means the intentional spread of HIV through sexual means. He refers to the bill currently being discussed in the Ugandan parliament that would make it a capital offence to intentionally spread HIV and I think the bill is aimed at sexual transmission, though I’m not sure and I doubt if many Ugandans, including the ‘Dr’ in question, are sure either. Anyhow, Dr Ayiko says that ‘in virtually all the 112 districts [of Uganda], there are people who boast of having successfully lured 20 plus people into unprotected sex knowing they are HIV positive’.

The deluded man goes on to make the ‘modest’ assumption that there are eight such people in each district and that if each of them infects 20 people who all go on to infect two more people, there will be many tens of thousands of people infected (although his calculations go a bit awry here). Even if Dr Ayiko is right in assuming that there are many people who behave this way and that they have many partners who also have many partners, HIV is not transmitted quite so fast. If it was, HIV prevalence would be a lot higher, in every country in the world, not just in Uganda. The partners of HIV positive people can remain HIV negative for many years, even if they are having regular, unprotected sex. HIV just doesn’t spread that quickly through heterosexual sex.

What the doctor needs to do is calculate how many times each of the 8 people per district would have had to have sex with the 20 others and how many times they would have to have sex in order to infect two others each, given the probability of heterosexual HIV transmission per sex act. That’s not a simple calculation and I won’t even attempt it here. But even if the probability is relatively high, each HIV positive person would have to have sex with each HIV negative person several hundred times for HIV to spread at the speed Dr Ayiko suggests. Deliberately spreading HIV is despicable, especially where there may be force or coercion involved. But deliberate spread of HIV through heterosexual intercourse would be a very slow process indeed. However heinous, it is not a major factor in Uganda’s HIV epidemic.

I would suggest to Dr Ayiko and others who support the Ugandan bill that purposely ignoring what could be the main modes of HIV transmission, non-sexual modes, is despicable. Not only is it despicable but some non-sexual modes of transmission, such as certain unsafe medical practices, are very efficient, far more efficient than sexual transmission. Worse still, the same people who have all the data and the epidemiological expertise that Dr Ayiko lacks are the ones who continue to ignore these modes of HIV transmission. UNAIDS, WHO, CDC and the rest of the HIV industry know that they are wrong about non-sexual HIV transmission in developing countries but they don’t admit it, for some reason.

Tim Allen notes the current dependency on large scale rollout of antiretroviral treatment (ART) as a possible remedy for HIV epidemics, despite the fact that we know so little about how these epidemics increase and decline. He warns that such dependence could give rise to widespread resistance, which could result in Uganda’s epidemic taking a serious turn for the worse. And it does seem sensible to find out how the epidemic progressed in the first place before climbing on the latest bandwagon, ART. In a country where it is not even clear how much medical treatment contributed to the epidemic, it seems rash to advocate purely for more medical treatment. There’s something of the black box about the HIV industry.

Promoting HIV Transmission

A recent survey in Chad has shown that a third of sex workers think that mosquito bites or sharing a meal can spread Aids. National HIV prevalence in Chad is 3.3%, only half the prevalence in countries like Kenya, Uganda and Tanzania. But among sex workers in Chad, HIV prevalence is 20%. In Mombasa, it is estimated to be about 31%. Yet in Mombasa, and throughout Kenya, the vast majority of people, male and female, know the right answer to the questions they are regularly asked about Aids and how to protect themselves.

Many years of data on HIV prevalence, HIV knowledge and HIV behaviour show that these three are not very closely connected. People may know all the HIV industry want them to know about HIV but their behaviour is relatively uninfluenced by their knowledge. More to the point, their sexual behaviour is not very closely connected with HIV prevalence. Those who do all the things the HIV industry would like them to do often have higher HIV prevalence than those whose levels of unsafe behaviour would be deemed very high by the industry.

Indeed, sex workers in Kenya have been targeted for a long time. But the shockingly high prevalence found among sex workers in the 1980s, which peaked at 81% in 1986, fell continuously thereafter, falling below 50% in 1997 and remaining below this level. The amazing thing is that behaviour change didn't occur till a long time later. HIV and other sexually transmitted infections (STI) fell even though people didn't change their behaviour significantly. It simply became less likely that people in this group, said to be at high risk of becoming infected, would become infected with HIV or other STIs.

I write 'said to be at high risk' because it is only in some countries that sex workers are at much higher risk of being infected with HIV than other groups. In other countries, sex workers are only really at risk of becoming infected with HIV if they are also intravenous drug users (IDU), which only some sex workers in African cities are. But this kind of data seems to suggest that HIV appears to be a sexually transmitted infection in African countries whereas it is mainly transmitted among men who have sex with men and IDUs in rich countries.

This is not to suggest that HIV is not sexually transmitted, just to remind people that it is not entirely sexually transmitted. But there is a surprising lack of clarity about how much HIV is transmitted sexually and how much non-sexually, especially in African countries with high HIV prevalence. It is clear that HIV can be and is transmitted by unsafe medical and cosmetic practices but it is not clear what percentage of HIV transmission is caused by such practices. The only thing that is clear is that the HIV industry doesn't want to admit that non-sexual HIV transmission is something to worry about in African countries.

Note, they are not saying that no one should worry. Those in the industry worry about their own employees and the risks they face when they visit developing countries. They warn their own employees not to visit clinics unless they are approved, because the industry has its own well funded clinics. They just don't worry about the fact that people who have to live in these countries have no option but to use whatever clinics are available. The even deny that there is a significant risk from medical treatment in these countries while, at the same time, warning their own employees about this risk!

So what is the HIV industry going to teach people, especially sex workers, in Chad? If they approach the problem in the same way that they did in Kenya, prevalence is unlikely to drop. It reached a peak of about 10% in Kenya in the late 1990s and even higher in Uganda some time earlier. But over a decade of 'HIV prevention' later, both countries have prevalence of over 6%. That's nothing to boast about. Will people in Chad be told the truth, rather than a little bit of the truth?

The truth is that people there are at risk of being infected with HIV by medical and cosmetic procedures. How high a risk is not really clear, it depends on how good the hospitals are and how many people have easy access to them. If there are few hospitals and few people go to them, they are probably less likely to be infected with HIV, though they could be more likely to suffer from and die from numerous other preventable and curable conditions. But people need to be warned that sexual behaviour is not the only risk.

I was in Nairobi a few days ago and I talked to several sex workers and, in common with many other people I have talked to in East Africa, they have heard a lot about sexual transmission of HIV. They have heard a little about the risk from intravenous drug use and only brief and infrequent remarks about risks from contaminated blood, such as during blood transfusions. But they are not told that they and their children could be at risk when they go to a clinic or to the hairdresser. Sex workers, especially, go to clinics a lot. They usually go to clinics that specifically target sex workers, where the risk of being infected with an STI would be higher than in clinics not targeting sex workers.

If people in Chad and other African countries are only told how to protect themselves from sexually transmitted HIV, they will not be very well protected. They also need to be told about non-sexual risks, unsafe medical and cosmetic practices. If they don't know about these risks they will not what measures to take to reduce the risks they and their families face. It would also be unsurprising if they continue to believe that they are at risk from mosquito bites and from sharing food.

As long as the HIV industry continues to insist that HIV is primarily transmitted by sexual behaviour in African countries and that other risks are not significant, a lot of preventable HIV infection will continue to occur. If medical facilities are risky for UN employees then they are also risky for Africans. It's hard to believe that the UN can have one story for Africans and another for their employees, but that seems to be the case at the moment.

Institutional Sexism and HIV Transmission

There was a time when HIV was thought to affect men far more than women. That may be partly because it was first recognized in rich countries, where people infected were usually male and had sex with men. But it was soon accepted by the health care profession that both men and women could be infected, sexually and non-sexually. In developing countries, the number of women infected soon outnumbered the men. In Kenya, the ratio of HIV positive females went from 1:2.7 in 1986 to 2:1 in 2006 and it's probably about the same now, in 2010.

That makes HIV much more of a woman's disease than many others, even sexually transmitted diseases. The orthodoxy of UNAIDS, the WHO, CDC and others is that women are more susceptible, for various reasons, than men. But these institutions have been trying for years to say what it is that makes women more likely to be infected with HIV in developing countries than women in rich countries. They have come up with a lot of theories about African sexual behaviour, many of which are not borne out by the evidence. These 'theories' are mere prejudices in the absence of evidence, but they have been used to influence most of the HIV prevention activities carried out in high prevalence countries.

It's no wonder that most of these high prevalence countries have only seen small drops in HIV transmission. If there is no evidence for very high rates of unsafe sexual behaviour in high prevalence countries, and plenty of evidence for higher rates of unsafe sexual behaviour in low prevalence countries, the behavioural paradigm, the belief that most HIV transmission is due to high levels of unsafe heterosexual behaviour, is clearly faulty.

The behavioural paradigm was not so evident in the 1980s or even in the early 1990s. It arrived later, probably on the back of large amounts of donor funding from countries who chose, for political or religious reasons of some kind, to see HIV transmission as a moral issue. They chose to see high HIV prevalence as a sign that people in some countries were the victims of immoral behaviour and they switched their attention from non-sexual transmission modes to sexual modes.

The issue of institutional racism on the part of these institutions, UNAIDS, the WHO, CDC and others, has been raised on this blog before. The belief that Africans have higher levels of unsafe sex than non-Africans, when all the evidence says this is not so, lays the charge of institutional racism on their doorsteps. Never mind their posturing about wanting to reduce stigma or improve the lot of women.

But these institutions are also guilty of institutional sexism. Far from reducing stigma, the orthodoxy that says that HIV is mainly transmitted by heterosexual sex in developing countries stigmatizes women more than it stigmatizes men. How are HIV positive women supposed to see themselves in the light of this kind of orthodoxy? What options do they have to defend themselves from the implication that they are promiscuous? And how do they explain their positive HIV status to their husbands when they find that they are infected when their husband is not?

The orthodox view, the racist and sexist orthodox view, says that the majority of people infected, including the 53% of married HIV positive women, were infected by having unsafe sex of some kind. Some HIV positive women with HIV positive husbands are not even infected by their husbands because they are infected with a different genetic strain of the virus. All these women and men are tarred with the same brush, stigmatized by the very institutions that use public money, ostensibly, to reduce stigma, to reduce HIV transmission, to find out why HIV is being transmitted at such high rates in some countries and not in others.

We can offer HIV positive people in developing countries some hope of not being stigmatized. But only if we accept that the behavioural paradigm is wrong, that we don't yet know why people are being infected in such huge numbers. We can offer then a thorough investigation of the non-sexual modes of transmission, because this is clearly relevant. We just don't know the significance of non-sexual transmission yet and that is because we, or at least UNAIDS, the WHO and CDC, have steadfastly refused to investigate properly why HIV transmission is still so high in some countries. We behave like people who don't know anything about HIV transmission. But, in reality, we know the behavioural paradigm is a piece of racist and sexist nonsense.

Are we going to continue to allow people to become infected with a chronic and life threatening illness, even though we know that our policies are based on prejudice rather than on scientific knowledge? How do we face off the charges of institutional racism and sexism that we are so clearly guilty of? Or do we need to go through a process of truth and reconciliation, where the movers and shakers of the HIV industry are allowed to admit their abject failure and promise to eradicate racism and sexism from their institutions? This is not a time for professional, political or religious pride: until we admit we were wrong, we will continue to allow people to suffer and die.

Big Media: Double Standards or Negligence?

I searched in vain for any mention of the risks of non-sexually transmitted HIV before the World Cup. But all the big news sources, CNN, BBC, Al Jazeera, along with lots of newspapers and news sites, covered sexual transmission of HIV, exclusively. They warned people about unprotected sex and using condoms, etc, but none of them warned people that in South Africa, medical and cosmetic treatment can carry huge risks from unsterilized equipment and unsafe procedures.

This is particularly odd because I would put money on it that these same organizations warn their own employees about non-sexual dangers. I could be wrong, perhaps they don't warn their own employees. But many big organizations do, such as the UN, WHO and CDC. Even an MSF Kenya employee I talked to recently said she and her colleagues wouldn't use local medical or dental facilities (though, inexplicably, she didn't seem to think medical transmission posed much of a risk to people who lived in the country). So big media are either guilty of the double standard of warning their own employees of a risk that everyone in African countries face without warning African people; or they are guilty of negligence in not warning their employees about this serious risk.

Of course, they may have been advised by UNAIDS or the like that medical treatment does not pose much of a risk. What they mean by this is that they are currently admitting that in excess of 5% of HIV is transmitted by medical treatment. These thousands of people infected are so insignificant that UNAIDS deems it better to keep talking about sexual transmission and completely ignoring medical transmission because otherwise, people might not have confidence in their medical service providers. So, is there a risk or is there not?

If the risk is so small, only a few tens or perhaps hundreds of thousands of new cases every year, why not warn people about it? Because if the risk is small, they shouldn't be unduly worried about their medical service providers. But then, if the risk is small, why do UN agencies warn their own employees away from using medical services in African countries that are not approved by the UN? And while in excess of 5% of cases may not seem so significant to UNAIDS, that's 8 or 9 times higher than the contribution of medical treatment to HIV prevalence claimed for Kenya, which the same UNAIDS put at about 0.6%.

What is so wrong with saying that people face risk from both sexually transmitted and non-sexually transmitted HIV? Is it so hard to admit that when millions of needles and other sharp objects are stuck into people every day, some diseases may be accidentally transmitted? Because, if UNAIDS had the balls (or do I mean teeth?) to admit this obvious possibility, people living in African countries would be in a position to do something to protect themselves, perhaps even to lobby their governments to change things so that they don't face these dangers.

I think UNAIDS are right, if people found out that they or their children face an appreciable risk of being infected with HIV, they would think twice before having routine medical treatment. But what would UNAIDS prefer? That tens of thousands of preventable HIV infections continue to occur because they think that number is insignificant compared to people suspecting that their medical service providers are not very safe?

Either the danger of medical transmission is insignificant, and then it shouldn't be beyond the capability of UNAIDS and their chums to manage the fallout from telling the truth: that there is some danger. Or medical transmission is anything but insignificant, in which case UNAIDS and all other relevant agencies should lose no more time in warning people of the risks and in mitigating those risks so that people can return to their medical service providers with greater confidence.

I don't accept that it is better to keep people in the dark and allow some of them to become infected with HIV when this is completely avoidable. I don't accept that it is better not to tell people how to protect themselves or to try to cover up the danger on the grounds that people not using medical services is a bigger evil. African people are being treated like idiots, who don't know how to evaluate risks and to take measures to avoid them.

It looks as if people visiting the World Cup are being treated the same way, being told to avoid sex or to use a condom. Some of the more self righteous in the HIV industry like to say that the only way to be 100% sure of not contracting HIV is to abstain from sex. But this is not true. Abstaining from sex has not protected the thousands who have been infected non-sexually and the thousands more who will continue to be infected because UNAIDS, in their great collective wisdom, don't wish to inform people that there are also non-sexual risks that abstaining from sex and wearing a condom won't protect you from.

What is so difficult about telling the whole story, that HIV can be transmitted sexually and non-sexually? And if UNAIDS can't be trusted to do so, why is it so difficult for news agencies to do so? Do they really all care that little about HIV continuing to spread, unnecessarily? Or are they just so obsessed with sexual behaviour that only sexual risks are considered worth reporting?

Condoms Won't Protect Fans Against Non-Sexual HIV Risk

Since writing about HIV and the World Cup in the last few days, I have looked for news outlets and the like for coverage of non-sexual HIV risks that people visiting or living in South Africa face. I found nothing. A couple of sites mention needle sharing as a potential risk but the tone of the warning suggests that it is aimed at intravenous drug users. There is no mention of the risks of visiting a dentist, a doctor, a nurse, a surgeon, a tattoo artist, a hairdresser or any other non-sexual risks. Can journalists and others trying to squeeze all that they can out of the World Cup not find space for a brief mention of these issues?

The remarkable thing about medical transmission of HIV in African countries is not that it doesn't happen. It's that no investigations have been carried out when medical transmission has clearly occurred or where it may have occurred. Infants, children and even adults who have had no sexual exposure are HIV positive, yet there have been no calls by international health institutions, African governments or HIV donors for investigations. In most African countries, the number of women infected far exceeds the number of men infected. And though women's groups fall over themselves to get their issues heard, they don't seem to be outraged that women seem to comprise the largest number of victims of medically transmitted HIV.

Compare this to a story in Australia. There are fears that thousands of patients at a clinic may have been infected with HIV, hepatitis and other diseases after hygiene standards were found to be seriously deficient. The clinic has been closed while the investigations take place. I don't know of any similar investigation in an African country and I've rarely heard of a hospital or clinic closing merely because patients health and lives may be at risk.

Endoscope and biopsy equipment were found to have been insufficiently sterilized after nine patients became sick. There was also a contaminated anaesthetic involved. These are problems that African hospitals face all the time. They often don't have the equipment to sterilize everything properly, nor even enough trained staff to carry out the work. African hospitals also have the problem of old equipment, shortages of equipment and the need to reuse things that are designed to be disposable. Health workers are not going to do without gloves just because there is a shortage. How many options do they have?

In Australian hospitals, people are far less likely to be infected with HIV, hepatitis or other serious illness. But in African countries, where only the sickest go to hospital and many serious diseases are endemic, the risks are very high. But patients becoming ill after receiving medical treatment in African hospitals is so common that this is unlikely to trigger any kind of investigation, as happened in the Australian instance. And if people die, there are unlikely to be any questions asked. Many people die every day of all sorts of things. Health workers have little enough time to deal with sick people, let alone dead people.

In the UK, children who may have been jabbed with discarded hypodermic needles in a paddling pool are being monitored for HIV and other conditions. The have to wait three months to be sure they have not been infected with HIV, but at least they and their parents were alert to the fact that they may have been contaminated. I have passed through a couple of health facilities in East Africa and seen needles and other sharps in the grass where people walk in rubber sandals and where children play. I wonder if African children running around in bare feet would even notice a pinprick or scratch from a needle.

But I know that the parents of most children here would have no idea that needles and other hospital wastes carry a risk of infection with HIV and other diseases. Some people can tell you that sharing needles and the like carries a risk but most have not been fully warned about the risks associated with medical and cosmetic facilities. Indeed, the official line is that there is only a tiny risk from medical and cosmetic transmission of HIV. Those responsible for the official line, UNAIDS, WHO, CDC and the rest, must be well aware that non-sexual risks are far higher than they admit. But for some reason, they don't want Africans to know that these risks exist and, consequently, how to protect themselves.

And so, as the Western world worries about Westerners going to the World Cup being infected with HIV through some kind of sexual encounter, it's quite amazing that there are no warnings about non-sexual risks. Football supporters don't just like drinking and having sex after matches, they also like fighting, especially when their team loses. And drunk people can be prone to all sorts of accidents. People will end up in accident and emergency wards, dental surgeries and the like. People also may like to get that special football tattoo in South Africa, where it may be cheaper, but also more dangerous.

No doubt, there will be the usual slew of stories after the event about how various efforts and initiatives failed and how things should have been done differently. Journalists will never close the stable door if they can make a story about the bolted horse. So if the media, websites, officials and other sources of information will say nothing about non-sexually transmitted HIV, instead concentrating exclusively on sexual transmission, there will also be stories about how people are let down by health services and how unhygienic tattooists, hairdressers and ear piercers are. But only when it is too late for the victims.

If the Western press is really so worried about the health of Westerners, they should highlight the risks of non-sexually transmitted HIV and other health risks that people receiving medical and cosmetic treatment in South Africa face. They clearly are not worried about the risks that South Africans face and will continue to face after the World Cup has ceased to be front page news. But there is hope that South Africans themselves will one day question the official line, that they have so much sex that this explains why the country has more HIV positive people than any other. South Africans themselves may question the state of the health services that are available to them and ask why they have not been warned about non-sexual HIV risks or how to protect themselves. This is a very good time for them to raise these questions, before the Western press goes back to seeing Africa as a far away place populated by foreigners who have a lot of risky sex.

Paying Ugandans to Transmit HIV

For years, we have been blasted with ‘news’ about how successful Uganda was at controlling its HIV epidemic in the early days of the virus. Even articles about HIV in other countries were almost guaranteed to refer to Uganda’s ‘success’ and this was usually put down to the country’s adoption of ABC (Abstain, Be faithful and use a Condom) programmes. This is despite the fact that ABC campaigns didn’t exist anywhere in the late 1980s and early 1990s, at a time that HIV prevalence rates in Uganda were dropping fast. It wasn’t until many years later that Uganda and other countries were sold this rather spurious set of claims, which went so far as to claim that abstinence alone was responsible for falling HIV prevalence.

But it became rather embarrassing in the early 2000s, when Uganda’s prevalence rates appeared to be flatlining and perhaps even rising. Now that it has become too obvious for even the usual suspects at UNAIDS, CDC, WHO and the journalists who spread their wisdom to continue claiming that all is well in Uganda, people are asking what went wrong and how can the country get back on the right track. The UNAIDS Uganda country co-ordinator, Musa Bungudu, is interviewed and his answers show serious lack of understanding about HIV in general and HIV in Uganda in particular.

He emphasises the ‘behavioural change approach that helped Uganda to reduce HIV prevalence in the past’. Among the many who have echoed the praise for Uganda, there have been a few who have questioned the history of HIV there and especially the reasons given for Uganda’s early success and the country’s subsequent failures to eradicate the virus. In an article entitled ‘How Uganda Reversed Its HIV Epidemic’, a number of authors who worked in Uganda in the 1980s and 1990s (Gary Slutkin, Sam Okware, Warren Naamara, Don Sutherland, Donna Flanagan, Michel Carael, Erik Blas, Paul Delay and Daniel Tarantola) remember things very differently.

The story they give is that a campaign was mounted to inform people about all the modes of transmission and ways to avoid infection. Rather than just being a behaviour change campaign aimed at sexual behaviour, people were informed about medical transmission and other non-sexual modes, research and monitoring were carried out to determine who was at risk and why, etc. And these were, we are told, the usual strategies for an early Aids programme. The epidemic in Uganda was one of the first to peak. Therefore, the country would have benefited a lot more from such a campaign than countries where HIV was peaking later, once the ABC and abstinence only adherents managed to wrest most of the money from genuine health professionals.

In contrast, in Kenya, the epidemic peaked 10 years later, by which time politicians, religious leaders and commercial interests had taken the front seat and all reason and sense was stuck in the boot, where it languishes to this day. Interestingly, a completely coincidental sexually transmitted infection (STI) programme had been rolled out in Nairobi, just before HIV had been identified. During the time this programme was going on, HIV prevalence rose from very low rates (determined through stored blood samples) to prevalence rates of over 80%, only to drop dramatically as the STI programme was phased out. Aside from this remarkable coincidence, Kenya as a whole did as little as possible to reduce the spread of HIV and as much as possible to deny that there was even a serious epidemic in the country.

So, Uganda were successful in the early days of the epidemic and people often ask why, what did they do that other countries could have done and what were they doing that they are not doing now. Well, perhaps it was the adoption of the behavioural paradigm, so beloved by politicians, religious leaders and other bigots, the belief that HIV is mostly transmitted by unsafe heterosexual intercourse in African countries because, as the story goes, Africans have inordinately more sex than everyone else. And even Mr Bungudu, a Ugandan, doesn’t seem to feel the need to question the possibility that this behavioural paradigm is wrong.

He mentions that HIV prevalence was perhaps as high as 20% in the 1980s and that it dropped to about 6% by 2000, which would have been, to a large extent, due to very high death rates in the 1990s. He mentions that prevalence is even increasing but, most importantly, he notes that the rate of new infections is increasing. About half the HIV positive people who need antiretroviral treatment (ART), which means that HIV prevalence, the number of people living with HIV, should be rising. But Uganda continued with the programmes said to reduce HIV transmission, so why are they not working now?

One explanation appears to be that the country did, indeed, start off well, approaching every mode of transmission, not just sexual transmission. But once they embraced ABC, abstinence only and anything else that followed from the behavioural paradigm, transmission by all non-sexual routes started to increase. The country, effectively, abandoned a major part of their earlier campaign. In this pursuit, they were amply supported by their major donors, who didn’t want to hear about anything but sexual transmission and ineffective behaviour change campaigns. In fact, most countries are afraid to run any campaign that doesn’t explicitly mention sexual transmission to the exclusion of all other routes of transmission for fear of losing their funding. They are right to worry about losing their funding. But, as a result, they have lost control of the epidemic.

Bungudu then performs the classic UNAIDS trick of attributing most new HIV infections to low risk sex (entailing the contradiction that a virus that is difficult to transmit sexually is frequently transmitted sexually). Most new infections have been found to be among married people. Worse still, most of those infected are women whose husbands are HIV negative. Does Bungudu want to subscribe to the racist view that, not only do most Africans have a lot of sex, but also that many married women are sleeping with people other than their husbands, perhaps for money? To explain such high rates of sexual HIV transmission among married women whose husbands are HIV positive would require that they sleep with an awful lot of other men. HIV negative people married to HIV positive partners can remain HIV negative for years, even if they have regular unprotected sex.

But yes, Bungudu mentions high levels of unfaithfulness and all the other explanations that UNAIDS cling to, even saying that “a poor woman is likely to go out with a rich man for his money. If he is infected, she may get HIV.” What he doesn’t seem to appreciate is that this would take an awful lot of poor women having an awful lot of sex with a lot of rich people (are there many rich people in Uganda?). But we know that, for a long time, HIV prevalence was higher in richer sectors of the population. And this trend was as true for rich women as for rich men. The problem with everything that Bungudu says is that it all presupposes the truth of the behavioural paradigm. And it all ignores the obvious conclusion, that sexual behaviour does not explain why HIV is so high in some African countries and so low in most other countries.

Continuing the official line, which I suppose he has to do if wants funding to continue, Bungudu reflects on the fact that prevention messages are not getting to remote communities. He completely misses the fact that HIV prevalence in remote areas has always been lower than in urban areas. But once ‘messages’ start reaching these areas, in the form of assumptions about people’s sexual behaviour, HIV transmission tends to rise. This is being experienced in Gulu, now that the area is being ‘developed’. Prevalence has doubled in the last few years despite the fact that roads, hospitals, schools and other social services are being built.

It is a good thing that all these amenities are being built and I’m certainly not arguing otherwise. But if the HIV message continues to be about sexual transmission and excludes non-sexual routes, many more people in Gulu and other areas will continue to be infected. People like Bungudu and others need to open their eyes, to question what is happening and not just to repeat the prejudiced rubbish they have been fed by international health institutions.

The only hopeful thing Bungudu mentions is that Uganda’s HIV efforts are about 90% foreign funded. If the Ugandan government can find a way to provide more of the funding, they may be able to find a way to turn the epidemic around. But only if they also reject the simplistic and highly prejudicial maunderings that make up international HIV policy to date. Otherwise, the fact that most Ugandans are not able to access health services could be the only thing that gives them some protection from HIV. But if Ugandans are not prepared to stand up for other Ugandans in the face of such prejudice, no one else will.

Face the Problem of Medically Transmitted HIV, Don’t Cover it Up

In December of last year, three researchers published a paper in the peer-reviewed journal, the International Journal of STD and Aids (IJSA), concerning HIV infected children with HIV negative mothers in Kenya and Swaziland (entitled 'Horizontally-acquired HIV infection in Kenyan and Swazi children'). The researchers concluded that blood exposures are the most likely routes of transmission in these cases. The researchers also called for greater surveillance and investigation of such phenomena and public education about the risks people face, along with steps they can take to reduce these risks.

The Swazi Observer, the Swazi Times and the English Telegraph all covered the research in question, with the two Swazi papers appearing to refer to the Telegraph article, rather than the original research article. [It should be noted that the Telegraph's figure of 5 million new cases of HIV being created annually by healthcare practices is an error as it's higher than the total number of new infections, which was about 2.5 million in 2007.] These newspaper articles were alarmist and tended to go way beyond anything written in the IJSA article. But they were probably no more or less irresponsible than normal newspaper coverage of medical and other issues.

A member of the public working for or studying with the London School of Hygiene and Tropical Medicine (LSHTM) then wrote to the Swazi papers complaining that this kind of sensationalist reporting is a danger to the health of Swazi people. On balance, the newspaper articles were sensationalist and distorted the findings of a careful and professional study.

But this correspondent goes on to criticize the IJSA article itself. These criticisms may need to be dealt with by the authors and by other professionals involved. However, the correspondent’s criticisms are either irrelevant or they relate to limitations that are made quite clear in the paper. It is true that the authors of the paper don’t ‘prove’ that the children were infected by medical procedures; no investigation was done in Swazi health facilities; and the data on routes of transmission were for Kenyan children, not Swazi children. These matters are all made clear in the methodology and throughout the paper.

The correspondent puts great effort into grasping at straws to defend the health services that are not necessarily being attacked by the IJSA article. And in this way, she seems to imply that there is no need to investigate the very possibility that people face risks when they attend medical facilities (and hairdressers, traditional healers, cosmetic service facilities, etc). Even the WHO and the UN would admit that there are serious risks of blood borne transmission of HIV in African medical facilities. They just don’t bother to do anything about it in African countries. They content themselves with endlessly repeating the discredited mantra that HIV is mostly spread through unprotected sex.

The correspondent goes on to clarify her worry: that people needlessly fear going to clinics for medical procedures that may save their lives, including HIV testing, and that these newspaper articles could confirm people’s fears. The IJSA authors come up with questions about the safety of health procedures in African countries, something even the WHO doubts, estimating that up to 50% of injections could be unsafe, and this correspondent thinks the public are worrying needlessly!

Perhaps this correspondent is afraid that people will think they are being lied to. And to assuage their worries, she advocates lying to them. Or, at least, she advocates keeping the truth from them. Is this the LSHTM take on medical ethics? The correspondent goes on to indulge in a bit of sensationalism herself, about newspaper articles killing people and their babies because members of the public are afraid to seek medical treatment. Her attack on the newspapers ends without further reference to a careful piece of research which shows that many questions need to be raised about medical services in Swaziland (and other countries). It is because these incidents have remained uninvestigated that the public need to be made aware. It is because they have remained unaired that people will fear medical facilities: their fears have already been realised.

The date of the newspaper articles is significant, the 2nd of December, the day after the HIV industry gets together to slap each other on the back for the great work they have done and the successes they have had in reducing HIV transmission over the past year. No doubt, it stung those in the industry to get a wake up call the day after International World Aids Day, especially those working in Swaziland, which has one of the highest prevalence figures in the world. But a sensationalist rant about sensationalist reporting should not be used to deflect attention to what may turn out to be one of the biggest drivers of HIV transmission: non-sexual transmission, either through medical procedures, cosmetic procedures or various other modes.

Anyone studying or working in public health should be concerned if there is evidence that lax procedures may be allowing people to become infected with HIV or other blood borne diseases. Anyone truly concerned with the safety of patients and members of the public would advocate that potential medical transmissions be investigated. And they would not let themselves be distracted by entirely separate issues, such as irresponsible newspaper reporting. To date, the many peer-reviewed articles highlighting possible instances of medical HIV transmission in African countries have been ignored. No investigations have been carried out. But those who are most aware of these matters (WHO, UN, CDC) continue to claim that HIV is primarily transmitted though heterosexual intercourse. If people object to what the newspapers are saying or to what the researchers in the IJSA are saying, they should carry out a thorough investigation.

If the LSHTM student or employee is so concerned about newspapers behaving irresponsibly, she could take to task the ones who always tow the official line on HIV, that it is primarily transmitted by heterosexual sex in African countries. As a result of this official view of HIV, people who find they are HIV positive are stigmatized. HIV is so closely related to illicit or unsafe sexual behaviour in people’s minds that they don’t even know that they could be at risk when they visit the dentist, the doctor or the manicurist. And if they don’t know they are at risk, they will not make any effort to protect themselves. It’s all the other newspaper articles that read like UNAIDS press releases that we should object to, not the few questioning the status quo.

If we don’t want the ‘sensationalist’ press to warn the public of the dangers they and their children may face when they visit medical facilities, we need some credible party to let people know. People need and have a right to know in order to protect themselves. But by refusing to investigate any possible instances of medically transmitted HIV, the WHO, the UN and the CDC show that they are not credible parties. It would not be a desirable outcome for people to avoid medical treatment, but nor would it be a desirable outcome for people to continue getting treatment that may be transmitting HIV. This is a dilemma that those working with HIV need to face, not cover up.