HIV and Circumcision: the Emperor's New Condom

It may seem like the issue of male circumcision crops up a lot on this blog. But if there was ever an intervention ostensibly intended to reduce HIV transmission whose time had not come, circumcision is it. It may, under certain circumstances which have yet to be identified, reduce HIV transmission from females to males. But it is very likely to increase transmission from males to females. Females in African countries where mass male circumcision campaigns are being carried out are far more likely to be infected with HIV than men. Therefore, females face the greatest risks if these ill-advised campaigns go wrong.

One prominent study intended to show that circumcision was effective in reducing transmission unfortunately suggested that the operation actually increased transmission from males to females. The trial was stopped early; this was clearly the wrong result. But even some studies that are openly in favor of the intervention also raise serious questions. A mathematical model of transmission where mass circumcision has been achieved looks at some potential effects, including behavioral disinhibition, where behavior can become less safe, or revert to being less safe, because people think circumcision protects them from infecting others, or from being infected themselves.

The long term population effects for males and females investigated by this model are found not to be strongly linked and "there are many possible ways in which an intervention which reduces prevalence in males might nonetheless increase prevalence in females." Despite such potential drawbacks, the authors seem happy for these campaigns to continue, with some minor adjustments. Let's hope that those baying for mass male circumcision can find funding for the modifications the authors recommend in the estimated $1.5 billion figure being bandied about for a campaign that promises (threatens?) to circumcise 20-30 million African men.

 Before it was acknowledged that male to female transmission might increase, it was assumed that females would be indirectly protected because there would be fewer HIV positive males in the population. But, in addition to facing increased direct risks from circumcised males, the indirect benefits hoped for may also be eroded by changes in sexual behavior, presumably influenced to some extent by people's beliefs. Some circumcised men already think they are protected from HIV; some women think circumcised men are protected; some men are only willing to be circumcised because they think it confers very high levels of protection; and women seem to have been railroaded into persuading partners to be circumcised under the misapprehension that it will mean the men will be protected.

The highly dubious but often repeated arguments in favor of circumcision were originally concocted for scenarios where it was adult males being circumcised, and those opting for the operation were HIV negative. But it's a game of moving goalposts and now, HIV positive men are also offered free circumcision in case denying them the operation might lead to 'stigma'. The arguments are also now being used for those who are too young to give consent for the operation and even for newborns, for whom even the dubious benefits are known not to be relevant. But at least the authors of the above paper admit that their simulation shows a relatively small overall effect of circumcision rollout.

An article entitled 'Male Circumcision and HIV Prevention - Insufficient Evidence and Neglected External Validity', asks if research carried out so far really does support the rapid scale up of mass male circumcision programs. The three trials used to argue for circumcision suffer from a number of biases and one of the issues circumcision enthusiasts don't seem keen to discuss is the fact that many of the participants who seroconverted don't appear to have been infected as a result of their sexual behavior. Male circumcision will not protect against non-sexually transmitted HIV, such as through unsafe healthcare (or during the circumcision operation), tattooing, dentistry, body piercing, etc.

Those arguing for questionable HIV reduction and reproductive health strategies often claim that circumcision, pre-exposure prophylaxis (PrEP), injectable Depo Provera, microbicides and others benefit women, or even that they are 'women controlled'. But in reality, control is being wrested from people, male and female. Circumcision seems to increase the risks that women face in several ways. The extraordinary folklore that has grown up around the strategy shows that African men and women have been taken in; how will ordinary people ever be in a position to question something that seems to have so much academic, institutional and financial clout behind it? It's a bit like the mythical 'cloak of invisibility', which leads wearers to do things they wouldn't otherwise have done, not realizing that they are fully visible.

Maybe all or most African men will rally to the HIV industry's call, lining up to be circumcised and then returing home to use condoms for as long as they are sexually active. Maybe women will be galvanized into compelling men to use condoms, something they haven't been able to do so far. But the authors questioning circumcision as a HIV reduction strategy conclude that: "The policy questions to be considered are not whether a link exists between male circumcision and reduced rates of HIV infection, but, rather, whether mass circumcision is (1) an ethical and safe public health choice, and (2) the most cost-effective use of limited resources." At best, the answer to these questions is 'not yet', at worst, a resounding 'no'.

[For more about male circumcision as a strategy for HIV reduction, see the Don't Get Stuck With HIV site.]

Even Sex Tourists Are Susceptible to Non-Sexually Transmitted HIV

Not that all British people contracting HIV abroad are sex tourists, but you might think that sometimes. The British HIV Association's HIV Medicine has a brief article about HIV infections contracted by British people when abroad. 2066 out of 13,891 (15%) are said to have been so acquired between 2002 and 2010. While only 22% of HIV infections in the UK are said to be a result of heterosexual sex, the figure is estimated to be 70% for those who acquire the virus abroad. Oddly, the article doesn't mention non-sexually transmitted infections. While these may not be so common in the US, where a sizable number of the infections may have been contracted, they could well be common in Thailand and South Africa, which are also said to the source country for many of the infections (particularly Thailand).

The article makes the following recommendation: "[That] HIV prevention and testing efforts be extended to include travelers abroad, and that sexual health advice be provided routinely in travel health consultations and in occupational health travel advice packs, particularly to those traveling to high HIV prevalence areas and destinations for sex tourism. Safer sex messages should include an awareness of the potential detrimental health and social impacts of the sex industry."

This could be compared with the advice found in the Lonely Planet travel guide - East Africa, 5th Edition: "Any exposure to blood, blood products or body fluids may put the individual at risk [of HIV infection]. The disease is often transmitted through sexual contact or dirty needles - vaccinations, acupuncture, tattooing and body piercing can be potentially as dangerous as intravenous drug use. HIV/AIDS can also be spread through infected blood transfusions; some developing countries cannot afford to screen blood used for transfusions. If you do need an injection, ask to see the syringe unwrapped in front of you. Fear of HIV infection should never preclude treatment for more serious medical conditions."

Personally, I'd prefer the latter advice. If HIV experts are not prepared to discuss non-sexual risks, people might be better off turning to popular travel guides, which tend to give the sort of advice also given to UN employees working and traveling in developing countries:  “In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections.” But, “[b]ecause we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care.” WHO also advises those who are not able to access an approved clinic: “Avoid any procedures that pierce the skin, such as acupuncture and dental work, unless they are genuinely necessary. Before submitting to any treatment that may give an entry point to HIV, ask whether the instruments to be used have been properly sterilized.”

The only problem is that UNAIDS, WHO and others don't extend the above advice to Africans; the British HIV Association seem to be following their example in not extending it to British people traveling abroad. It's quite possible that the British people who are said to have acquired HIV abroad really did have unprotected sex, as the article claims. But it is also possible that some of them received medical treatment, possibly for a sexually transmitted infection, possibly in the kind of conditions that UN employees (but not Africans) are advised to avoid. 9% of the females infected abroad were thought to have been infected in Kenya and nearly 8% in South Africa. Infections probably acquired in Nigeria and Zimbabwe were also reported. If health facilities are risky for UN employees they are also risky for Africans, and even for visiting British people.


[For more information about non-sexually transmitted HIV from unsafe health and cosmetic practices, visit the Don't Get Stuck With HIV site and blog.]

Birth Control Not a Solution to Unsafe Healthcare; Safe Healthcare Is

Paula Donovan of AIDS-Free World, writing in the Huffington Post, makes some important points about an article by Vanessa Cullins of the Planned Parenthood Federation of America (PPFA), also writing in the Huffington Post. Donovan corrects some of Cullins' errors about the WHO's decision not to change the advice it gives women in African countries about injectable hormonal contraceptives such as Depo Provera. As Donovan says, the WHO's decision for now is that they don't know if use of injectable Depo really increases transmission of HIV from women to men and from men to women. All WHO did was reiterate their advice that condoms be used in conjunction with Depo.

Donovan is a bit hopeful in thinking that WHO reviewed "all the best scientific research available." They reviewed some research, left out some and still found the data difficult to interpret. But not too difficult to decide in favor of advising that people continue using the method, with condoms, until more decisive research can be carried out. That might be understandable if Depo were the only form of birth control available or if injection was the only or best method method of administration; but neither are the case.

In fact, what AIDS-Free World, PPFA and WHO fail to mention is that all the data that was considered was about sexually transmitted HIV. Not all HIV is transmitted sexually, but it is usually assumed that all or most is transmitted through heterosexual sex in African countries. Neither condoms, Depo Provera, however administered, nor probably any other contraceptive method, protects against certain types of HIV transmission, such as through unsafe healthcare or cosmetic services. Indeed, high use of injections in healthcare facilities where safety standards are not very closely adhered to might be part of the problem; or it may have been part of the problem at one time.

Donovan asks "What if women at high risk of HIV hear that experts are concerned about injectable hormones, and choose to stop using them until researchers have come to definitive conclusions?" Well, as long as they use some other form of contraception, what if they do stop using Depo? Donovon goes on: "What if, as a result of that choice, many more women in countries with high rates of maternal mortality become pregnant?" One of the reasons why maternal mortality rates are high is because conditions in health facilities are extremely bad; so bad that many opt not to use them and rely on something that may or may not be a lot worse.

If AIDS-Free World, PPFA and even WHO are worried about maternal, infant or child mortality, choice of contraceptive method is really not the most important issue. Especially if the 'choice' to use injectable Depo could be exposing women to risk of infection with HIV and other diseases (or may have done in the past). The solution to the problem of unsafe healthcare is safe healthcare, not birth control. I suspect PPFA and the like have been imagining that they are 'saving' lots of women by persuading them to use their (the NGO's) favored method of birth control; but if healthcare facilities remain as appalling as they are now, even those follow current advice may still risk being infected with non-sexually transmitted HIV and other healthcare associated infections.

PPFA use the rather emotive term "lifesaving contraceptive methods", as if women's lives depend on Depo, injectables or any single type of contraceptive. But if they are so worried about women's safety, they should take more interest in conditions in healthcare facilities, or they could be exposing them to far higher risks. Cullins even recognizes that condoms on their own give 'dual' protection against unplanned pregnancies and sexually transmitted infections, including HIV; but there are several other methods she doesn't even mention. Injectible Depo Provera has been aggressively marketed in African countries for a long time, so it could be a little tenuous to claim that it is 'popular'.

If women need more options, as Cullins argues, that should include non-hormonal methods, non-injectable methods, etc. Even Michael Sidibe of UNAIDS points out that women need safe contraceptive and HIV prevention options, but he rather piously mentions 'ownership' and 'management'. One of the reasons injectable Depo has been favored by those who promote it is because they themselves can 'own' and 'manage' it. Women just go to the health facility every three months. There may be a sense in which Depo is more 'female controlled' than male condoms, for example. But if women can't control men's use of condoms, injectable Depo Provera may well be the last method they should consider using; after all, you would be failing to follow WHO's advice if you used Depo even though your sexual partner refused to use a condom.

Both AIDS-Free World and PPFA seem to recognize that healthcare conditions are not particularly good in some countries. So why not warn people that they may be exposed to HIV and other diseases through their use of these facilities? If people don't recognize the risks they will not be able to avoid them. Whatever about the dangers of hormonal contraceptives per se, injections and other skin piercing practices are highly efficient modes of HIV infection, far more efficient than heterosexual sex. When healthcare conditions are poor, injections are best avoided. Low levels of maternal health and high maternal mortality are not primarily a matter of birth control method; women need safe healthcare and appropriate birth control methods, not whatever commodity NGOs like PPFA happen to be pushing.

To What Extent Does Male Circumcision Reduce HIV Transmission?

Probably in common with many bloggers, HIV in Kenya is my own take on things of interest to me that relate to HIV, development, Africa, health and various other subjects. I am not 'giving a voice to the voiceless', just saying what I think because few people or institutions that I know of are saying the same thing. Taking a keen interest in something does not necessarily make me an expert, but if I am wrong, surely I am more likely to be set right by airing my views in public, with arguments and citations that I feel support my views? In the process, sometimes I change my views imperceptibly (perhaps even to myself), sometimes I do so radically.

But one thing I will not do is leave what can be highly technical subjects to those who are seen as, and/or who see themselves as, experts. I may at times defer to them, but I also question them. This is because I have read many apparently well researched and well written papers, with mountains of citations and erudite passages, often published in respected, even venerated, peer-reviewed journals, whose conclusions seem to fly in the face of my own analyses, observations and experiences. We may not all have the same academic credentials, but we should have a lot in common in virtue of being humans. Yet, I constantly find myself reading 'scientific' papers that either state, imply or evidently assume that some humans are capable of behavior that would be beyond the ability, inclination or both, of most people.

There are so many overlapping groups who have been 'identified' as being at risk of infection with HIV, often mistakenly, that this approach is of very limited value on its own. Aside from at times stating, incorrectly, that 'everyone' is at risk, or is at equal risk, at other times the finger has been pointed at men, women, children, Africans, Haitians, gays, soldiers, teachers, young brides, older men, long distance truckers, immigrants, migrant laborers, prisoners, sex workers, clients of sex workers, intravenous drug users, victims of female genital mutilation, uncircumcised men, fishermen, widows, alcoholics, internally displaced people, sex tourists, sugar daddies, partners of sugar daddies, poor people, rich people, uneducated people, students, people with certain diseases, especially sexually transmitted infections, and the list goes on.

Almost all of those groups listed above are said to be at risk of infection with HIV because of some kind of sexual behavior, and some of them are indeed at risk, others may be at risk. But HIV is not always transmitted sexually. Aside from the more obvious intravenous drug use and mother to child transmission, there are additional non-sexual HIV risks that are rarely mentioned in the literature except to be denied or diminished. What I would really like to know is the relative contribution of non-sexual HIV transmission, especially from unsafe healthcare, and perhaps to a lesser extent from unsafe cosmetic practices. It could be true that unsafe healthcare plays a very minor role in serious HIV epidemics in Africa. But I don't believe that, especially when I read documents such as the Service Provision Assessment documents for Kenya, Uganda and other countries.

Similarly, there is much written about the potential effectiveness of conditional and unconditional cash transfers, particularly to young girls, mass male circumcision, pre-exposure prophylaxis, testing everyone (or at least 80% of people) in HIV endemic countries and treating everyone found to be infected, microbicides and various strategies, including abstaining from sex. Indeed, organizations involved in all sorts of activities, such as birth control, poverty, gender based violence, alcohol and drug abuse, reproductive health, religious practices, sex education, even selling commodities such as condoms, pharmaceuticals and various devices and services, all find their best market, sometimes their only market, in HIV. Some of these may be effective, even good value, some are probably not effective and others are harmful or potentially harmful.

Among the many disputes that I have been part of though my blogging are marketing of inappropriate pharmaceutical products, questionable ethical practices, especially in drug trials, dissemination of questionable data and information that affects peoples' health; I have also specifically raised questions about use of injectible Depo Provera hormonal contraceptive, strategies such as 'ABC' (abstain, be faithful, use a condom), pre-exposure prophylaxis in populations where it is unclear who is at risk of HIV infection and what kind of risks they face (whether they are sexual or non-sexual); and in particular, I have raised questions about mass male circumcision, over and over again. True, there are quite a number of recent papers about circumcision which make strong claims about its effectiveness. But there is also a wealth of literature that is more critical, much of which is ignored in the favorable papers.

In a word, the debate is highly polarized. There are those who only seem to concentrate on what they see as advantages in circumcising 30-40 million Africans, at vast expense; and there are those who keep asking questions about what seems like a lot of propaganda, and citing numerous possible disadvantages. Living in East Africa, I have heard people talking about circumcision and they have all been in the first group, those who only mention the advantages. As a result, many of the recipients of this information think they are already protected, being circumcised; many women seem to share this view. Uncircumcised men are, unsurprisingly, more reticent. But if the numbers we read are true, tens of thousands, even hundreds of thousands are turning up to be circumcised. It would be interesting to know what it was that convinced them and if they were convinced by propaganda, because there doesn't seem to be a lot else readily available.

Anyhow, I have cited many of these papers that are clearly in favor of mass male circumcision, often regardless of their research findings; and in addition, I have cited papers which are opposed, all of which seem to get far less attention from the mainstream, health and scientific press. One of those papers, written by Gregory Boyle and George Hill, makes a claim about the absolute risk reduction for male circumcision not being statistically significant and comparing this to the relative risk reduction. Whereas the relative risk reduction looks impressive and is endlessly cited by the mainstream press and in academic sources, the absolute risk reduction figure is very small, certainly not useful for propaganda purposes. But is the absolute risk reduction statistically significant? A visitor to my blog post on Poz.com believes it is and accuses Boyle and Hill (and myself) of lying by claiming otherwise. I have notified the corresponding author and will leave it to them to defend their claim.

This is not the first time I have cited something that has turned out to be questionable. I have also inadvertently drawn incorrect conclusions, even miss-cited sources and made other errors. Thankfully, either I have noticed and made amends, or someone has contacted me to let me know there is a problem. At other times, people are not particularly polite, perhaps because they have an axe to grind or some kind of interest, financial, political, personal, whatever. Nevertheless, I'd rather get a kick in the ass from someone who is right than a pat on the back from someone who is knowingly or carelessly peddling rubbish. And much though I hate to admit it, 'you would say that, wouldn't you' is a fallacy. Even if someone is saying something because it's their party line, and not because they always fight for their convictions, that doesn't mean they are wrong.

Even at risk of saying (or citing) something that turns out not to be true, I am going to continue objecting to what I believe to be wrong until I become convinced that it is not wrong. I have yet to be convinced that mass male circumcision will reduce HIV transmission, just as I have yet to be convinced that HIV is almost always transmitted through heterosexual sex in Africa. Therefore, I shall continue to express these views on my blog.

Kenya's Health Act, 2012

Kenya's Daily Nation recently ran an article about the country's Health Act, 2012, and how it may possibly allow people's sexual partners to access their health records when they pertain to HIV or other sexually transmitted infections. It is not clear how people would prove that they are sexual partners, especially if the person in question has a lot of them. But this proposed exception to confidentiality of health records was only discussed in a footnote, which, we are told at the start of the document means it is not part of the law. Other legal instruments are referred to that may clarify this, however. [Click for a draft of the document.]

So, as yet, "All information concerning a user, including information relating to his or her health status, treatment or stay in a health facility is confidential." But it is high time to address the problem that many people either avoid finding out their status or avoid informing their partner once they know.

According to the act, the healthcare practitioner has a "right to a safe working environment that minimizes the risk of disease transmission and injury or damage to the health care personnel or to their clients, families or property". I wonder if this covers inadvertent infection with blood borne diseases through reuse or careless use of unsterile equipment? In the section entitled 'Promotion and advancement of public and environmental health', there is mention of legislation to be enacted by Parliament to provide measures for "Strengthening infection prevention and control systems including health care waste management in all health facilities".

Of course, healthcare transmitted HIV infections may rarely occur, as is claimed by UNAIDS. But it is possible that the Kenyan government is not prepared to leave the matter to chance, as some of the big players in the HIV industry have done so far.

WHO and UNAIDS Bless Crusade to Circumcise Africans

I recently mentioned a paper that exposes how poor much of the research into male circumcision as a HIV prevention is and I have now got hold of the full paper; 'Sub-Saharan African randomised clinical trials into male circumcision and HIV transmission: Methodological, ethical and legal concerns', by Gregory Boyle and George Hill. The authors show that the results of the trials are not reliable and should not be used to argue for mass male circumcision programs.

One of the most striking aspects of these trials is that the figures purporting to show that such programs can reduce HIV transmission are those for relative risk reduction, not absolute risk reduction. While a 60% relative risk reduction may sound impressive, a 1.3% absolute risk reduction is not even statistically significant. Why are we being given selective and highly misleading data about circumcision if it is as important an intervention as we are told it is by its proponents?

The simple answer is that there is no credible evidence in favor of mass male circumcision; it needs to be manufactured. In fact, there is evidence that circumcision substantially increases the risk of transmission of HIV from males to females and more than a hint that men risk being infected with HIV through the circumcision operation itself. As a result of the well funded propaganda surrounding these circumcision campaigns, a whole set of myths is emerging. Some people, male and female, think circumcision protects against HIV; it is claimed that it is not possible to be hygienic if uncircumcised; there are allusions to circumcision being more aesthetically pleasing; it is implied that the operation is 'fashionable' or modern, etc.

The levels of misinformation being spread about male circumcision are astounding. Arguments for adult male circumcision have even been used for infant circumcision, although the claimed effects of adult circumcision have not been demonstrated for infant circumcision. 'Experts' extol the multiple virtues of circumcision, ignoring the lack of evidence for their claims, indeed, apparently blind to the entirely unscientific nature of many of the claims. After stating that "a circumcised [male organ] is definitely cleaner than an uncircumcised one" 'Dr' Khumbulani Moyo, Clinical Director of Population Services International goes on to say "Circumcised men are also more likely to be assertive sexually as awareness of a good body image is a very important factor in building self confidence." I wonder what his doctoral thesis was on; yoga perhaps?

Boyle and Hill note that the three trials purporting to show the effectiveness of circumcision were carried out in countries where it was already clear that HIV prevalence was higher among uncircumcised men. However, there are just as many countries where HIV prevalence is higher among circumcised men. They ask why the evidence to support a program that may aim to circumcise as many as 38 million men is so selective and point out that with less selective analysis, the program would not be supported. There are so many biases and inadequacies in the data that it can not be used to justify carrying out what is likely to be a dangerous, unnecessary and perhaps even counterproductive program.

It's hard to do this lengthy and well researched paper justice in a short blog post, but it's worth mentioning that one of the many flaws in the research is that non-sexual transmission of HIV was not reported. Quite a number of the men infected with HIV during the trials were probably not infected sexually and could have been infected through unsafe healthcare, perhaps even the treatment they received through taking part in the trial. Mass male circumcision enthusiasts claim that the operation reduces sexual transmission, but many men (and women) might face high non-sexual risks in addition to any sexual risks. But trials into circumcision and other HIV prevention interventions rarely seem to consider non-sexual risk.

There is a substantial body of evidence showing that male circumcision either doesn't reduce HIV transmission or even that it increases transmission. This evidence is not often mentioned by those whose aim appears to be to promote the strategy at all costs. In contrast, there is evidence that 'circumcising' women may be associated with some reduction in HIV transmission without this giving rise to the same enthusiasm for female genital mutilation. There is something of the crusader about the circumcision enthusiasts, something cabalistic in their methods. But what appears to be entirely lacking is science and logic.

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

Timberg and Halperin's Tinderbox: a Veritable Candle on a Sunny Day

The authors of another book on the putative origins of HIV has been published by journalist Craig Timberg and academic (and ardent circumcision enthusiast) Daniel Halperin. There's a lengthy article plugging the book by the authors in the Washington Post, for whom Timberg works. Few know how to plug the latest pot-boiler like a journalist, especially one who wrote the book. But the article is a bit of a damp squib after Jacques Pepin's 'Origins of AIDS'. Timberg and Co. don't really deliver the goods, having promised something explosive.

While Pepin argues that the epidemic would never have got going without widespread colonial healthcare programs, and even with them it still took some decades, Timberg and Co. relegate everything about unsafe healthcare to a parenthetical comment. And though Pepin's argument becomes flakey when he claims that sexual behavior alone wouldn't have been enough to give rise to a serious epidemic, yet that it was enough to ensure that prevalence reached massive levels at some point, Timberg and Co. argue "it’s clear that colonial commerce created massive new networks of sexual interactions — and massive new transmissions of infections."

For them, it's quite simple: a hunter was infected by a chimp through a cut and went on to infect a sexual partner. As far as they are concerned, it was just a matter of there being a "population large enough to sustain an outbreak and a sexual culture in which people often have more than one partner, creating networks of interaction that propel the virus onward." For them, Kinshasa was that place. But while that city has been identified as the place where some of the earliest large scale transmission occurred, this does not mean all transmission, or even most transmission, was through heterosexual intercourse.

There is a problem with Kinshasa as a candidate for high levels of 'unsafe' sexual behavior: syphilis, the sexually transmitted infection (STI) that didn't bite. In 1958, nearly 100,000 men, all the men in the city, were screened for STIs; only 44 possibly had syphilis (and there were a few hundred with other STIs). Even some of those who possibly had syphilis may equally have been infected with the non-sexually transmitted yaws, which was too similar to distinguish.

Timberg and Co. are not too generous with dates in their article, so it could be argued that sexual behavior in Kinshasa changed after independence; this is what Pepin argues, albeit unconvincingly. But patterns of syphilis transmission just don't resemble patterns of HIV transmission. Males and females, urban and rural dwellers are infected with syphilis in fairly similar proportions, whereas HIV transmission is far higher among females and urban dwellers. And whereas HIV tends to infect wealthier people who have higher levels of education, syphilis tends to infect poorer people with less education.

In fact, trends in syphilis rates in many areas have gone in the opposite direction to trends in HIV prevalence. But syphilis rates do testify to at least two things; unprotected sex and poor sexual health facilities. In the few years before HIV was identified, these two factors came together in countries like Kenya, Tanzania and others in ways that may suggest when and where the real 'explosion' occurred. The highest HIV prevalence figures found in African countries were among sex workers, many of whom had been targetted by STI treatment and vaccination. Such rates have not since been found among this group. Significantly, in several non-African countries, HIV rates are not particularly high among sex workers unless they are also intravenous drug users.

Timberg and Halperin's argument doesn't work. HIV can be transmitted sexually but, as they and Pepin point out, it usually isn't. Pepin demonstrates very convincingly how unsafe healthcare programs, even ones that he himself was involved in, were required to enable the virus to infect huge numbers of people in a short space of time, something sexual transmission alone could not have done. But while Pepin doesn't successfully demonstrate how sexual behavior could take over from unsafe healthcare, Timberg and Halperin don't appear to demonstrate anything worth writing a whole book about.

The authors blame 'The Scramble for Africa', but without shedding any light on how various colonial maneuvers did, and continue to do, so much damage in former colonies. They and Pepin point a finger at 'urbanization', which is common in the HIV literature. But what, in particular, is it about colonization and urbanization that influence how a virus that is difficult to transmit sexually becomes a pandemic, and one driven primarily by sexual behavior if the HIV orthodoxy is to be believed? This is not merely a problem for historians: if the HIV industry continues to behave as if the virus is almost always heterosexually transmitted, non-sexual transmission will not be addressed, as it so urgently needs to be.

[This blog post is about Timberg and Halpern's article plugging their book, not on the book itself, which may take some time to acquire in East Africa. For more about non-sexually transmitted HIV, see the Don't Get Stuck With HIV site.