Sunday, December 27, 2009

Apologies for Lack of Posting

I haven't given up but I am in a place where I don't have much opportunity to use the internet. I will be back at work in early January and should have ample opportunity then. I wish readers a good holiday.


Monday, December 14, 2009

Aids Denialism Doesn't Make the Disease Go Away

There are many controversies surrounding HIV, development in general and various other things. So, writing a blog about these can attract some controversial remarks, in theory. In practice, I have received some comments but few that are controversial. When remarks have little or nothing to do with what I have posted, I delete them. If the post is clearly just an attempt to attract attention to some site, product, issue, service or person, I am also likely to delete them.

But a comment I received today, anonymous of course, purported to be about my most recent posting, which discusses levels of HIV transmission from unsafe medical practices. 'Anonymous' may have thought that in questioning certain aspects of HIV funding and the like, I am aligning myself with certain Aids sceptics, who deny that HIV causes Aids, or whatever. Whether this anonymous contributor represents or not is irrelevant; I do not agree with what the site stands for and I would not wish to have anything to do with a group of people whose only aim seems to be to further muddy these already turbid waters.

My approach to HIV in Kenya has been that of a general scientist. My interest is in the overall conditions in Kenya and how they changed as HIV arrived, spread and continues to spread. Therefore, I look at history, economics, social practices, lifestyles and many other things, in addition to medical and social science aspects of the virus. I do not have the scientific expertise to address all the details of the AliveandWell site. There are plenty of people who can do that, if they deem the content of the site worth the effort.

As for the idea that HIV and Aids were 'invented' by some wealthy people so they could make money (or even take over the world), I have never heard anything that could make such a hypothesis the least bit plausible. No doubt the AliveandWell site is teeming with such evidence, but I think I have more worthwhile things to spend my time on.

Some of the numerous 'experts' cited on the site may well have a great deal of expertise, I really can't say. Certainly, some of them seem to have lots of letters after their name. But people can make up qualifications, or pay for them. And plenty of well qualified people come out with utter rubbish that can be used by whoever wishes to shore up some rant that they like to call 'theory' or 'hypothesis'.

The anonymous poster says AliveandWell advocates 'scepticism' around HIV but the site is the work of a group of Aids denialists who encourage the use of 'alternative therapies' for HIV positive people. HIV positive people would be well advised to consider the fate of the woman who started the site, Christine Maggiore, who died of Aids, along with her infant daughter. Maggiore refused antiretroviral treatment for herself and for her daughter.

To adopt the stance that Maggiore and her followers recommend is not scepticism, it is idiocy. Some adults may wish to adopt such a stance, which is regrettable. But there is no justification for imposing such idiocy on people who are unable to defend themselves. There is enough disinformation about HIV/Aids in developing countries already without this sort of deception being peddled and I hope people who visit AliveandWell see the site for what it is.

Those are my thoughts on your wonderings, Anonymous.


Saturday, December 12, 2009

Don't Have Sex and Don't Go to the Hospital

Over the past twenty years or so, there have been a few papers pointing out that HIV transmission through unsafe medical practices, especially in Sub Saharan African countries, may be higher than previously thought. These papers don't seem to have had much impact and when modes of HIV transmission surveys have analyzed the part that such practices might have played in the current HIV pandemic, they have usually reported that heterosexual transmission is the most common, followed by things like male to male sex, intravenous drug use, commercial sex work, etc.

The possibility of unsafe medical practices playing a large part in HIV transmission is being raised again, though it is hotly disputed by some. But given the amount of guesswork involved in estimating HIV prevalence in high prevalence countries, it would not be surprising if the figures were open to question. If it were established that HIV was regularly transmitted through medical practices, it would certainly dent the widely held belief that HIV can be fought purely by trying to control people's sexual behaviour.

I and some others have long opposed the view that sexual behaviour alone can adequately explain the massive rates of HIV transmission in certain countries, compared to the relatively small rates in other countries. This is not to deny that sexual behaviour is an important factor in HIV transmission, just to question the idea that certain people in certain African countries have more sex or have more partners or whatever, than people in other countries around the world.

But unsafe medical practices would be unsurprising in a country that spends so little on health, a country that has so few properly trained medical personnel, so few hospitals, a country where the vast majority of people can't afford to go to a health professional when they are ill and who may often be better advised not to go at all.

The cries of those who claim that massive funding for HIV treatment and care is justified may be well founded, I don't know. But one thing is for sure: in the time that HIV treatment has been well funded, hospitals and clinics have not improved noticeably, rather, they have disimproved. Staff numbers have fallen. Disease rates have risen. All the indicators suggest that the disimprovements in health that started in the 1980s, before Aids had had much impact, have continued right up to the present, high Aids funding levels notwithstanding.

So, as the anti circumcision lobby might say, this is not a good time to start mass male circumcision programmes. There may never be a good time, the case for mass male circumcision is still unconvincing, but no one in their right mind would opt for an operation on their penis or the penis of their child or relative until health services have been improved. People need to be confident that they will get better in hospital, not worse. Children in Swaziland whose mothers are HIV negative and who had attended hospitals and clinics a lot were found to be most likely to be HIV positive. Similar studies have been carried out in other African countries.

Whether you are going to a clinic or hospital for HIV related services or anything else, you are in danger of suffering from unsafe medical practices. The health service in Kenya is on its knees. Expensive HIV treatment or circumcision programmes either need to have their own infrastructure built from the ground up, which seems highly inefficient, or they have to wait until health services are built up in their entirety.

Kenyan's are still waiting for their health service to be rebuilt. The circumcision programmes have stalled, thankfully, some would say. And the HIV treatment campaigns are seriously hampered by the condition of the country's health services. Indeed, antiretroviral treatment is probably also hampered by the low levels of health in the population, but who is going to notice that? There just aren't enough health professionals to bear witness to the chaos that exists.

The whole issue is a reminder of how little is known about the true nature of different HIV epidemics in different countries. Many of the figures that are used to shape the various approaches to the disease are pure guesswork and interpretations are often strongly shaped by influences that have little to do with science or even reason, for example politics, religions and 'morality'.

A sensible conclusion to draw from warnings about the safety of medical procedures would be to spend more money on health infrastructure and especially on training more health personnel. More money is probably need for HIV specifically, but it will be money thrown down the drain until health infrastructure has been improved.


Thursday, December 10, 2009

The One Trick Pony That Can't Defy Gravity

When debates become polarized there can be a danger that neither side can accurately characterize the view of their opponent. Thus, Gregg Gonsalves of the International Treatment Preparedness Coalition characterizes a particular view as the 'Aids backlash' and lumps together a number of views that may not even be held by any particular person or group. He characterizes the backlash thus:

The belief that "the fight against AIDS has misdirected our energies towards broader goals in health and development; the provision of antiretroviral therapy is a folly, it's too expensive and isn't worth the money to continue its expansion; efforts against AIDS are destroying health systems and promoting unnecessary deaths from other simpler-to-treat diseases and conditions such as childhood diarrhea".

Personally I think there is probably not enough money put into the fight against Aids and that much of that money is not being used very well. In particular, I think too little of the money is being spent on prevention and almost all of that is not being used very well. True, it took some time for the international community to face the threat that Aids presented but when they did face it, they came up with a level of funding that has never been matched by campaigns against other diseases or disease groups (such as sexually transmitted infections, water borne diseases, etc).

I don't think the provision of antiretroviral therapy (ART) is a folly and I don't think people who hold the sort of sceptical view I've expressed in the last paragraph necessarily do either. The fact that there are many more people becoming infected than there are being put on ART is not an argument to reduce ART programmes, rather, it is an argument for finding out why HIV prevention is being ignored and rectifying this situation urgently. There is little point in spending nothing on people until they become infected with an incurable illness if something could be done to prevent them from becoming infected.

But also, there is little point in treating people for HIV and leaving them to die of something else. There are many preventable and treatable diseases that are killing people, including people who are HIV positive. I think that this is, in part, because of poor health facilities and services and an acute shortage of personnel. But also, there is a lack of funding that goes back several decades.

I am in complete agreement with Gonsalves when he points out that poor health services are not a result of the Aids pandemic. This is clearly true in Kenya and many other developing countries, where poor health services date back to the early 1980s, when Aids existed but hadn't been identified and certainly hadn't even begun to wreak the havoc that came later. Aids didn't help these ailing health services and certainly decimated the health workforce, as well as the workforce as a whole. But in short, Aids was just another nail in the coffin for public services in general, not just health.

I sympathize with Gonsalves to some extent, but when is money going to be spent on HIV prevention programmes that work, as opposed to programmes that promote purely political (including religious and pseudo-religious) ends? When is money going to be spent on the things that concern the most people, the many diseases and social problems that most people face? I needn't list the diseases or even the problems, Gonsalves would be more aware of them than most.

Some of the people that Gonsalves may gloss over as the 'Aids backlash' wonder how HIV positive people will benefit from a one trick pony health programme that can give them ART but nothing much else, perhaps not even the food they need to be able to take the antiretroviral drugs. They wonder why HIV positive people with certain diseases are more worthy of treatment than those who are dying of the very same easily preventable and treatable diseases. They wonder why those who are at risk of becoming infected with HIV are not entitled to very much, but if they become infected, they may receive a great deal.

But, more importantly, I think: what kind of HIV programmes can be implemented successfully in countries that have inadequate health services, along with poor standards of education, hardly any social services, very little infrastructure, lack of political leadership, governance, legal systems and levels of equality that would be required for these very expensive programmes to work? Even one trick ponies can't work without any solid foundation, as the Aids one trick pony amply demonstrates.


Friday, December 4, 2009

Foundations for HIV Prevention

I rarely come across articles criticizing HIV prevention programmes for their lack of success, but apparently a contributor to the Social Aspects of HIV/AIDS Research Alliance conference this year draws attention to the fact that many 'prevention' interventions were implemented without ever being tried. He may have gone on to say that ones that were tried and found to be useless continue to attract most prevention funding, but I wasn't at the conference.

Professor Geoff Setswe is right that HIV took some time to be recognised and had already infected many people before the most appropriate methods of preventing its spread had been investigated. But more than 25 years later, prevention programmes continue to be rolled out that are untested or that are tested but found to have little or no benefit. But no one is counting bodies when there is money to be made.

It's easy to blame health and other social problems on the global economic crisis now, but that wasn't the problem just over a year ago. In Kenya, since the 1980s, one excuse after another has been blamed on the lack of progress in education, health and other areas. If it wasn't economic, it was oil or food or political or environmental and if it wasn't a crisis it was a disaster. The HIV pandemic itself is just one of those many 'disasters' or 'crises'.

But poor health in Kenya is not a disaster, nor is it a short term crisis. Health services have been reduced in Kenya at least since the early 1980s, when the Moi government depended on loans from international financial institutions to prop up his form of democracy. These institutions funded him in return for his agreement to cut spending on social services and the public sector in general. It seems unlikely he or his colleagues (who overlap considerably with the present administration) were particularly worried about the idea of reducing public spending.

Health service spending in Kenya is now minimal (as are spending on education and other social services). Health infrastructure needs to be built from the ground up, more or less. Most people don't go to hospitals or clinics and many who do fare worse than they would have if they had stayed at home. It's little wonder that HIV was transmitted rapidly in Kenya during the 1980s and continues to spread today, despite the hundreds of millions of dollars spent on the disease. There are still far more people being newly infected than receiving treatment, though a lot more money is spent on treatment.

Fine, Professor Setswe, clinical trials are not always appropriate for testing social and behavioural interventions. But are clinical trials needed to show that starving people need food, that those suffering from malnutrition need proper nourishment, that poor people need support, that sick people, whatever they are suffering from, need medical attention, that those without adequate supplies of water die of thirst or water borne diseases? And the list goes on. Those who pigheadedly continue to talk about how difficult HIV is to prevent seem to be uninterested in what those in high HIV prevalence countries really suffer from.

HIV is a real disease. Those suffering from it need treatment and care. Those who are in danger of becoming infected need to be protected from it or to be enabled to protect themselves from it. But most people will get up in the morning and have food, water, work, school fees, day to day health and many other things on their minds. And in all the time that HIV has been around, these other concerns have been largely deprived of attention and funding.

Finally, mass male circumcision is mentioned as a possible HIV prevention method that is supported by a lot of evidence but has been held up for various reasons. Perhaps one of the reasons that circumcision has been held up is because health services in Kenya and other countries who were tricked by those same international financial institutions have been reduced to the extent that it is not possible to roll out any kind of mass health programme. Some of the HIV programmes that were rolled out failed because infrastructure, education, health and many other areas have been so underfunded for so long.

The same article mentions a Dr Ntanganira, who says that "We know what works". But the article doesn't say what works, unfortunately.


Tuesday, December 1, 2009

The Aids Industry Sure Knows How to Blow its Own Trumpet

Yesterday was World Aids Day again and in Kenya you couldn't miss the copious amounts of advertising, bunting, leafleting, t-shirts, sun visors and other paraphernalia of the industry. High and not so high officials were out in strength to collect their per diem, without which, presumably, nothing important could happen. There were the mobile testing clinics in areas that already have static testing clinics and millions and millions of condoms distributed.

For all it's faults, the Aids industry has published some figures that certainly look good. Botswana, which has one of the worst HIV epidemics in the world, has the highest percentage in any African country of people on antiretroviral therapy (ART), the highest rates of HIV testing and the highest number of women on ART to prevent mother to child transmission (PMTCT). They also have the third highest percentage of children on ART.

Over several decades, the campaigns to recognise the rights of HIV positive people to receive treatment have been successful in a lot of countries. In many developing countries, a sizable percentage of HIV positive people in need of treatment are on treatment. In the West, very few babies born to HIV positive mothers are themselves HIV positive. Indeed, the percentage of HIV positive babies born to HIV positive mothers is declining in a number of developing countries too and should be relatively low by now in a country like Botswana, where such a high percentage of HIV positive mothers are receiving PMTCT.

But rights seem to be most commonly recognised for those who are already infected with HIV. If you read various developing country HIV strategic plans (which are curiously similar, despite the epidemics being very different in quality), you will notice that the word 'rights' is rarely used except in relation to HIV positive people, mainly in relation to access to treatment. The rights of those who are not yet HIV positive, and that's most people, are rarely mentioned. Yet they have a right to the things that will ensure that they remain HIV negative.

Of course, it is hard to quantify the effects of the various HIV prevention programmes that have been rolled out in Kenya and other African countryies. Most of them were run by wealthy organisations who could afford the 'research' and publicity that would make them look very successful. The reality is that very little is known about preventing HIV and, beneath the hype, few programmes have been truly successful.

I would be the first one to admit that the very idea of cutting HIV transmission is fraught with difficulties. Many things have been tried, some of them perhaps even well thought out. But in the end, there is very little money to be made out of prevention and therefore very little money put into it. Condom distribution is an exception, but where there is little or no health or science education, let alone sexual and reproductive health education, condoms haven't really taken off that well. You may have heard otherwise but there are good commercial reasons for that.

The problem with the majority of the prevention programmes that have received some of the relatively small amount of money that is available for HIV prevention is abstinence. Most programmes relied on the idea that if people would just abstain from sex, they would not be likely to be infected. The more liberal advocated abstinence until marriage, until it was noticed that more and more people are becoming infected by their spouse. But various programmes were cobbled together that, one way or another, advocated abstinence or what amounts to abstinence. People didn't abstain and most of them won't. This is not something peculiar about developing countries. Abstinence campaigns have failed where ever they have been tried.

The reason I mention the rights of people who are HIV negative is that many of them will, sooner or later, become infected with HIV because one or several of their rights are presently being denied. People, whether adults, children, male or female, have a right to health and a right to treatment when they are sick. Yet more people in Kenya and other developing countries are dying of easily treatable and curable diseases than are dying of Aids.

Children have a right to a decent education and part of that should include levels of health and science education that should give them the prerequisites to attain enough understanding of sex, sexuality and reproductive health to avoid becoming infected with HIV or other sexually transmitted diseases and to avoid unplanned pregnancies. In a word, people need education to lead healthy lives.

People have a right to a decent standard of living for themselves and their children, they have a right to adequate food and nutrition, they have a right to good standards of governance and security, water, sanitation, infrastructure and many other things. They have a right to a legal system that protects them from harm and persecution and the like. Women need to be given the same rights as men, in the workplace, in the economy, in education, in health and everywhere else. Men who have sex with men, intravenous drug users and commercial sex workers need their rights protected.

It is the denial of the sorts of rights mentioned above, along with various other rights, that leaves people vulnerable to becoming infected with HIV and suffering many other serious consequences. People in developing countries who are suffering from HIV now, and those who have died of it, were likely denied one or several of their rights. HIV is not transmitted in isolation from people's circumstances, from the conditions in which they live and work.

Those who are HIV positive and those who are HIV negative are equally entitled to their rights, though skewed funding for Aids would suggest that this is not the case. In order to avoid transmitting HIV to others and in order to remain HIV negative, everybody's rights need to be protected. In short, everyone is entitled to these rights and without them, the treatment and care programmes for people who are HIV positive will be, to a large extent, in vain; the half hearted prevention efforts will also be in vain.

Prevention has proved to be a slippery fish. But treatment and care for one disease in isolation from all the other things people can and do suffer from has also been less successful than it should have been. There is little point in treating one incurable disease and ignoring the many others that are more easily treatable and often even curable. But that is what's happening. The Aids industry is just too rich and powerful to allow people to know that.