Once the Stereotypes Have Gone, What Goes in Their Place?

Francois Venter makes a number of interesting comments in his article in the Cape Times, which starts by criticizing Helen Zille for her recent public outburst about criminalizing 'unsafe' sexual behavior, which only served to show how little she knows about HIV, health, sex and the law (and how much she knows about pseudo-morality, petty politics and mainstream media). But Venter goes a lot further, taking on the mantra that has launched a thousand careers: HIV is spread through promiscuity.

Venter recognizes something that UNAIDS and the HIV industry have yet to understand, that Africans are people. Shocking as that may sound, even HIV positive Africans are people. They are not sex machines, engaging in levels of coital activity that would leave little time or energy for anything else. They have jobs and families and lives that don't allow for 24/7 sex.

The HIV industry have never actually calculated how high levels of sexual behavior would need to be to account for the notoriously high levels of HIV transmission found in countries like South Africa to even be feasible. They just went ahead and informed the world that Africans are weired when it comes to sex and that if they could just stop being so irresponsible, everything would be OK.

Venter is unlikely to be a recipient of HIV industry controlled funds, or he won't be for long, because he even goes so far as to point out that "HIV is actually not terribly transmissible when looking at risks per sex act measured in developed countries, when compared to other viruses like herpes." He contrasts this with the fact that "a young woman in KwaZulu-Natal has an almost 1-in-3 chance of being HIV positive by the age of 21 years."

There is clearly something different going on in South Africa, and it is not just sexual behavior. So Venter suggests the possibility of some biological factor that makes sexual transmission of HIV more efficient in certain places.

While I am in sympathy with him, I'm not sure I go for his contention that "the geography" could be more significant than the behavior, not in the way he seems to mean, anyhow. Africans in the US are far more likely to be infected, even if they are heterosexual and not intravenous drug users. The geography is very important in some ways, also in South Africa, when you look at those living in urban as opposed to rural areas; those in rural areas are far less likely to be infected.

Venter vaguely suggests more susceptible genes, a more virulent strain of HIV or some undiscovered environmental factor. These may all be relevant in some way, but there is a more likely possibility, given the considerations he mentions, and that is the relative contribution of unsafe healthcare and perhaps cosmetic services. In South Africa, even people living close to roads are more likely to be infected than those further away. In Malawi, those living close to health facilities are more likely to be infected than those further away.

Various co-factors Venter mentions may play some part, some co-factors almost definitely do. But Venter still reverts to the behavioral paradigm, concluding "It’s sex, sure, but high risk sex largely independent of how or with whom you have it." This is a pity as Venter even presents some of the evidence that shows that sex can't play as big a role as the HIV industry would have us believe. Sex plays a part, perhaps a big part, but it can not explain entire epidemics, such as the one in South Africa. The question is, what are the relative contributions of sexual and non-sexual transmission in high prevalence African countries?

I applaud Venter for going as far as he does, however, I don't think he goes far enough. But there is good news. Venter mentions costs. Well, campaigns to warn people about blood contacts, such as in healthcare and cosmetic facilities, along with efforts to properly investigate infections that are unexplained by sexual behavior would not cost much. They are even things he could do as part of his own work as a GP.

And most importantly, genuinely competitive pricing for generic antiretroviral drugs, without the connivance of Big Pharma and their friends (such as Bills Clinton and Gates), produced in high prevalence countries, would also reduce the ever increasing amounts of money thrown into the pockets of various multinationals. This may hurt, Dr Venter, but it won't hurt your patients.

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

Global Fund Cuts: Callous Disregard for HIV Industry

The Global Fund for AIDS, TB and Malaria has dried up. Perhaps not for ever, but for long enough for us to realize that providing increasing numbers of people with increasingly expensive drugs for decades may not be wholly sustainable.

If any effort had been made to reduce transmission of HIV (or even TB or malaria, although they do seem like a bit of an afterthought) over the last 10 years, the costs of 'universal access' to antiretroviral drugs might have gradually become achieveable. But with more people being infected than being put on drugs, the Fund has presided over ten more years of missed opportunities in the field of HIV prevention.

There's lots of talk about treatment being prevention, on the grounds that those on treatment are less likely to transmit HIV. But that is still just talk, and the levels of testing, treatment, support and monitoring required to effect such a program are probably beyond the means of all HIV funding put together. Treatment is vital, and greater access to treatment may help prevent some infections, but it will never obviate the need for effective prevention strategies.

So Kenya is being advised to "Seek Alternative Ways of Funding Healthcare", as no new programs will be funded for the next two years. Ten years of ignoring health systems and diseases that were not considered sexy enough now means there is a lot of catching up to do and no money to do it with. For all the billions that have gone into HIV, African health systems have little to show for it. It's late in the day for a decision to start to see HIV for what it is, a disease, one among many. It's also late to decide that "it is time to dismantle the many parallel HIV programmes created mainly to compete for donor funding but which are unsustainable".

Uganda finds that the "Aid Cut [will] Affect One Million HIV Positive Citizens". Apparently the country had massive plans to eradicate HIV, even more massive than the ones that didn't eradicate it over the last twenty years. There were plans to put most people on treatment, especially mothers and children. But the virus appears to be making a comeback in certain sectors of the population, and has been doing so for some years. Exactly what have they been doing?

The Ugandan Government is also "Advised to Use Local Resources to Fight Aids", which would probably be good advice if such local resources exist. But African governments might also be well advised to form their own health strategies, with HIV fitting appropriately into those strategies, rather than remaining apart from health and other social services and completely dominating most agenda, as it has done for so many years. The various organizations and institutions that have been sucking on the HIV nipple will need to diversify, downsize or disappear.

None of this sounds like a reason to celebrate. But it is a good time to change, if African governments decide to do so. It may now be up to them to identify the main drivers of the virus, to assess the relative contribution of each mode of transmission and to decide on the most appropriate ways of preventing the further spread of HIV. If the donor community is no longer paying, perhaps Africans will notice that their sexual behavior is not that different from that of non-Africans. Perhaps the way will be open for programs that rely less on expensive technologies and an unwarranted assumption that HIV transmission all a matter of sex.

Because currently, things are great for the pharmaceutical industry and the HIV industry in general. Not without some serious lobbying, I'm sure, but everything has been going their way for years. Donor funding has poured into their coffers and every year a new scheme is dreamed up to increase the tonnage of drugs shipped to poor countries, where far more people are dying for lack of clean water and decent levels of nutrition than HIV.

Perhaps now, the 'experts', the ones that African countries couldn't do without, will have to go home and find a job in healthcare, with the appropriate retraining, of course. I believe it's called 'task shifting'. Africans will not suddenly start losing out as a result of Global Fund cuts, they have been losing out for years. But the HIV industry will lose out. Expect a lot of emotive pleas, ostensibly for 'dying Africans', but hear those pleas for what they really are: self interest.

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

UNAIDS 'Getting To Zero'; Zero Lies?

The Nairobi Star has just noticed that HIV prevalence is far higher among employed people than unemployed people, according to the Demographic and Health Survey, 2008-09. They don't cite the correct figures (see graph for corrected figures), but this is not a new trend. So why would employed people be more likely to be infected? According to the Star, it's because they have "disposable incomes which provide the ability to support multiple sex partners and even buy sex, living away from spouses because of employment, drug and alcohol use and abuse of recreation" [sic].

(Source: Kenya Demographic and Health Survey 2008-09, Table 14.5)

If the author is right, and she certainly holds the orthodox view, then women must be buying a lot of sex too, perhaps more than men. But the same survey also shows that levels of 'unsafe' sexual behavior are far higher among men than women. Men are also more likely to abuse drugs and alcohol. Yet HIV prevalence is consistently higher among women. Prevalence is also higher among people with more education, people with more money (whether employed or not) and people in urban, as opposed to rural areas.

Tempting as it must be for a journalist to present sex as the 'obvious' answer to higher HIV prevalence among employed people, perhaps they should look at another possibility, the possibility that sex is not responsible for all HIV transmission. Most HIV transmission in Kenya (Uganda and Tanzania) occurs between people who do not take many risks under the orthodox criteria for risky sex. HIV prevalence patterns do not seem to relate to sexual behavior patterns.

Maybe journalists would like to look at another scenario: employed people, better educated people, wealthier people and urban dwelling people have greater access to health and cosmetic facilities, where conditions may not be very safe. UNAIDS believes that their own employees need to take care in health facilities that have not been approved by the UN. But will they ever get around to warning Africans?

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

HIV Industry Need Non-Racist Answer to the Question 'Why Africa, Why Africans'?

After flailing around blindly, spending billions and ending up with little to show for it, the massively wealthy but spectacularly ineffective AIDS industry may finally box its way out of a wet paper bag. What it will do after that is another matter. But it's nice to see progress, however hard it is to detect.

Right at the end of a paper entitled 'Redesigning the AIDS response for long-term impact', Heidi J Larson, Stefano Bertozzi and Peter Piot make a few things clear which have, up until now, been clear to everyone but those working for the AIDS industry. But they do now accept that funding should support infection control programs relating to safe blood transfusions and injections.

Unfortunately, they deprioritize infection control in general. This would be fine if infection control was covered by health system strengthening funding (or some other way), but it's not. It would also be acceptable that AIDS money no be longer used for sexually transmitted infection (STI) programs if STI reduction received funding from elsewhere, but it doesn't.

The authors note that "The difficulty of changing sexual and drug-using behaviours was...greatly underestimated" and that "prevention tools continue to be implemented without evaluating their effectiveness in different settings." But they don't appear to question the entire vertical approach to HIV/AIDS at a time when health funding in general was totally inadequate in high HIV prevalence countries; the approach to HIV has only diverted funding further.

Instead, they seem to be suggesting that HIV funding be focused even more narrowly than before, rather than on just avoiding ineffective approaches. Do they not yet see the bigger picture of HIV epidemics thriving in countries with low and flat or declining health spending? Instead of talking about mainstreaming, integration and other nice theories, how about treating HIV as just another disease, with overlapping determinants to other diseases, such as hepatitis B and C, with similar needs, such as functional and safe health services?

Reducing HIV transmission is not just a matter of scale, as these authors must appreciate, being aware of the huge increases in funding for lucrative areas of HIV treatment and the like. But the industry, if it's to have any impact on transmission, needs to lose its obsession with sex and African sexuality, and look at disease transmission in context. This means tracing the risks HIV positive people have faced, not just tracing the sexual risks they face; non-sexual risks also need to be reduced, which involves informing people about them and how to avoid them.

Let's leave the fatuous reflexes about 'treatment being prevention' for the marketing people because treatment is not prevention. More than two and a half million infections a year show that treatment is not prevention. Saying we need to put more money into treatment will not make treatment into prevention either. Most new infections occur among people who only face low levels of sexual risk (though the industry has failed to assess non-sexual risk).

But even if treatment could possibly become a significant part of prevention, and there are serious doubts, who will be paying for this? Current programs are failing because of falling funding and an almost complete absence of infrastructure, in other words, a complete lack of health systems strengthening, among other things.

The authors conclude that there are "no short term solutions". At the rate they are going, that's all too true. But the "fundamental redesign" they call for requires a closer look at a disease that is difficult to transmit sexually, yet it spreads quickly among people whose sexual behavior is similar to that of people everywhere. The question is still 'why Africa, why Africans'? The industry needs to answer that question.

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

Ugandan Politicians Blame Gays for Loss of Funding; Media Obediently Follows

Uganda's Daily Vision claims that the "Global Fund [to fight HIV.AIDS, TB and malaria is withholding] Shs700b for ARV Treatment Over Gay Rights". There are plenty of things to criticize the fund for, but this article is just one of many that are really about African and Western politicians trying to use the issue of homosexuality and homophobia to drive their own agenda, whatever they may be.

There are several reasons why some of the funding Uganda applied for is being withheld. The government being "harsh on sexual minorities" is only a minor reason in a minor category of reasons. The rights of minorities are not derailing the fight against HIV, as the Ugandan AIDS control manager Dr Zainabl Akol claims. Rather, their rights are being used as a pawn, along with funding for HIV, HIV positive people and various other vulnerable minorities, in a complicated game for power and wealth.

One of the main reasons the Global Fund is withholding most of the Round 10 funding is because Uganda hasn't yet spent nearly 90% of the money they received in Round 7. In fact, despite receiving larger amounts of money than some countries with more serious HIV epidemics, Uganda has only managed to get a relatively small percentage of HIV positive people on antiretroviral treatment. Despite years of media praise, Uganda has done little to understand or control its HIV epidemic.

There are several other reasons why the Global Fund and other donors might withhold funding, in addition to their apparent inability to spend much of what they receive and to account for much of what they spend. For example, an article in the Uganda Monitor reports that it is inadequacies in the country's health system that is "derailing the fight against HIV/Aids". There are chronic shortages of health personnel and health supplies. These go back a long way, pre-dating the Global Fund itself by many years.

Apparently the Ministry of Health has even blamed gay rights for the country's stagnant prevalence rates. This is ludricous. Gay rights are far more important than the political pawn that politicians see them as being, but they are not 'responsible' for Uganda's epidemic. In fact, men having sex with men accounts for a pretty small proportion of HIV transmission in African countries.

Dr Akol is right to demand that gay rights be kept separate from HIV, to the extent that lumping them together is not going to further either interests. Both issues need to be addressed, but one, HIV, is a health issue. Homosexuality is not a health issue and it is not, or should not be, a determinant of health. But nor should either be used as mere political tools.

Another reason donors are likely to reconsider funding in Uganda is corruption, financial management and low standards. These are the reasons why the Dutch government is withdrawing 14 million Euro in funding for education. The Irish and UK governments have made similar moves in East Africa in recent months. These countries may have other reasons for cutting funding that they are not revealing, of course, but the Ugandan government and others are disingenuous to suggest that any funding has been denied purely on the grounds of poor human rights, for homosexuals or any other group.

It's convenient for the Ugandan government to blame gay rights. And stupid comments like those of David Cameron about withholding aid money if Uganda and other African countries don't play ball don't help at all. But these comments really were about playing (political) ball games, not about rights. Cameron and other Western leaders don't give a damn about Africans in general, not just African gays. Heterosexual Africans should not flatter themselves so.

I contacted a media officer at the Global Fund who confirmend that there were several reasons for withholding funding, some of which were very serious. In addition to the reasons mentioned above, the Fund said that the proposal "failed to adequately address equitable access of services especially with respect to particularly vulnerable populations". This would include gay people, but does not refer to them exclusively.

Cameron, Clinton and other Western politicians are as wrong as African political leaders to use funding for HIV or anything else as a bargaining tool when human rights are at stake. But the fact that funding is being used as a bargaining tool does not mean that the Global Fund are withholding money entirely because of how Uganda deals with gay rights. Both gay rights and HIV need to be addressed, not conflated, confused or kicked around by homophobes or other kinds of bigot.

Political Smokescreens and the Corporate Barebacking of Africa

English premier David Cameron played the homosexuality card to draw attention to his current flavor of British aid to Africa, but presumably to draw attention away from the fact that the actual amount of aid is shrinking, and perhaps a few other political indiscretions. He probably wouldn't like anyone to scrutinize how much of the aid still flowing is 'ghost' aid, or just a subsidy to British industry and consultancies.

Even less would he like anyone to scrutinize how much money leaves countries like Tanzania, destined for one of those tax havens, most of which are also controlled by Britain, to swell the bulging numbered accounts of wealthy British companies. Of course, some of those companies go bust, but it's Tanzania and Tanzanians who pay the biggest price.

Now the Tanzanian premier, Mizengo Pinda, is playing the homophobia card, which could draw attention away from any number of political shenanigans. The country has "refused to accept homosexuality because the country wants to safeguard its people's moral standards". But is it 'the people's' moral standards that are in need of safeguarding? What about the moral standards of those who have soaked up millions of dollars of aid money every year for several decades?

Will the Tanzanian government ask Britain's Sun Biofuels, or David Cameron's sanctimonious government, to compensate the victims of just one of many land-grabbing operations that both governments ably (and, presumably, profitably) facilitated? Or is the moral 'threat' of homosexuality likely to cause more poverty, more starvation, more disease and more death than all the corporate thieves currently making off with the country's resources while Tanzanians starve?

Just a kilometer down the road from where I work there are cut flower production units, famous for producing cheap flowers for rich countries, with the judicious use of cheap labor, sanctioned by various nice sounding schemes, such as 'export processing zones', trade agreements, etc. A little further away there's a Tanzanite operation, famous for keeping costs low by the use of child labor.

In several regions there are gold mines and Tanzania has the third biggest gold reserves in the whole of Africa. But it's not Tanzania or Tanzanians who get the bulk of profits for these exports, it's not even Africans. There are also uranium mines, coal, natural gas and various other commodities extracted from the country with the use of favorable 'regulation', cheap labor and raw materials, but without the need to pay any more than a few percent to the Tanzanian government, no more than 3% and probably a lot less.

The smokescreen of abortion is used to hide the serious lack of health provision and appalling conditions, especially for the poorest. The smokescreen of contraception aims to hide the use of Africans as a massive market for birth control methods that are considered too dangerous to be used by non-Africans, and there's the use of illiterate and vulnerable people as cheap research fodder for drugs that are ultimately only affordable to Westerners (and sometimes to Western aid budgets).

There's even the (so-called voluntary) sterilization of African women, said to be of global benefit, because population control is the favored development paradigm for many of the best funded international NGOs. Mass male circumcision to reduce 'sexual' transmission of HIV and other diseases hides the fact that the 'global health' industry has no wish to eradicate HIV, or anything else, when it's so lucrative not to do so.

Are all those who are denying Tanzanians their rights, their wealth, their health and their lives homosexuals? Are all thieves, especially the multinational, state-sponsored ones, homosexuals? Is all the 'immorality' one finds in Tanzania so bound up with homosexuality that the issue needs to be raised in parliament and senior politicians need to 'protect' Tanzanians from these terrible threats? Politicians aside, don't Tanzanians realize who is doing the barebacking?

Zille's Rhetoric about Criminalizing Unprotected Sex is Misinformed

South African premier Helen Zille [Sorry, Premier of Western Cape!] shows a worrying level of ignorance about HIV transmission in calling for "men who have multiple sexual partners and refuse to use condoms to be charged with attempted murder." She's right that using condoms reduces the likelihood of sexual transmission of HIV, substantially. But she's wrong if she thinks that HIV is almost always transmitted sexually in South Africa and other high prevalence countries.

Leaving aside the sheer stupidity of expecting to control HIV transmission by making unprotected sex with multiple partners a crime, increased condom use, even consistent condom use, is not always associated with reduced HIV transmission. If HIV were almost always transmitted sexually, as UNAIDS and the HIV industry claim, the effect of increased condom use would be very likely to have the desired effect. But often, HIV prevalence among condom users is the same as among non-users, or even higher.

A study of data from 22 countries shows that HIV prevalence is usually higher among women than among men and higher in urban than rural areas, particularly in high prevalence African countries. Prevalence is also generally higher among the wealthier and the better educated, unlike other transmissible diseases, which tend to infect poor and less well educated people in higher numbers.

But the report is clear on the issue of condom use: use of condoms is generally associated with higher HIV prevalence, among those who use condoms at all, and even among those who use them consistently. In some cases HIV prevalence may be lower, even much lower, but in others prevalence can be much higher. This is not evidence that condoms are not effective. It could suggest that most people don't use condoms often enough. But it is also an indication that HIV may not always be transmitted sexually.

Remarkably, Zille doesn't mention male circumcision, which is another very media friendly thing to throw into a speech. But this report finds that "There appears no clear pattern of association between male circumcision and HIV prevalence - in 8 of 18 countries with data, HIV prevalence is lower among circumcised men, while in the remaining 10 countries it is higher." It is customary for reports to ignore those countries where HIV rates are higher among circumcised men.

Zille and any misguided followers she may have should also read an article showing that sexual risk behavior is generally higher among young people in the US than in South Africa, yet HIV prevalence is many times lower among young people in the US. In South Africa, prevalence among 18-24 year olds was over 10%, compared to less than 1% in the US. Yet, young people in the US become sexually active earlier than those in SA; number of lifetime partners is higher in the US; and use of condoms is lower in the US. There are often greater age differences between females and their partners in SA, but that could only account for a relatively small proportion of transmission.

That article concludes that effective HIV prevention demands an accurate perception of the spread of HIV. This is something Zille lacks. But she's not the only one. Among those also lacking an accurate perception of HIV transmission in African countries are UNAIDS, WHO, Johns Hopkins Medical School, the London School of Hygiene and Tropical Medicine and many others. She's in 'good' company, well-funded company. However, Zille's latest outburst will not reduce HIV transmission and will probably do a lot of damage to SA's HIV reduction efforts.