Friday, December 31, 2010

For the New Year; Less Talk About Sex, More About Unsafe Healthcare

Doug Kirby is only one in a long list of people to speculate about Uganda's 'success' in reducing HIV transmission from relatively high rates in the 80s and 90s to relatively low but steady rates in the 2000s.

As he and others wonder what happened, some sceptics have doubted if Uganda did anything in particular and have even suggested that the epidemic may have arrived, spread and declined, almost entirely independently of anything that was done to prevent it.

A lot is made of the so called ABC program (Abstinence, Be faithful, use a Condom), as if all HIV is transmitted sexually. It isn't, it never was and at one time, even in Uganda, this important fact was acknowledged.

Anyhow, no one working in Uganda in the 1980s and 1990s remembers the term ABC, it appears to have been invented later, and not even in Uganda. Also, no one seems to remember the sheer idiocy of an 'abstinence only' program, either in name or in nature. But let's indulge in Kirby's apparent sincerity as he speaks for the majority of HIV researchers.

The notion of abstinence is inherently vague; is it to abstain from sex for ever, to abstain until marriage (one of the senses used by Demographic and Health Surveys), to abstain for a period (such as during the day during the course of Ramadam), to abstain from certain kinds of sex, to abstain from sex with one's main partner, to abstain from sex with those other than one's main partner, to not have had sex for the past week/month/year, etc.

Knowledge of ABC as a whole is also deceptive because it clearly doesn't lead to the expected behaviors and HIV rates are often higher among those who appear to have higher levels of knowledge about 'safe' sex. In Tanzania, for example, knowledge is higher among wealthier, better educated, urban dwelling, 20-39 year olds, but so are HIV rates.

Indeed it has never been shown that people with the 'requisite' knowledge are less likely to be infected. In fact, those with the requisite knowledge appear to be more likely to be infected. This is not to suggest that knowing what they are taught about HIV puts people at higher risk. I am suggesting that this 'knowledge' is just not particularly relevant and it leaves out things people really need to know, such as details of non-sexual risks and how to avoid them.

None of these 'methods' of reducing the chances of being infected with HIV really amount to much. So they couldn't explain how Uganda's epidemic declined. They might have contributed a little but it's impossible to say how much. They are not really testable. They are simply based on the incorrect assumption that almost all HIV is tranmsitted sexually in African countries, so if people don't have sex, they won't be infected.

Education is a right that need have no connection with HIV or any other disease. As it happens, better educated people usually enjoy better health. But there is no useful list of causal connections between education and health. Sex, sexuality and reproduction education are also rights, but a reasonable level of general education is a prerequisite in order for people to be well educated about these issues.

Lack of knowledge about sex, sexuality and reproduction is likely to cause many problems. People growing up in ignorance of such issues face many risks, such as sexually transmitted infections, unwanted pregnancies and possibly emotional and psychological problems.

But when it comes to HIV, this area of education is not enough. People also need to know about non-sexual risks, faced in cosmetic and hairdressing facilities, tattoo and body piercing parlors, traditional healing and related contexts and, most importantly, in health and medical facilities.

If people don't know about non-sexual risks, they will not know how to take steps to avoid them. They will not know enough to check if the hairdresser sterilizes their equipment adequately, that some processes are better avoided if their safety is unknown and that in underfunded, understaffed, undersupplied health facilities, you have to check that the equipment being used is sterile, whether that equipment is new and unused or reused but properly sterilized.

If none of these measures are taken regarding non-sexual HIV transmission, no number of condoms delivered, sexual experiences foregone or anything else will guarantee protection against HIV (and other viruses, such as hepatitis B and C).

Uganda may have taken some of these precautions against non-sexual HIV transmission in the early days of the epidemic. Doug Kirby doesn't mention them much, but that doesn't mean they didn't occur. But the health access situation in Uganda is quite similar to those in Tanzania and Kenya. Most people don't have access to health services and when they do, the quality is low. But as health services spread, or as people move to access health services, HIV also spreads.

In contrast, in Southern African countries, far more people can access health services. Unfortunately, those health services are also of very low quality. So the chances of being infected in health facilities is even higher in Southern African countries. Therefore, it is unlikely to be a coincidence that Southern African countries have the highest HIV rates in the world.

Of course, I could be completely wrong, Perhaps UNAIDS are right that only 2-5% of HIV transmission comes from unsafe healthcare. Or WHO may be right that only 15-20% of transmission comes from unsafe healthcare. What I would like to see is proper investigation of health care facilities and a credible estimation of what proportion of HIV is being transmitted non-sexually (not just in health care facilities, but also as a result of traditional practices, cosmetic practices and anything else that may be involved).

We have been very unsuccessful in influencing sexual behavior and this lack of success may continue. But providing people with affordable and safe healthcare would not be nearly so elusive. And people have the right to know what the major non-sexual HIV risks are and how to avoid them. Up to now, Africans have been treated with utter contempt and, as a result, millions have been infected with HIV. Many have died and many more will die, despite all the money being churned into antiretroviral drugs.


Thursday, December 30, 2010

No Leap of Faith Required to Question HIV Orthodoxy, Just Honesty

Many millions of words have been dedicated to what was said to have happened in Uganda in the 1980s and 1990s that resulted in a serious HIV epidemic peaking and declining dramatically.

Well, for a start, all the high figures cited for HIV prevalence in Uganda in the early days of the epidemic are for specific groups, such as pregnant women. Prevalence for the whole sexually active population at that time is rarely given and is probably not clear, even now.

Once more detailed prevalence figures were established for later periods in the epidemic, it became clear that there had long been more women infected than men. This should have resulted in questions about who infected all these women.

But HIV professionals don't ask such questions because they don't fit the 'behavioral paradigm', the view that HIV is almost always transmitted sexually in African countries (but not in non-African countries, go figure). They are content to talk about how low the prevalence figures are now, though they are nothing to boast about.

So the 'dramatic' drops in HIV prevalence, from double figures to single figures in a few years, never occurred. What drops in prevalence did occur would mostly have been down to very high death rates.

All the talk about behavior change was mostly just that, talk. Some behavior change may have occurred, probably as a result of people witnessing massive levels of sickness and death, but this would have been after incidence rates had already peaked and declined.

Why incidence rose so rapidly in the 1980s and perhaps before, and why they peaked and declined, is not clear. At least, it's not clear if you accept the behavioral paradigm. There is no evidence that 'unsafe' sexual behavior inexplicably increased in the late 1970s and early 1980s and then declined again before the end of the 1980s.

Unless there was some identifiable change in levels of sexual behavior that led to barely credible feats of promiscuity in Uganda some years before the HIV epidemic peaked, it remains a mystery why the epidemic ever infected so many people.

And it's not just in Uganda that there remains this mystery. The massive rise in promiscuity that occurred there must have taken place a few years earlier in Western Equatorial countries, where HIV had been a less serious epidemic for even longer. Sometimes it becomes more of a mystery to explain why some places in Africa never experienced this strange phenomenon.

Anyhow, this totally unrecorded rise in promiscuity must have taken place in Tanzania a bit later than it did in Uganda. In Kenya it must have taken place a few years later still, because incidence there increased and peaked a few years later.

Then Southern African countries experienced this same unrecorded and mysterious increase in promiscuity that barely affected Western and Northern African countries at all.

Outside of African countries, no wave of promiscuity was needed to explain serious HIV epidemics because this virus which is said to be spread predominantly through sexual behavior in African countries is accepted as a virus that spreads most efficiently through unsafe injections among intravenous drug users and among men who have sex with men.

That's the way the behavioral paradigm goes, anyhow. It claims that Africans have inordinate amounts of unsafe sex and that different African countries at different times experienced enormous increases in unsafe sexual behavior that 'explain' the resulting difference between low HIV prevalence countries such as Senegal, medium prevalence countries such as Uganda and high prevalence countries such as Swaziland.

The original question about what 'happened' in Uganda, prevention interventions and the like, was if the same thing could occur in other countries. Well, the same thing didn't occur in other countries, according to the official story. Outside of Uganda, most governments denied the existence of HIV or ignored the epidemic. Very few leaders were in any way open about HIV in their own country.

Despite this, most medium and high prevalence countries have followed a similar epidemic pattern to that found in Uganda: HIV arrived and spread rapidly, peaked and declined. Since the initial decline, infection rates have continued at a relatively low rate, as have death rates.

But all this appears to have occurred independently of anything the respective governments did or didn't do. Whether governments reacted to the epidemic or ignored it, roughly the same pattern resulted.

So, the two things the behavioral paradigm encourages us to believe are different but not wholly compatible: firstly, the paradigm paints Africans as grossly promiscuous and unconcerned about their own health or the health of their children.

And secondly, when called upon to explain the original increase, peak and deline in HIV infections, the orthodoxy makes up a story of a promiscuous people (because all Africans are the same under this paradigm) becoming even more promiscuous, because of urbanization or some other factor that may have little or no explanatory power.

We are then left with the problem that the Senegalese and people from various other low prevalence countries have never really been particularly promiscuous. And even some tribes in a country like Kenya have less sex than others. The Luo, with high HIV prevalence, according to the paradigm, must have a lot more 'unsafe' sex than the Somalis, who have low HIV prevalence (despite having the highest fertility rates in the country).

If we accept a sexual explanation and follow the argument through, we still have to tie ourselves in knots. What gave rise to an epidemic of promiscuity that eventually resulted in a serious HIV epidemic in only some parts of some countries?

It's way past the time for HIV 'experts' to accept the fact that HIV is spread both sexually and non-sexually and that when it can't be adequately explained by normal sexual behavior, found in every country in the world, that something other than sexual behavior must be involved.

No leap of faith is required to question the HIV orthodoxy; all that is required is a bit of honesty and integrity. I don't think that's too much to ask but, we're still waiting.


Wednesday, December 29, 2010

Academics Can Not Be Trusted to Tell the Truth About HIV

Until HIV academics lose their obsession with sex, HIV epidemic patterns will continue to be misrepresented, giving instead a seriously biased picture. This bias does not just have consequences for academic papers; it translates into biased policy, biased intervention programs and biased reporting. As a result, HIV continues to infect and kill millions of people, unchecked by those who are supposed be best placed to control the epidemic.

Doug Kirby had an article a couple of years ago entitled 'Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence'. The 'conclusion' that sexual behavior was behind all African epidemics is not really the issue here; that is something of a reflex.

The issue is about 'confirmation' from 'multiple' sources of evidence. In a nutshell, the paper does not lend confirmation to the behavioral paradigm, the belief that HIV is almost always transmitted sexually in African countries. Nor are the 'multiple' sources of evidence wholly independent of each other.

The fact that adherents of the behavioral paradigm have persuaded most of those working in the field to sing from the same hymn sheet does not have the effect of strengthening the evidence.

The reason all this talk about sexual behavior in Uganda does not confirm the behavioral paradigm, during the 1980s or any during other period,  is that it simply ignores non-sexual HIV transmission. People are rarely asked questions about anything but their sexual behavior, knowledge and attitudes. And yet it is thereby concluded that only sexual behavior, knowledge and attitudes are relevant.

Kirby's article even mentions that people were "more careful in general, avoided people with AIDS, were careful with blood, were careful with injections, etc." This glosses over what may be useful evidence about non-sexual HIV transmission.

But this was in 1989, when it was still acceptable to mention non-sexual HIV transmission. Not long after that it ceased to be acceptable. People were rarely asked about anything but their sexual behavior, knowledge and attitudes. Therefore, there is little data available. And this article, like so many others, skates over anything that is not about sex.

In fact, Kirby's point seems to contradict his thesis: the majority of people had made no change in their behavior or merely intended to make changes. Only a small minority had actually made changes. Not only is there little evidence that sexual behavior change was likely to have any impact on the epidemic, that relevant behavior change actually occurred and had any impact on the epidemic, or that it will ever have a substantial impact on the epidemic anywhere, but the whole paper assumes the truth of its conclusions, despite the paucity of evidence.

As for the 'multiple' sources of evidence, newspaper articles published whatever the going story was at the time. This would have been influenced by a mixture of half-baked policies, misinformed pronouncements and a handful of 'academic' papers that happened to suit the current buzz around AIDS.

The focus groups and other qualitative data is likely to have been heavily influenced by the same media buzz. In other words, most people would have been remembering what they heard, read and talked about as much as by what was happening, which was and continues to be largely misunderstood.

'Models' of what was happening, especially when the figures came from ante-natal clinics and STI (sexually transmitted infection) clinics tend to be somewhat circular. These facilities would have had very high figures for HIV infection because they were established to deal with the epidemic. In addition to the fact that figures from these facilities could not be generalized (although they were and sometimes continue to be), it is likely that many people were infected in health facilities through unsafe medical procedures.

It is not much talked about now and when it is, it is usually talked about as if it doesn't happen any more. But in the eighties especially, and sometimes in the 1990s, HIV was not just seen as an STI. It was also seen as a virus that was spread through various medical procedures. Blood transfusions were one of the most prominent medical procedures because the probability of transmission through contaminated blood was extremely high.

But most people don't receive blood transfusions. What most people do receive are injections and various other procedures which carry a high risk of transmission if equipment is contaminated. The risk is nowhere near as high as it is with transfusions but it is orders of magnitude higher than it is for sexual transmission, the probability of which is quite low per sex act.

Articles like Kirby's simply leave non-sexual transmission out of the picture. What proportion of various country epidemics are down to non-sexual transmission is unknown. What is known about sexual transmission is impossible to evaluate because we have little idea what proportion of overall transmission it accounts for.

Indeed, it is no secret that sexual behavior can not really explain why some countries and parts of countries have inordinately high HIV prevalence. But those who take the behavioral paradigm as their starting point still make up the majority among HIV academics.

Exactly why academics have continued to present this biased view of HIV epidemics is really not clear. Surely the desire to appear to be right, now that thay have been painting themselves into this corner for so long, cannot explain why so many millions of people are being condemned to avoidable sickness and death? But that doesn't really solve the problem of how to change this situation.

It appears that academics can not be trusted to tell the truth. They are not content to research, analyze and report unless their writings conform to what amounts to a dangerously biased orthodoxy. Will they continue to lie until their consequent irrelevance becomes widely recognised? Or will we simply let them get on with not doing their job while innocent people, women, men and children, suffer the consequences?

Kirby claims to have no competing interests but some of the funding was supplied by UNAIDS, that great bastion of the behavioral paradigm and attacker of anyone who suggests that HIV is not all about sex. Kirby also mentions help from Daniel Halperin, which would also have ensured that the conclusion wouldn't shock or offend anyone in the orthodox camp by reducing bias or acknowledging any of the more serious limitations of the study.


Tuesday, December 21, 2010

Anal Sex Can Be Dangerous But Likely to Be Ignored in African Countries

Ostensibly, Kenya's Modes of Transmission Survey aims to establish what factors are driving the country's HIV epidemic. I say 'ostensibly' because there are two glaring figures that cast doubt on all the other figures. The first is the figure for men having sex with men (MSM), which is lumped together with HIV in prison populations. The second is the figure for health facility related infections, which, at 2.5%, is extremely low compared to WHO figures for unsafe injections alone, which could be 8 or 9 times higher.

However, I've mentioned health facility related infections on many occasions, so I'll concentrate on MSM on this occasion. Prison populations would be at risk of HIV transmission through heterosexual sex, like everyone else. But more importantly, those infected through intravenous drug use are more likely to be in prison, given that the practice is a crime. Those in prisons may also be more likely to be infected through tattooing, taking blood oaths and, arguably, through unsafe healthcare.

That puts the provenance of one third of Kenya's HIV infections in serious doubt, the proportion either claimed to be or suspected of being from MSM and/or unsafe healthcare. The fact that another half of infections are said to come from relatively low risk sex makes the Survey seem like a pretty blunt instrument. But anal sex, whether homosexual or heterosexual, is known to be high risk sex. And, despite the need to target MSM, it is completely unclear what proportion of people engage in this practice.

What is clear is that MSM (and others engaging in anal sex) are not targeted particularly well. For a start, the practice is illegal and the country's Prime Minister Odinga recently called for the arrest and imprisonment of all practicing homosexuals. As a result of such attitudes and outbursts, who Kenya's MSM are and where they are is not only unclear, but likely to remain so.

Given these circumstances, it's not surprising that a survey of male sex workers providing services to men in Mombasa found that 35% of respondents did not know that HIV can be transmitted through anal sex. It is therefore unlikely that heterosexuals are aware that anal sex is an efficient transmitter of HIV, regardless of the gender of those involved, or that it is far more dangerous for the receptive partner.

Just over 20% knew that a water based lubricant should be used with latex condoms and again, it seems unlikely that heterosexuals engaging in anal sex are any more likely to know this. They are probably less likely to be targeted with correct information, despite evidence that many people think that anal sex does not transmit HIV at all. Even if people knew, they would be unlikely to find an appropriate lubricant easily. Many are said to resort to household products, some of which are more likely to weaken condoms than reduce the risk in any way.

Odinga, the Modes of Transmission Survey and the current calls for homosexuality to be punished even more severely than it already is suggests that Kenya is more interested in pointing the finger than in dealing with serious problems that are not just going to disappear. After frittering away tens of millions of dollars of donated HIV funds, Kenya was refused funding on several occasions.

And now, despite the continued lack of transparency, the Global Fund has decided to give the country nearly 40 billion Kenyan shillings in funding. The Global Fund, going by its title, is earmarked for HIV, TB and malaria, rather than for health systems or infrastructure. So its effects are going to be limited.

But ignoring risky sex (along with most non-sexual modes of transmission) and concentrating mainly on those who don't engage in risky sex seems like completely the wrong way to go about things. For a start, let's stop pretending that the majority of people are at risk of being infected sexually and find out why people engaging in low risk sex seem to be the largest contributor to Kenya's HIV epidemic.

The least we can ask of the Global Fund, then, is that even if they are not prepared to spend anything on non-sexually transmitted HIV, they should seriously consider targeting those who are genuinely at risk of sexual transmission: MSM and sex workers, and perhaps some others.


Monday, December 20, 2010

Mass Male Circumcision; a Motiveless Crime?

Some of the staunchest advocates of mass male circumcision (MMC) as a means of protecting men from infection with HIV, and even herpes simplex virus (HSV-2), have found that the operation is unlikely to have very much effect. Many years of 'research' has been carried out on how to ram MMC down the throats of male members of the Luo tribe in Kenya's Nyanza province.

There has never been much convincing evidence that MMC would be effective in the first place, but circumcision advocates don't seem bothered by that. And the more certain it is that MMC will not do any good, that it may even do a lot of harm, the more enthusiastic advocates become. In fact, this data was collected before large numbers of Luo men were circumcised (or were claimed to have been circumcised, actual numbers are hard to come by).

This particular piece of research found extremely high HIV (and HSV-2) prevalence; 17% among males and 26% among females. Rates for both viruses were similar for circumcised and uncircumcised males. Rates like this contrast strongly with those found in the rest of Kenya, with national prevalence standing at 6 or 7%. The second highest male prevalence rates, found among the Maasai, are about half those found among the Luo.

Those promoting circumcision have not explained the huge differences between tribes in HIV prevalence rates. There are even anomalies such as the extremely high rates among female Luhyas (12%) when rates among male Luhyas are relatively low (1.9%).

In short, HIV rates are high among the Luo, many of whom are not circumcised. But circumcised Luos have equally high HIV rates. So why insist that lack of circumcision explains why members of this tribe have such high HIV rates? And why insist on MMC when this is obviously not going have much positive impact on transmission rates and may have a negative impact?

The research also shows that people have been hoodwinked by the hype that MMC has received. Men think they are less likely to be infected with HIV if they are circumcised and women think circumcised men are less likely to be HIV positive. What most people don't seem to realize is that the 60% protection that circumcision arguably imparts requires that condoms are also used.

But if condoms are used, uncircumcised men are also protected. The operation is not only possibly useless and potentially harmful but it is also completely unnecessary, even for those who think it may protect them. They could just use condoms.

The research notes that "Uncircumcised men who preferred circumcision were more likely to report inconsistent or no condom use, describe sexual partners as ‘casual’, and report current/recent genital ulcerations" and that these men may 'self-select' for an MMC program. The authors see this as a good thing but I would question their analysis of this finding.

Other research suggests that many men and women think male circumcision will protect them from HIV and that they don't need to use condoms. Even people who can give the 'correct' answers to questions about HIV and circumcision, as a result of having them drummed into their heads, seem a little too anxious to embrace an intervention which is not well understood (by them or anyone else).

Recommending, and even carrying out, an operation that is clearly unnecessary and possibly hazardous sounds distinctly unethical. Failing to establish why HIV transmission rates are so high among the Luo after so many years of research is bad enough, but it certainly does not support the contention that what Luos need is MMC. Having said all that, I am unable to supply a motive for the behavior of circumcision advocates and would love to hear from anyone who could do so.


Thursday, December 16, 2010

Circumcision Could Increase HIV Transmission But Strategy Will Continue

With all the publicity about mass male circumcision (MMC) and the great part it could play in reducing HIV transmission in high prevalence countries, little is said about the likely effect of such a strategy on women. After all, it is women who are most likely to be infected, women who are most susceptible, women who are said to have the least power in relationships, etc.

Well, something like a report, but without the balance you might expect, has been published on MMC and women. The fact that AVAC (a pharmaceutical industry front) and the Gates Foundation are involved means that, whatever the report finds, it will be used to support MMC. It certainly won't be used to slow things down and consider whether this is the right way to go about it.

The report finds that women lack detailed factual information about how MMC is supposed to play a part in HIV prevention. This is not surprising, considering the heavily biased reporting on the technique. The average of '60% protection' claimed on the basis of three brief trials involving small numbers of people doesn't stand up to scrutiny.

The fact is, it is not clear how circumcision protects men against being infected with HIV, if it really does protect them. What is clear is that HIV prevalence is only lower among circumcised men in some countries. In other countries, HIV prevalence is higher among circumcised men. How that problem will be resolved is not clear.

Also, MMC does not directly protect women at all. It could be argued that if fewer men are HIV positive, fewer women will become infected, so they are indirectly protected. But, in addition to the lack of clarity about how much it protects men, it is not clear than most women are infected with HIV through sexual intercourse.

Many HIV positive women have a HIV negative husband, yet many of these women only have one partner. Even if their husband is as sexually promiscuous as African men are said to be, something there is no evidence for, their husband didn't infect them if they are not themselves infected. If some people are not being infected sexually, circumcision will have no benefit for them.

But are circumcised men who are HIV positive less likely to transmit HIV to women, or more likely? There is evidence that they are more likely. Many HIV positive men are circumcised and many more will become infected. It needs to be clear whether MMC will also reduce transmission by men who are already infected or who have yet to become infected.

The 'report' finds that many women think they are directly protected from HIV transmission if their partner is circumcised. But many men also believe that they are protected and they will argue that they don't need to use other precautions, such as condoms. Even the circumcision trials advised those taking part to use condoms. Circumcision, even according to its most ardent advocates, does not guarantee against infection and the 60% figure refers to circumcision in conjunction with consistent and correct condom use.

When it comes to negotiating 'safe' sex, it will be even harder for women to negotiate for condom use if the man, and perhaps even the woman, think that circumcision obviates the need for condoms. And even if the man doesn't believe that he can safely have unprotected sex, he could still use the claim to support his case, if he wished to. If people associate circumcision with a lower likelihood of being infected with HIV, the operation could put women in more danger from unprotected sex, rather than less.

There is also the problem of circumcision performed in a non-clinical setting, which carries high risks of various kinds of infection, including HIV. Many men have been and many will continue to be circumcised outside of clinical settings, where the may not be tested, before or after, and the risk of transmission under such circumstances may be increased as a result of circumcision.

Some have even conflated male circumcision with female genital mutilation(FGM), whether inadvertently or otherwise. Even the promoters of MMC have not tried to promote FGM, but there are those who believe, or wish to believe, that it also reduces HIV transmission.

This is where things become more mystifying. Areas with high rates of FGM tend to have low HIV prevalence (such as the Kuria and Kisii tribes in Nyanza province). And some areas with low FGM rates have high HIV prevalence (such as the Luo tribe, also in Nyanza).

This is not because FGM reduces transmission, although the reason for the correlation is not clear. In other words, even if there is a correlation between high rates of FGM and low HIV prevalence, most people wouldn't claim that there is a causal connection between the two phenomena.

But then, advocating MMC on the basis of similar correlations seems particularly foolish. There is speculation about why removing the foreskin could possibly give some protection but there has been no explanation of exactly how this might work. And the assumed process is not just unclear, it is not even consistent if circumcised men in some areas show higher prevalence rates than uncircumcised men.

This report makes it clear that, despite evidence against the claimed benefits of MMC, including the finding that it will increase the vulnerability of women, MMC will go ahead. The findings of the report are profound, but not as profound as the stupidity of continuing with MMC under the guise of reducing HIV transmission. It is difficult to comprehend, but advocates of MMC have always intended to procede with the intervention, regardless of the consequences. Amazingly, this report confirms that intention, without explaining what advocates, or anyone else, has to gain.

This report claims to be opposed to stigma and advocates dispelling myths that support stigmatizing attitudes. But an MMC strategy ony lends support to the common belief that 'promiscuous' women spread HIV. The conflation of FGM with MMC also goes back a long way and is also being used to justify this and other violent acts against women. But the almost guaranteed failure of HIV prevention strageties has never put the HIV industry off in the past, so why should it do so now?

[AVAC and the Gates Foundation are also deeply involved in the CAPRISA 004 vaginal gel trial; more on my other blog]


Monday, December 13, 2010

Is it Safe Yet to Come Out of the Condom?

Dr Joseph Sonnabend has an excellent critique of the iPrEx trial, the use of oral Truvada as pre-exposure prophylaxis (PrEP) against HIV. PrEP is the use of antiretroviral drugs in HIV negative people who are considered to be at high risk of infection. The trial achieved a 44% success rate, which is disappointing, but it's best to read Dr Sonnabend's critique if you're interested in a more balanced account of the trial than you'll find in the mainstream press or in the academic literature.

One of the many interesting points in the article, however, is not about PrEP, it's about HIV prevention interventions that aim to reduce HIV transmission by influencing people's sexual behavior. I have always objected to the view that HIV is almost entirely a result of 'unsafe' sexual behavior in African countries. So this means that I also feel a lot of behavioral interventions are not, despite claims to the contrary, contributing significantly to reductions in HIV transmission.

Dr Sonnabend argues that "If prevention education has been a failure, it’s not because it doesn’t work, but because we have not provided it well enough. There has been too little and most has not been properly targeted."

It's important to note that Dr Sonnabend is not writing about Africa, he is writing about a US, urban context. But what he says about behavioral interventions not being provided well enough is, I think, true of Africa too. And it is only now that PrEP is being bandied about as the solution to the HIV pandemic that others who promoted behavioral interventions in the past are beginning to question their effectiveness.

I am not opposed to behavioral interventions per se, I just haven't heard of any that have been particularly successful in reducing HIV transmission in Africa. But I think exercising some restraint over partner choice, number of partners, unprotected sex, age of sexual debut, unplanned pregnancy and many other things, is important. I also think these measures are important regardless of whether HIV is an issue.

However, in the African context, targeting could refer to two very different issues. The first issue in African countries with high HIV prevalence, I would argue, is not that some people have a lot of 'unsafe' sex but that many people are not being infected sexually. If people being infected sexually can be targeted and can be subjected to appropriate behavioral interventions, that should reduce sexual transmission of HIV.

But as things stand, with the assumption that most HIV is transmitted sexually, there is virtually no targeting. Everyone who has sex is considered to be at risk and anyone who is infected is considered to have engaged in 'unsafe' sex. This is despite plenty of evidence that non-sexual modes of HIV transmission are contributing significantly to African epidemics. Non-sexual modes of transmission need quite different types of intervention.

You might think that those most at risk of  sexually transmitted HIV, such as sex workers and men who have sex with men, would be targeted in African countries because of their levels of sexual exposure. This a second kind of targeting issue, but these groups are almost completely ignored by HIV programming. That's unless you count the self-righteous rhetoric, which needn't cost very much.

Also in relation to behavioral interventions, Dr Sonnabend makes an observation about condoms that is missing from any of the prevention literature I have seen:

"Condoms can be a barrier to intimacy which for many is the most essential aspect of sexual intercourse, for both receptive and insertive partners. So recommending the use of condoms without acknowledging the significant obstacle they may present to a fulfilling sexual experience is a real problem. Pleasure is part of that fulfilment and for some insertive partners condoms are a significant impediment to experiencing it."

Given that condoms are the best behavioral intervention we have got, we need to be realistic about their use, which is often low among those who may be most in need of them. The three hackneyed imperatives, those to abstain, be faithful and use a condom, could all be trumped by one of the most basic and sometimes the most intense of human desires, the desire for sexual intimacy. Perhaps imperatives delivered without any authority whatsoever achieve the opposite to their intended result.

One day, it may be possible to supplement behavioral interventions with PrEP, microbicides and vaccines. But even then, it will be human behavior that determines whether this successfully prevents HIV transmission. As the iPrEx trial has shown, if people don't take the pills, they won't work. Unfortunately, the trial hasn't yet shown that if people do take the pills they do work. There's still a lot to learn about human behavior when it comes to HIV prevention interventions. The question is, will what we learn continue to be ignored?

By the way, it is not safe yet.


Saturday, December 11, 2010

Do Sick People Attend Health Facilities or Do Health Facilities Spread Disease?

A systematic review by Didier Pittet and others finds that rates of health care associated infections (HAI) are far higher in developing countries than they are in Europe and the USA. This is no great surprise, but such findings by prominent academics in a prestigious journal may make UNAIDS and others in the AIDS industry sit up and take notice for a change.

The HAI prevalence rate in developing countries was found to be 15.5 per 100 patients, more than double the rate in Europe and nearly four times the rate in the USA. In some hospital areas, such as intensive care, the rates were far higher. The report also finds that surveillance is rare and HAI rates are seriously underestimated. Developing countries simply don't have the resources to carry out such work.

However, an example of a cheap and simple surveillance exercise was carried out in Northern Tanzania in 2003. This exercise found that HAI incidence was 14.8% on the day they collected data. It also found that rates were far higher in some hospital locations, such as intensive care, surgical and even general medical wards.

The main concern of this blog is the rate of non-sexually transmitted HIV, especially the rate of blood-borne infections, that may be related to unsafe health care. According to SafePoint Trust, as many as 260,000 HIV infections every year result from unsafe injections (which is only one area of unsafe health care practice).

To put the WHO estimated rate of nosocomial (medical procedure related) HIV infection of over 14% in perspective, it is far higher than the rate of infection found among sex workers, sex worker clients, sex worker client partners and even men having sex with men. People attending health facilities are one of the highest risk groups in developing countries.

In addition, an estimated 1 million hepatitis C (over 30% of all cases) and 21 million hepatitis B infections (40% of all cases) result from unsafe injections. Syringes, designed to be used only once, are reused, often without adequate sterilization. More people are killed every year by unsafe injections than by malaria.

It's not just syringes that are reused without sterilization. Catheters, ventilators, dental and other invasive equipment can all be involved in transmitting infections of various kinds.

A particular worry is HAI rates among infants and young children, which can be many times higher than those among adults. But whenever the issue of nosocomial HIV infection in children is raised, 'professional' health care commentators get in a flap about putting people in developing countries off using health facilities (this is just one small example).

However, if these facilities are as dangerous as the above report suggests, people are entitled to know the risks and take steps to avoid them. More importantly, governments in developing countries need to take action. They receive billions of dollars in donor funding to treat people for HIV. A small amount of this would ensure than hundreds of thousands of infections are avoided in the first place.

High rates of HIV transmission tend to be found in areas with health facilities. Low rates of HIV transmission tend to be found in areas where health facilities are inaccessible or non-existant. These tendencies are established by population based surveys.

The Lancet report identifies the potential determinants of HAIs as: "inadequate environmental hygienic conditions; poor infrastructure; insufficient equipment; understaffing; overcrowding; paucity of knowledge and application of basic infection-control measures; prolonged and inappropriate use of invasive devices and antibiotics; and scarcity of local and national guidelines and policies." It also notes reuse of scarce resources, such as needles and gloves.

The question is, are people flocking to health facilities because they are infected with HIV or are health facilities playing a part in transmitting HIV, and if so, to what extent? This question needs to be answered before another year passes and another 260,000 avoidable HIV infections occur.


Friday, December 10, 2010

What We Don't Know Can Hurt More Than What We Think We Know

Since HIV was first identified in the early 1980s, there have been three major trends in sub-Saharan African epidemics. The first is that about ten or more years after the virus began to spread, rates of transmission peaked and started to decline. The second is that after another ten years or so prevalence declined rapidly because of high death rates. The third is that prevalence flatlined, with deaths being replaced by new infections.

The question of why the virus started to spread rapidly in the first place has never been addressed adequately. It continues to be assumed that its spread was something to do with 'unsafe' sexual behavior, despite there being no evidence that credible levels sexual behavior could ever explain the massive transmission rates found in many countries. Nor has there been any evidence that levels of unsafe sexual behavior have ever been higher in high prevalence countries.

As to why transmission rates peaked and declined after a period, this has not been addressed either. Researchers seem to hope that no one will notice this gap in their knowledge. Not only is there no evidence that sexual behavior changed radically at around the time the virus started to spread, but nor is there evidence that some earlier increase in unsafe sexual behavior was subsequently reversed. HIV prevention programs, such as they were, didn't come along till much later and most of them had little impact.

Many countries where prevalence rates never went above 1% are seeing the same flatlining. Others are experiencing increases, including some Eastern and Central European countries, some Asian countries and some developed countries. Only those with exceptionally high rates of HVI transmission, all in Southern Africa, are seeing significant drops in prevalence. This is due to high death rates and reflects the stage that epidemics there have reached. HIV arrived in these countries relatively late.

Hordes of HIV-related papers have been published, most of them concentrating on possible links between sexual behavior and HIV rates. Some find correlations and these are held up as 'proof' that the virus is mainly transmitted sexually. Some research has noted a lack of such correlations and a lot of work has gone into trying to explain these findings away. And only a small amount of research has gone into non-sexual HIV transmission.

The lack of research into non-sexual HIV transmission is inexplicable, as is the level of contempt that the research that has been carried out appears to receive. No amount of research into sexual transmission will obviate the fact that non-sexual transmission has always played a part in the pandemic, a huge part in African countries. High correlations between levels of sexual behavior and levels of HIV prevalence are irrelevant to non-sexual transmission.

Ignoring non-sexual transmission of HIV has very serious consequences. The virus continues to be transmitted in health facilities and other places, unnecessarily and avoidably. People take risks that they don't even know are risks, such as attending an ante-natal clinic when pregnant and visiting an STI (sexually transmitted infection) clinic when in need of a sexual health checkup. No matter how vigilantly they apply all they hear about safe sex and protecting themselves against sexual transmission of HIV, this will never protect them from non-sexual transmission.

Currently, a lot of money is being poured into research into various technologies to reduce sexual transmission of HIV. These include microbicides, pills and various strategies. But much of this research will be invalid and probably unethical if it fails to factor in the possibility of non-sexual HIV transmission. The HIV pandemic may continue to flatline but it will not just go away. And there is always the possibility that the conditions, whatever they were, which resulted in rapid transmission rates seen in the early stage of the pandemic will return.


Wednesday, December 8, 2010

Academics Diligently Toe the Party Line

In addition to the sexualization of HIV, which yesterday's blog post was about, there is also the rather childish reflex which amounts to 'all men are violent, all women are victims'. There may be some truth in the reflex, that's not my objection. But it isn't very helpful in the HIV prevention field to assume that the virus is mainly spread by men in high prevalence countries. It isn't now and it never was.

An article notes: "The expectation that men rather than women are the index cases has been widely promoted by evidence of low condom use by men, a greater burden of sexually transmitted infections, male dominance in sex-related negotiations, greater number of sexual partners (including polygamous marriages), more frequent alcohol misuse, and greater likelihood of transactional (when a client exchanges money or gifts for sex) or intergenerational sex."

Of course, if HIV is not solely, perhaps not even primarily driven by sex, the assumption that it is driven by men becomes equally untenable. But even if HIV is primarily driven by sex, there has never been any clear support for the assumed role of men in playing a greater role in spreading HIV, with women being, almost always, innocent victims.

This article on discordant relationships, relationships where only one partner in a couple is HIV positive, finds that the woman is just as likely as the man to be the 'index case', the one infected (or the first one in the relationship to be infected). That has been recognized in the past but this paper collects together a number of studies involving thousands of participants.

In Kenya and Uganda, modes of transmission studies have shown that some of the most at risk people are those in long term, monogamous, heterosexual relationships, such as married people. Despite this, the term 'most at risk' has been reserved for men who have sex with men, commercial sex workers and intravenous drug users.

In spite of identifying these last three groups as being at high risk of HIV infection, very little money or programming has been used to target them in prevention programs. And in spite of the fact that HIV is clearly spreading inside stable relationships, programming has generally concentrated on advising people to avoid sex outside of such relationships.

You could say that the HIV prevention strategy has been, and continues to be, to advise people who are probably not engaging in unsafe sex to avoid unsafe sex. And the strategy simply ignores those who are probably at high risk of becoming infected. They are not completely ignored, but these groups receive very little attention, funding or viable prevention programs. This strategy hasn't changed much, despite 20 years of research.

HIV prevention programming has concentrated on a lot of finger-wagging about sex and 'unsafe' sex, when it has long been clear that sex, unsafe or otherwise, is unlikely to be involved in a substantial proportion of HIV transmission in the highest prevalence countries. Little or nothing has been said about non-sexually transmitted HIV.

Findings about discordant couples never seem to have set off alarm bells, even though many people in such relationships have claimed to only have had sex with their partner or to have taken precautions against HIV, unplanned pregnancy and sexually transmitted infections. In some couples where both partners were infected, they were infected by different strains of HIV.

Such evidence that HIV may not always have been transmitted sexually was sometimes interpreted as evidence that women can be promiscuous too. And it was sometimes even presented, uninterpreted, as if there is a great mystery to HIV transmission that is not related to sexual behavior.

The possibility of non-sexual transmission playing a part is briefly considered before being summarily dismissed. Perhaps the authors, Oghenowede Eyawo, Damien de Walque, Nathan Ford, Gloria Gakii, Richard T Lester, and Edward J Mills, are more concerned what their peers might think if they were to challenge the view that all Africans are promiscuous, irresponsible, ignorant and many other things that form the mainstream view of HIV in Africa.


Tuesday, December 7, 2010

The Dogmatic Sexualization of HIV

The main thrust of this blog has been to challenge the 'behavioral paradigm', the view that HIV is almost entirely transmitted by sexual behavior in African countries (The figure '90%' is often bandied about but there is no evidence for it). Therefore, any articles that either support or challenge the behavioral paradigm are of particular interest. As for the belief that the paradigm only holds for African countries, it is difficult to see that as anything other than racism.

A group of people led by Munyaradzi Mapingure have published a paper suggesting that the behavioral paradigm may need to be reconsidered in the light of their findings. They discuss sexual behavior data for Zimbabwe and Tanzania which clearly does not correlate with HIV prevalence. Zimbabwe has some of the highest HIV rates in the world while Tanzania has relatively low HIV prevalence. Yet levels of 'unsafe' sexual behavior are far higher in Tanzania than they are in Zimbabwe.

This lack of correlation between HIV and sexual behavior considered to be unsafe is not rare. There have been many instances of it over the years, in many countries. But few researchers have used the lack of correlation to question the behavioral paradigm. In 2003, a number of researchers published papers suggesting that HIV may not be as closely connected with sexual behavior as HIV prevention programming would lead one to believe. The HIV orthodoxy has yet to refute the body of evidence.

Mapingure and colleagues find that "women in Tanzania reported more risky sexual behaviour than women in Zimbabwe, which is opposite to what is reflected in the HIV prevalence. Prevalence of risky sexual behaviour characteristics, such as having had a casual sexual partner in the previous 12 months, having had more than one lifetime sexual partner, early sexual debut, being in a polygamous relationship and having siblings by different fathers, were all higher for Tanzania. Alcohol consumption, which increases the tendency to engage in risky sexual behaviour, was also more common in Tanzania than in Zimbabwe."

The authors conclude :"Clearly, sexual behaviour only cannot explain the observed differences in HIV prevalence between the two countries" and ask how this "paradox" can be explained. But there is no paradox. They even discuss other papers which make it quite clear that the behavioral paradigm was never in the least bit tenable. Every few years, detailed data on sexual and other behaviors in African countries are found not to correlate with HIV prevalence (check the Demographic and Health Surveys by country).

This paper suggests a few reasons why their results appear paradoxical but the authors seriously consider the possibility that non-sexual HIV transmission might be playing a part in Zimbabwe (which doesn't rule out the possibility of non-sexual transmission playing a part in Tanzania, also). They qualify this possibility by suggesting that such transmission would have been more likely in the 1980s, before the dangers of unsafe medical procedures were widely recognized.

HIV epidemics such as the ones in Zimbabwe, Swaziland, South Africa and others suggest that rates of transmission were probably still high well into the 1990s and perhaps the 2000s. The dangers of nosocomial transmission of HIV, transmission from unsafe medical procedures, may have been recognized a long time ago. But there is little evidence that this form of transmission was successfully eradicated in any sub-Saharan African country. It is more likely that relatively low HIV prevalence in Tanzania is a result of very low access to health services.

Conversely, higher access to health services in Zimbabwe could go a long way towards explaining the incredibly high rates of transmission seen there. And the rates really are incredible. Given the low transmission probability for sexual transmission of HIV per sex-act, Zimbabweans would need to do little else but have sex to explain national prevalence, which reached almost 30% at one time.

In an article commenting on the above paper, Mapingure says "early in the epidemic, syringes weren’t sterilized properly". WHO has recently accepted that as much as 14% of injections are unsafe. Disposable syringes are being reused, either because they are in short supply or because supplies are not reaching their target. Also, health workers are probably not fully trained in making their practices absolutely safe. Published Health Service Provision Assessments make it clear that many Kenyan and Tanzanian health facilities do not have the capacity to eliminate nosocomial infections.

He concludes “Most HIV prevention programmes are failing because they focus on sexual behaviour. We need to look at the whole sexualization of HIV.” This is not just a challenge to the behavioral paradigm. It is a challenge, a long overdue challenge, to the whole of the HIV orthodoxy. UNAIDS and those tasked with reducing the spread of HIV have failed miserably. To this day, they refuse to accept the possibility that non-sexual transmission of HIV is the only thing that can explain the huge differences in prevalence found between and within different countries.


Sunday, December 5, 2010

UNAIDS' Obsession with Sex Helps Spread HIV

According to an article in Tanzania's Citizen newspaper, there is 'growing concern' that HIV transmission is increasing among those in long term relationships and in marriages. Yet HIV prevalence has been high in these groups for a long time. Tanzania may not have carried out a Modes of Transmission Survey recently, as Kenya and Uganda have done. But the three countries have similar epidemics.

The advice that having sex with a long term partner or spouse will protect you from HIV has never been quite true. 'Safe' sex practices may include reducing the number of partners you have and various other measures, such as using condoms, avoiding sexually transmitted infections, etc. But HIV is not, and has never been, solely transmitted sexually. It is also transmitted through unsafe medical practices, such as unsterile injections, traditional medicine, cosmetic practices, such as shaving and tattooing and perhaps other means.

Telling people that they will be protected from HIV if they 'abstain' from sex or obey any of the other paternalistic strictures of the predominantly right wing 'Christian' prevention programs that dominate African country HIV strategies is extremely unethical. Since HIV was first identified, it was clear that it was mainly transmitted through contaminated blood. Sexual transmission was also recognised, especially through anal sex. But the risk of transmission through heterosexual sex was and is quite low.

People are entitled to know that if someone is HIV positive, this does not mean they are promiscuous. You can not tell how someone was infected with HIV without investigating, and even then, the exact cause may still remain unclear. It is worth bearing in mind that heterosexual sex is not an efficient transmitter of HIV. But contaminated blood is a very efficient transmitter.

Many people who are HIV positive are unaware of how they were infected and assume that because they are not virgins, they must have been infected sexually. However, they need to find out if their partner is infected. And even if their partner is infected, they may still not have been infected sexually. It's perfectly possible to be infected through unsafe injections, say, even though your partner was infected sexually.

It is vital that people are made aware of the risks they face and the steps they can take to reduce those risks. They need knowledge, skills and empowerment to be able to ask health and other professionals for evidence that they are observing all safety guidelines. This is necessary to ensure that neither HIV nor any other blood borne infections are transmitted during routine procedures. If people don't know about nosocomial HIV infection, infection through unsafe medical procedures, they will not be alert to the risks and will not take steps to avoid them.

It is heartening to hear that some have made the connection between exposure to contaminated blood and HIV transmission. A group in Kenya, and more recently in Tanzania, has recognised that HIV can be transmitted if care is not taken removing jiggers. This is often done using an unsterilized safety pin or other sharp object. If the object is then used on other people, there is a considerable risk of transmitting HIV and other viruses. Even if a virus is not transmitted, serious infections can result.

But despite small numbers of people in Kenya and Tanzania knowing that HIV is not just transmitted sexually, UNAIDS and others in the HIV industry are reluctant to accept the importance of non-sexual transmission. Official figures estimate that transmission through unsafe medical practices is very low. As a result, only a tiny fraction of the billions being ploughed into HIV prevention goes towards non-sexual HIV transmission.

Exactly why UNAIDS and the rest of the industry wish to ignore non-sexual HIV transmission is not clear. But the organization has always been pretty irrelevant to the HIV pandemic. With our without UNAIDS, people need to recognise the most common and the most serious risks they face. HIV is not just about sex and it has never been just about sex. Anything that involves exposure to blood or certain other bodily fluids can carry a risk of transmission of HIV and other viruses.

[For more about UNAIDS' and the HIV industry's obsession with sex, see my other blog.]


Saturday, December 4, 2010

Sexism, Racism, Homophobia and Individual Responsibility

The Kenyan Prime Minister, Raila Odinga, has called for the arrest of people involved in same sex relationships. Why he thinks that this will help anyone living in Kenya is a complete mystery. But he will probably gain the support of various 'christian' groups, right wing political interests and, of course, the police themselves.

There is a widespread belief that same sex relationships, especially men having sex with men (MSM), play a significant part in transmitting HIV. It is true that anal sex, whether among MSM or heterosexual couples, is a very efficient transmitter of HIV. But this is not, by any stretch, the biggest contributor to any high prevalence epidemics in Africa, if official figures are to be believed.

Official figures claim that the biggest contributor to the highest prevalence African HIV epidemics is heterosexual sex between married or cohabiting couples. In Kenya, low risk heterosexual sex accounts for 44% of all transmission. In other words, low risk sex is the biggest contributor, while whole populations are being warned against high risk sex.

Another 20% is said to be accounted for by casual heterosexual sex and the figures are similar in Uganda. Again, casual heterosexual sex is not exactly high risk when transmission probabilities can be as low as 1 in 500 male to female and 1 in 1000 female to male. Many factors can increase or decrease the transmission probability but casual heterosexual sex is not nearly as dangerous as many would have us believe.

But a word of caution about these figures. UNAIDS estimate that only 2.5% of transmission results from unsafe health care. This figure clearly came to someone in a dream and was found to be so attractive that the entire HIV mainstream have accepted it ever since. However, WHO estimates HIV transmission from unsafe injections alone to be 14% or higher. And various other medical procedures make a contribution that has yet to be fully investigated.

So, sex workers and their clients are thought to contribute 14% to Kenya's epidemic. But sex workers, like pregnant women, often have to put up with numerous injections, which means that sex is the least of their worries when it comes to serious diseases such as HIV, hepetitis and various other blood borne infections. Even sex work on its own may not carry as high a risk of HIV transmission as we are told.

Then we come to MSM. But the Kenyan Modes of Transmission Analysis doesn't even have an exact figure for this. Instead, we are given a figure for MSM plus prison populations. There are many ways prisoners could be infected with HIV, including unsafe health care, tattooing, sharing shaving equipment and various other routes.

This makes it quite unclear how much men having sex with men contributes to the country's epidemic. The figure is likely to be considerably lower than that for unsafe injections and probably half that from unsafe health care as a whole. And it's only a fraction of the contribution from heterosexual sex among married people and people in regular partnerships.

Personally, I think all of the figures in the Kenya Modes of Transmission Analysis are in need of careful review. They may be the official figures, the ones that policy is based on, the ostensible basis for funding allocations, etc. I just don't accept that sexual transmission is as high as these figures claim, nor that non-sexual transmission is so low.

But there is nothing in these figures that justifies punishing people who are at high risk of being infected with HIV, whether they are MSM, sex workers or intravenous drug users. In Uganda's Modes of Transmission Survey, sex workers account for less than 1% of transmissions while intravenous drug users account for even fewer. Added together, these three groups are estimated to contribute far less than unsafe medical injections.

Odinga has since denied that he made such a statement about gays and said that "gays have rights". But he was only playing to the gallery. What one politician says is unlikely to have much impact unless it resonates strongly with what people already believe. I would suggest that he made the initial statement because he had a fair idea what people believe about MSM. He can whip up a bit of righteous indignation but I doubt if he can significantly influence the views of large groups of people. Therefore, his retraction is futile.

There are several major prejudices at work here. The first is homophobia, the belief that heterosexual sex is the only kind of sexual relationship that is acceptable to humanity. The second is anti-African racism, the belief that Africans have too much sex, mostly 'unsafe' sex, and that they care little about their own health or the health of those around them.

A third major prejudice, perhaps the most prevalent one on every continent, is the belief that women are less capable of making decisions that affect their lives and the lives of those they care for. HIV in Africa is a virus that infects women in far higher numbers than men. It is women who face the highest risks from unsafe medical practices, in addition to the exaggerated risk of heterosexual sex. The claim that HIV transmission is a matter of individual responsibility is the main source of the stigma that has had such horrrifying results in African countries.


Friday, December 3, 2010

Effectiveness of Circumcision in Preventing HIV Has Not Been Demonstrated

The Journal of Medical Ethics [apologies for citing it as BMJ, earlier] has an uncharacteristically sane article on male circumcision as a proposed means of reducing HIV transmission, a subject that seems to attract an amazing number of nutters. The HIV industry in general is crazy about mass male circumcision campaigns and some barely credible claims have been made about how many operations have been carried out in Kenya. Let's hope they have been exaggerated, like so many HIV related statistics in Kenya.

This JME article reminds us that a 2009 Cochrane review about the effectiveness of the operation in preventing HIV transmission may have found some evidence but it also called for further studies into feasibility, desirability and cost-effectiveness. Until these studies have been carried out, mass male circumcision is still an unknown quantity. Despite this, numerous articles, by journalists and health professionals alike, have spewed out pronouncements about how this operation will turn around the epidemic.

Even if it works, it will not turn around the epidemic. It may even increase transmission. Kenya's hospitals have an unenviable reputation for cleanliness and hygiene and the reputation of other high HIV prevalence countries is no better. At present, HIV prevalence among men is often substantially lower than it is among women in many demographic sectors and among many tribes. But that is unlikely to remain the case.

So there are two main problems (although these are not the ones dealt with in the JME article). Firstly, circumcision is unlikely to prevent HIV transmission through heterosexual intercourse to any great extent and it may even increase it.

And secondly, a very significant proportion of HIV is probably being transmitted through non-sexual routes. According to WHO, 14% is transmitted by unsafe injections. Other forms of medical transmission are likely to make an additional contribution.

There are several other non-sexual routes, such as unsafe cosmetic practices. And the number of transmissions from mother to child is extremely high in high prevalence countries, despite antiretretroviral drugs being widely available for some time. Also, there is a lot of transmission through intravenous drug use in some countries.

The hype about circumcision is quite extraordinary, considering that the people who are most in favor of it should also be most aware of the reasons why the approach is flawed. They should be aware of conditions in hospitals, the fact that sexual transmission of HIV has been wildly exaggerated, the fragility of the handful of field trials that have been carried out and the statistically insignificant effect of circumcision in many countries.

The fact that countries where circumcised men are more likely to be infected than uncircumcised is usually not mentioned is disturbing. But those who express their support for circumcision must be aware that they have been quite selective in the figures they cite.

The JME article questions the ethics of advocating an intervention for which the evidence is highly questionable. It makes it quite clear that there is, as yet, insufficient evidence to proceed with such an intervention. Yet, if some sources are to be believed, well over 100,000 circumcision operations have been carried out in Kenya's Nyanza province and tens of thousands in other countries.

Not content with imposing the operation on adults, there is even talk about imposing it on infants as well. This is supposed to 'protect' them from HIV transmission through unsafe sex. Not only are they probably not at risk of infection through unsafe sex once they become sexually active; but people are being led to believe that they are safe from HIV if they take a handful of precautions that could only, at best, protect them from sexually transmitted HIV. None of these precautions will protect them from non-sexually transmitted HIV, the very possibility of which is often barely mentioned.

The behavior of the circumcision advocates is unethical in promoting an operation that will have minimal benefit. But they are also at fault in failing to inform people about the extremely high risk of being infected through unsafe healthcare. This results in people being unaware of how to protect themselves from healthcare transmission of HIV, hepatitis and various other infections. Such nosocomial infection is very common, but it is rarely mentioned in the literature.

The best known method of reducing HIV transmission through sexual intercourse is correct and consistent use of condoms. Even after circumcision, men need to continue to use condoms correctly and consistently, otherwise there is no guarantee the intervention will have any benefit. Advocates of circumcision would be better off forgetting about circumcision if they really wish to reduce HIV transmission and just concentrate on condoms. The worrying thing is, they are already well aware of these considerations but they behave as if they are oblivious to them.


Thursday, November 25, 2010

Are We About to Take the Biggest Step Yet in Reducing HIV Transmission?

Recently, I blogged about WHO's estimates for the number of people infected every year with HIV through unsafe injections and wondered why the number, 23,000, was so low. It was an error in the original reporting. In fact the number is 260,000 HIV infections. In addition, unsafe injections account for millions of transmissions of hepatitis B and C and a host of other diseases.

To put this in perspective, just under 10% of HIV in Uganda is transmitted via sex workers, their clients and their clients' partners, all together. The figure for Kenya is about 15%. But the contribution of unsafe injections is estimated at about 14%, and it could be a lot higher in some places.

The majority of HIV positive people in high prevalence countries did not engage in 'unsafe' sex, according to Modes of Transmission Surveys. But you'd never think that when you read articles about sexual behavior and commercial sex work. The percentage actually attributed to sex workers is less than 2%. It's the clients and partners of clients who make up the bulk of that 10% figure.

Despite sex playing a far smaller role in the AIDS pandemic than we are led to believe by most media and academic writings, the evidence that something else is playing a big part is all around. In South Africa, farm workers in two provinces have some of the highest rates ever found anywhere, almost 40%. Compare this to HIV prevalence among sex workers in India, which stands at about 7%. That's about the same as national prevalence in Kenya, Tanzania and Uganda. Are we supposed to conclude that some Africans engage in far more unsafe sex than Indian sex workers?

The Institute of Migration study, apparently, "could not pin-point a single factor causing this high rate of HIV infection on these farms but points instead to a combination of factors such as multiple and concurrent partnerships, transactional sex, irregular condom use, presence of Sexually Transmitted Infections (STIs) and/or TB and high levels of sexual violence". But these factors are present in many places in the world, in developing and developed countries, without giving rise to such astonishing HIV rates.

Dr Eric Ventura says that more research is clearly needed. But perhaps some different research is needed and even some investigation of the results of some already completed research. Not that there isn't plenty of research into non-sexual transmission, but UNAIDS and many others in the HIV industry choose to ignore it. Perhaps now that WHO have seen the light, UNAIDS will follow. But Ventura suggests, among other things, increasing farm worker acces to healthcare.

Perhaps access to healthcare is the biggest problem in South Africa and some of the surrounding high prevalence countries. Most of the very high HIV prevalence African countries have better access to healthcare than some of the medium prevalence countries, such as Kenya, Tanzania and Uganda. But what quality of healthcare? Increasing access to healthcare will be counterproductive if poor healthcare is contributing more to the pandemic than commercial sex, which has been such a popular punchbag up to now.

Very slowly, the issue of injection safety and other forms of non-sexual transmission of HIV is being raised and even being picked up by the media. The above figures about unsafe injections were supplied by Safepoint Tanzania, who have been trying to get this vital topic on the agenda. But when it comes to media attention, or even that of the HIV industry, sex always trumps boring old healthcare.

With all the interest in criminal HIV transmission (through 'unsafe' sex, of course), I wonder if we will ever look back on the days when UNAIDS and others tasked with reducing HIV transmission consistently refused to accept that a very significant proportion was coming from unsafe injections and ask ourselves how they could get away with this? Because what they are getting away with now constitutes professional negligence that far exceeds that of those who continued to use blood products contaminated with HIV long after they knew the risks.

As another World AIDS Day looms and the 'experts' drone on about what a brilliant job they have been doing, it's time to take what will be the biggest single step ever towards reducing HIV transmission in African countries. That is to recognize that HIV is not just about sex, unsafe or otherwise, and by acting to eliminate the most avoidable and preventable factors in the spread of the virus: unsafe injections and other healthcare procedures.


Tuesday, November 23, 2010

UNAIDS' Report: Prejudice, Wishful Thinking, Slick Marketing & a Veneer of Pop Science

World Aids Day is almost upon us, so the industry has to get its story together. It's clear that rich countries of the world have other things on their minds, such as money, so UNAIDS and their chums are not expecting them to be quite so generous in the near future.

But they have already adopted a new strategy: instead of constantly whining about the pandemic getting worse and the industry needing more money, they have started to whine about how the pandemic is getting better, so they need more money to keep things on the right trajectory.

"We have halted and begun to reverse the epidemic. Fewer people are becoming infected with HIV and fewer people are dying from AIDS", says the forward to UNAIDS' annual epidemic report. "But", it goes on, "we are not yet in a position to say 'mission accomplished.' Growth in investment for the AIDS response has flattened for the first time in 2009. Demand is outstripping supply. Stigma, discrimination, and bad laws continue to place roadblocks for people living with HIV and people on the margins."

Global press, observing the usual custom of repeating press releases without change, analysis, question or thought, are now busy saying what they are told to say. "HIV epidemic 'halted', says UN" says the BBC. The other news agencies I looked at appear to be in accord. But what UNAIDS are claiming is that the pandemic has been halted by their efforts; and there is precious little evidence that that is true.

HIV incidence in all the highest prevalence countries began to fall some 10 or 15 years after the virus started to spread. (Incidence is the annual rate of new infections, prevalence is the proportion of individuals in a population who have HIV at a speciļ¬c point in time.) This means that incidence in Kenya began to decline in the early to mid 1990s and in Uganda several years earlier. In Southern African countries, where HIV arrived later, the peak and subsequent decline was also later.

In fact, there are usually different sub-epidemics in countries and each one probably started, peaked and declined at different times. In Kenya, Uganda and Tanzania, national declines in incidence were followed by a peak in prevalence and then a rapid decline in prevalence as death rates started to climb. Once death rates peaked and declined, prevalence rates started to look as if they were going to go up again. So these three countries still have high enough rates of transmission to ensure that HIV will be endemic there for the foreseeable future.

But the most disturbing thing about this sort of epidemic dynamic is that we have no clear explanation of why HIV transmission peaked and started to decline long before anyone had got around to doing anything to reduce transmission.

Yes, we hear lots of triumphalist stories about what happened in Uganda, where HIV prevalence hasn't changed in years and is probably now increasing. We also hear that prevalence rates in some countries are static, or even climbing, because there are many HIV positive people being kept alive with antiretroviral treatment (ART). Some of the stories about Uganda may be true and there is little doubt that many people are being kept alive by ART.

But these don't explain why incidence peaked and declined. It also leaves the problem of why a disease that is difficult to transmit sexually is said to have suddenly started to spread at alarming rates in the 1970s, 1980s and 1990s without any apparent (and quite astonishing) increase in sexual behavior.

There is no evidence that rates of sexual behavior were ever high enough (or could ever be high enough) to give rise to such rates of transmission. Nor is there any evidence that rates of sexual behavior then declined as a result of some half baked behavior change programs, which few people still believe had any real impact.

In many non-African countries, where sexual behavior was never given as the entire explanation of how HIV became endemic, rates of transmission are rising. HIV transmission in these countries is more likely to be a result of intravenous drug use (IDU) and anal sex, homosexual and heterosexual. In non-African countries, HIV transmission rates correspond quite convincingly with levels of IDU and men having unprotected sex with men (figures for heterosexual anal sex are not so clear). Both IDU and anal sex are very efficient modes of HIV transmission.

The annual presentation of the industry orthodoxy as if it were infallible is bad enough. It's little more than a mix of prejudice, wishful thinking, slick marketing and a veneer of pop science. But it's insulting to people who suffer from HIV and AIDS, directly and indirectly, to be told that almost everything that can be done is being done. And it will be of little comfort to those who are at risk of becoming infected, either.

The 'hypothesis' about HIV arriving out of the blue, being spread by those highly sexually active Africans, then declining because some clever Western scientists told them to stop having so much sex doesn't work. But like any other lie, it requires more lies to shore it up until the liars come to realize that they are reaching the end of the credibility tether.

It remains to be seen how many people will be unnecessarily infected before UNAIDS and Co. tell the truth. Hopefully, they will then be abolished and replaced by an institution that is not entirely run by vested interests.


Sunday, November 21, 2010

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.]


Wednesday, November 17, 2010

UNAIDS' Secret Weapon: Bait-and-Switch

On first hearing about self-testing HIV kits you might think that it's a brilliant idea. The result would be that more people know their status, their status information would be up to date and it could be kept up to date. Also, people might find out their status far earlier than otherwise, which would hopefully mean they are less likely to transmit the infection.

But then it might strike you that those who know their status need not tell anyone. They would be especially unlikely to tell anyone if they lived in a country where there is a law against having sex without revealing your HIV status, transmitting HIV despite knowing your status, etc. People might even be reluctant to reveal their status in countries where HIV is deeply stigmatized, which is most countries, especially in Africa.

Stigma is especially deep in Africa because the HIV industry, UNAIDS and others, insist that HIV is almost always sexually transmitted. Speculation about what people would or wouldn't do if self-testing kits were available are all influenced by the assumption that transmission is almost always sexual.

Therefore, people may test when they suspect they were infected sexually, but they may not do so if they have no reason to suspect this. If they are infected through medical treatment, or some other non-sexual mode, they are unlikely to think of getting tested.

However, if person A tells person B that person A has just tested positive, person B is very likely to assume that person A was infected sexually. If person B is HIV negative, and married to person A, they will then accuse person A of infidelity. If person B is positive, they will accuse person A of infecting them.

Whether there will ever be any reliable way of telling which party was infected first suddenly becomes a lot more interesting. That's if one party doesn't beat up the other party, drive them out of the family home or even kill them.

The behavioral paradigm, the assumption that almost all HIV transmission in African countries is sexual, is not supported by evidence. On the contrary, it is controverted by a large body of evidence. But it is so widely held that HIV is almost universally associated with something illicit, drugs and men having sex with men in non-African countries, heterosexual sex in African countries.

Before a self-test kit for HIV becomes widely available, shouldn't we deal with the problem of the behavioral paradigm? Unless we deal with this assumption, stigma will not just disappear of its own accord. Simply repeating a mantra about non-stigmatization will not make it disappear.

These questions are not raised because of any objection to technical solutions, where those technical innovations really are solutions and where they are appropriate. But HIV testing has always been controversial. The HIV industry has stoked this controversy, it's not completely clear why, and as a result, HIV testing is 'opt-in' rather than 'opt-out', unlike other medical tests.

If finding out people's HIV status is carried out in order to treat them and prevent further transmission, self-test kits may be very useful. But HIV has been characterized as a threat and a punishment for some kind of imagined transgression by various political and religious interests; the claim that the test would be purely diagnostic does not stand up to scrutiny. Many people are far more worried about being stigmatized than they are about knowing their status, to the extent that many don't wish to know their status.

The worry is mainly about HIV in African countries because the behavioral paradigm is only believed to hold true there. Despite the claims of UNAIDS and others, HIV is not only transmitted sexually, it may not even be mainly transmitted sexually. But as long as the orthodoxy is maintained, the resulting stigma will ensure that wider HIV testing will not address the problem of understanding what is driving the epidemic.

There is little justification for wider levels of HIV testing if no effort is made to find out how people were infected (which includes finding out when they were infected as accurately as possible). Making self-test kits widely available may even do a lot of damage if current assumptions about African sexuality are not re-examined.

The most absurd thing about purely technical solutions is that they don't have any impact on sexual behavior, the very behavior which has for so long been blamed for spreading HIV. Absurd because of the incorrect association of HIV infection with illicit sex. But also because this has created the stigma which resulted in almost all programs to reduce HIV transmission being total failures.

In the end, all this stigma could have been avoided by establishing exactly how HIV is transmitted. Now it looks as if these technical 'solutions', microbicides, pre-exposure prophylaxis, test and treat policies, etc, will also have to fail before anything is done that is likely to reduce HIV transmission. UNAIDS' latest HIV strategy appears to be good old bait-and-switch, widely considered to be fraudulent in the broader commercial world.

[There is a brief note about HIV self-testing and it's relationship with pre-exposure prophylaxis on my other blog.]


Tuesday, November 16, 2010

UN's IRIN Fluffs Issue of HIV Transmission in Medical Facilities

The issue of non-sexually transmitted HIV is rarely discussed in medical or official literature, or anywhere else for that matter. But there is a recent article on IRIN's PlusNews about the risk of accidental HIV transmission to health workers in Kenya. The article notes the need to provide health workers with proper safety equipment and education.

These are vital, not just to protect health workers, but to protect patients. If health workers don't have adequate equipment or if they don't adhere to strict hygiene practices, their patients face far higher risks than the health workers.

Unfortunately, the article botches the message in the second paragraph. They say that 2.5% of new HIV infections every year occur in health facilities. But this does not mean that 2.5% of the country's HIV infections occur among health workers. It means that the figure some epidemiologists have modeled, somehow, suggest that as few as 2.5% of HIV infections are caused by medical procedures, some of those being among health workers. There is no attempt to work out how many health workers are infected. And it's not as if such occurrences are properly recorded, that would be far too sensible.

In fact, the figure of 2.5% is just not credible. The WHO accepts that 70% of injections in developing countries are unnecessary and that almost 20% in some countries are unsafe. Why should Kenya, with it's deplorable health facilities, only have a 2.5% rate of medical transmission? The article even claims that "most government facilities adhere to safety guidelines" and blame "private practitioners in poor areas" for medical transmission.

Kenya's Service Provision Assessment suggests, on the other hand, that safety guidelines are not common. The assessment doesn't even question whether the guidelines are adhered to. They do assess how many facilities have the requisite equipment; not many.

The article seems to suggest that those living in rural areas are more at risk of unsafe health care. People in rural areas may face different risks that urban dwellers, possibly even high risks. But HIV rates are far higher in urban areas. People in rural areas are, however, far less likely to receive any kind of modern medical services. It's striking how the most isolated places of all have very few cases of HIV.

The article says that "patients themselves may not be knowledgeable enough to question unsafe practices", so it isn't a complete waste of space. Patients, Kenyans and other Africans, are quite unaware of the dangers they face, mainly because articles like this one seriously underestimate the level of risk.

A 'self-employed' health worker admits that they don't always have safety equipment, though they frequently give injections. Health workers are right to be concerned for their own health. But the government and those involved in improving medical safety should pay a lot more attention to patients. Health workers may receive the odd scratch or jab from a needle but patients receive much of whatever the equipment is contaminated with, under their skin, into their muscles or even into their veins.

Given the lack of training and equipment among health workers, any initiative to increase training and supplies should be commended. But this is not going to happen overnight, if it even happens at all. Everybody visiting a health facility should know about the risks they and their family members face so that they can take steps to protect themselves against nosocomial transmission of HIV, hepatitis and other blood borne diseases.

Yet again, an article touching on the issues of medical safety and the risk of HIV transmission through unsafe medical procedures completely fluffs the issue. Visiting medical facilities in African countries is extremely hazardous. An indication of how hazardous it is can be gleaned from the advice given by UNAIDS to UN employees:

"Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood — to avoid not only HIV but also hepatitis and other bloodborne infections."

This is great advice for UN employees (IRIN is part of the UN), even though they have access to UN approved facilities and the option to wait till they are in a country with better medical facilities. However, UNAIDS doesn't feel it is necessary to give the same advice to Africans. They, it appears, only face a very small risk of infection.