Why is HIV Policy in Africa Written By Racists?

Kenya appears to have yet another 'campaign' to reduce HIV transmission. This one purports to target HIV positive people, whom, some 'senior government officials' claim, have been ignored so far. This is an odd claim, considering the largest part of the vast sums of money being spent on HIV for many hears now has gone into treatment for HIV positive people. HIV prevention has received a very small amount of money and much of that has been frittered away on 'behaviour change programmes' widely acknowledged to be useless in Western countries.

Of course, HIV positive people must be part of the equation when trying to reduce HIV transmission. But so must HIV negative people. Concentrating on one group and ignoring the other has been counterproductive. One of the reasons that big funders are questioning the continuation of ever increasing funding for HIV drugs is that this approach hasn't yet had much effect on HIV prevalence. As HIV drugs are rolled out, more and more people continue to become infected. If there was an end in sight, perhaps in the form of significant reductions in transmission in high prevalence countries, funders might be persuaded to hang in for a bit longer.

The article is, in fact, very misleading:

"We have focused so much on empowering HIV-negative people to avoid infection. We now need to focus on people who are already infected and empower them to prevent new infections, re-infection, and maintain their own and their partners' good health," said Dr Nicholas Muraguri, head of the National AIDS and Sexually Transmitted Infections Control Programme.

I haven't seen much evidence of empowerment of HIV negative people, though I've seen many references to it. Whether the focus of most of the money and attention for the last several years on drugs and treatment has also included any empowerment for HIV positive people is another matter. It probably hasn't because pharmaceutical companies don't make money out of 'empowerment', they make money out of drug sales.

I have searched high and low for the guidelines in question without finding a copy but the article goes on:

One of the main aims of the guidelines is to ensure that all HIV-positive Kenyans are aware of their status; government statistics show that 84 percent of HIV-positive people do not know they are infected.

I hope this figure is out of date because it is the same as it was back in the 2008 Aids Indicator Survey, the data for which was collected in 2007. Since then, articles have claimed that several million more Kenyans have been tested, one even claiming that about 1.5 million were tested in a six week period near the end of last year.

The more people tested the better, but will any effort ever be made to figure out how people became infected? The assumption is still, despite plenty of evidence to the contrary, that most transmission in Kenya and other high prevalence African countries is due to unsafe sex.

Despite finding medical facilities to be too dangerous for UN employees, UNAIDS claims that medical transmission of HIV in Kenya is around 0.6%. There are children who are HIV positive whose mothers are not and nearly half the married women who are HIV positive are married to men who are HIV negative. Are we supposed to believe that all these women are becoming sexually infected with HIV through some relatively small number of men, to whom they are not married? Well, if you pander to the stereotype of the oversexed African, you may be happy with this explanation. But if you're an economist, no matter how bigoted, you may wonder how a large number women can have anything to gain by having sex with a small number of men to whom they are not married.

Dr Muraguri goes on to say "We want to de-stigmatise the HIV test so that HIV testing becomes a 'kawaida' [usual] thing". What better way could there be to stigmatise HIV than to assume that it is mainly sexually transmitted? Even the possibility that some HIV is transmitted non-sexually is not considered in most of the literature, perhaps from unsafe medical procedures, perhaps from unsafe cosmetic procedures or some other likely candidates. In what way, I wonder, is Dr Muraguri suggesting that this de-stigmatises anything? I see the sexual behavioural paradigm as the very source of HIV related stigma.

The article continues:

"At one point, every adult with sexually transmitted HIV was the HIV-negative partner in a discordant relationship," Muraguri said. "Over 44 percent of married HIV infected partners have an HIV-negative partner - if they are aware of their status, they can take steps to protect their partners from infection.

Yes, over 44% of married HIV positive people have a HIV-negative partner, and haven't people like the doctor ever wondered why this is? And if they were infected by some route other than sexually, their partners could also be infected non-sexually. Isn't it strange that HIV transmission in concordant relationships is so slow? Doesn't it suggest that sexual transmission of HIV alone may not be enough to explain the very high prevalence of HIV in Kenya and other African countries?

People who are aware of their status can protect their partners or protect themselves, but only if they know what the risks are. People can not protect themselves from medical, cosmetic or other non-sexual transmission by wearing a condom or even by abstaining from sex, especially if they don’t even know about these risks.

Anyone worried about reduced funding for HIV, as many claim to be at the moment, should be wondering why the various campaigns that were mere variations on Abstain, Be faithful and use a Condom (ABC), or even worse, abstinence only, have been so unsuccessful. As well as being intuitively unappealing, perhaps they were just barking up the wrong tree. Africans don't have more sex or more unsafe sex than non-Africans, so why should HIV prevalence be higher in many African countries than in many non-African countries?

In case there is any doubt remaining that the campaign excludes all but sexually transmitted HIV:

Prevention with Positives includes encouraging partner disclosure, scaling up prevention of mother-to-child transmission, increased condom use, large-scale male circumcision, and ensuring adherence to antiretroviral (ARV) drugs, which have been shown to significantly reduce the risk of mother-to-child as well as sexual HIV transmission.

This is all good advice, especially for sexually transmitted HIV. But for non-sexually transmitted HIV it offers nothing. People must know how they are becoming infected in order to protect themselves. The racist view that Africans are all having unsafe sex at such high rates that non-sexual transmission is almost irrelevant will not help to cut HIV transmission. But this latest Kenyan programme is being funded by some arch racists, it appears. The American President's Emergency Plan for Aids Relief, the Elizabeth Glaser Paediatric AIDS Foundation, and the US Centres for Disease Control are mentioned but apparently there are others.

Yet another stigamatising attitude is expressed by Nelson Otuoma, chairperson of the Network Empowerment of People Living with AIDS in Kenya (NEPHAK). This seems surprising, but he claims that the 18,000 or so members of NEPHAK have a "have a common message - they must not be generous with the virus, giving it away; they want to be mean with it, keeping it to themselves." There may have been rare (but very media friendly) exceptions of people deliberately or carelessly transmitting HIV but most people don't want their friends, partners, family or anyone else to become infected. Do people seriously believe otherwise?

Even nurses and other healthcare workers have been denied the knowledge that many people in Kenya probably became infected with HIV through a non-sexual route. Many people will list non-sexual ways of transmitting the disease, but it is clear that the assumption is that HIV is usually transmitted sexually. There is no reason for healthcare workers to assume that people face other risks because, regardless of how much money has been spent on improving healthcare (and I've seen little evidence of much of that in Kenya), they are bombarded with courses, publicity and literature on sexual transmission.

If I get to see the guidelines I'll link to them here. But I am very disappointed to hear that, yet again, non-sexual transmission of HIV has been ignored and the old stigma has been given more fuel, as if it needed any more. I have spoken to many people (laypeople and professionals) in Kenya, Uganda and Tanzania and most of them are willing to admit that things in health facilities are slack and must be giving rise to a lot of risks, whether for HIV or any other blood-borne diseases.

In addition to being able to access treatment when they are HIV positive, HIV negative Kenyans and other Africans need to be able to ensure that they stay negative. This means being made aware of the risks they face, not just sexual risks but risks they face when receiving medical treatment, cosmetic treatment, traditional medicine and other practices and the like. If they are not made aware of these risks, no matter how embarrassing it is to those in UNAIDS, CDC and other institutions that steadfastly deny that such risks exist, people will continue to become infected.

Unsafe medical practices are known to be common in some African countries, which means that everyone who receives medical treatment is at risk of becoming infected with HIV and other diseases. Continuing to maintain that sexual behavior is responsible for most HIV transmission among Africans, while warning non-Africans about these risks, is not the way to reduce HIV transmission. The belief that Africans have a lot of unsafe sex, and that’s why HIV prevalence is high in some African countries, is a prejudice: it arises despite evidence to the contrary, not because of evidence for the belief. But these two claims are what HIV policy in Africa tends to be based on.

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

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

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

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

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

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

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

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

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

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

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

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

Big HIV Funding and Blatant Racism

Many people and organizations in the HIV world, especially those involved in HIV treatment, as opposed to prevention, are worried about the effects of global financial belt tightening on HIV budgets. They are right to worry. A lot of big funders are capping funding or reducing it. And the global financial situation may not be the only reason for this austerity.

For many years, HIV prevention has taken a back seat to HIV treatment. Those in favour of treating as many people as possible and ignoring the fact that more people are becoming infected than going on treatment, assure us that mass roll out of treatment also plays a part in 'health systems strengthening'. This is supposed to make those concerned about a high rate of new infections feel better, as if new infections are being taken care of because those infected for some time are being treated in great numbers.

Indeed, defenders of the status quo that involves treating those who are infected and almost completely ignoring new infections, explicitly argue that HIV treatment also prevents new infections. To an extent that is difficult to quantify, this is true. HIV positive people who are responding to treatment (which means they also need adequate levels of nutrition and general health, etc) tend to have a lower viral load. They are less infectious and, therefore, less likely to infect others.

But this still leaves others vulnerable to infection. If many were not currently vulnerable to infection, the rate of new infections would be negatively correlated with the number of people who are responding to treatment. Those in favour of treatment at the expense of prevention claim to be averting infections, but only by using a circular argument; that the number of new infections must be lower than it would have been if treatment hadn't been rolled out because treatment reduces the incidence of new infections. The fact is, widespread treatment hasn't yet reduced new infections very much.

Well, if these treatment fundamentalists are really concerned about the effect that cuts in funding will have on the lives and health of people in developing countries, there are a number of alternatives they could consider. For a start, they will have to make some effort to reduce new infections at some stage. No person or organization would be wise to keep spending money on outrageously expensive drugs for treatment when the numbers of infections continues to rise, more or less unabated.

So these concerned and worried parties (Michel Kazatchkine, Michel Sidibe and others) can start campaigning for the sole use of generic versions of antireteroviral drugs (ARV), at least in poor countries. At present, expensive, branded versions are used almost universally. There has been a lot of pleading about how much pharmaceutical companies have dropped their prices but these reductions are nothing compared to the savings that use of generics could bring. To argue for more or continued funding for overpriced medicine is stupid and downright deceitful.

With the money saved by switching to generics, some money could be spent on prevention. And I don't mean the ABC (abstain, be faithful, use a condom) rubbish that has been churned out for more than ten years. This 'behaviour change communication' and any prevention programmes based on the idea that Africans have lots more sex than anyone else, has never worked and it never will work. More money has probably gone into publicity to show how successful this disgraceful waste of money has been than into programmes that really do work.

Plenty of research has shown that most of the 'prevention' programmes that have been carried out so far have achieved little, especially as far as reducing HIV transmission is concerned. But there is also research that receives a lot less attention which shows that HIV transmission can be reduced significantly, but also cheaply. Larry Sawers and Eileen Stillwaggon have argued for this in several publications, including in an article entitled 'Understanding the Southern African 'Anomaly'; Poverty, Endemic Disease and HIV'.

In this article, Sawers and Stillwaggon demonstrate that HIV transmission can be influenced by inexpensive measures such as providing people with deworming, sanitation, STI (sexually transmitted infection) treatment, mosquito control and safe water. These, they argue, are all essential in controlling HIV. In addition, these measures all have benefits that go beyond their effects on HIV and will improve the lives and health of tens of millions, perhaps hundreds of millions, of people in developing countries.

There is a lot of good money to be made in the HIV industry, especially where expensive drugs are involved. Attention to these drugs has been far higher than the success of ARV rollout could explain. Yes, many people are alive now who would not be alive without the drugs. But this has been achieved at a cost that is far higher than necessary. And as a result, preventing new infections has been given short shrift, even though this can be effected at relatively low cost. One might almost think that HIV has been seen as an opportunity to sell vast amounts of drugs that have a very small market outside of developing countries.

To make it clear, in case people may think I'm advocating against spending money on drugs for people who are HIV positive: I believe everyone who is in need of HIV drugs should receive them, but I believe they should be purchased at the lowest cost possible. This is not currently the case. Costs are kept artificially high by intellectual property laws (In other words, market protectionism) that favour rich countries and multinationals, by behind the scenes deals, by lobbying and by fancy marketing and publicity. The big HIV funders are being robbed blind, or perhaps they are being robbed and happen to be blind as well. I also believe that HIV positive people should have all their other health needs attended to and that they should have access to an adequate diet without which the drugs and treatment they receive are useless.

Once the cost of treating HIV positive people has been set at a level that poor countries and poor people can afford, there should be a lot more money available for preventing new infections. The approaches mentioned by Sawers and Stillwaggon, above, are all vital. And they are compatible with others, such as identifying instances of HIV being transmitted non-sexually, whether by unsafe medical practices, cosmetic practices, unsafe traditional medical practices or whatever.

As long as the big earners in the HIV industry continue to spend billions on overpriced medicine when cheaper alternatives are available, their wailing about rights and justice are so much hypocrisy. They are long enough in the business now to know what is going on, a lot better than laypeople do. And it must be as clear to them as it is to anyone who bothers to check that HIV prevention has to accompany HIV treatment if the disease is to be eradicated. Equally, these big earners cannot continue to ignore the evidence that they are wrong about sexual behaviour in African countries. Levels of risky sexual behaviour are higher in America and Europe than they are in Africa (and Sawers and Stillwaggon are particularly clear on this point in all their publications). Claiming otherwise is blatant racism.

UNAIDS: Mythmakers or Liars?

We have spent the last few days in Bukoba, talking to people about their memories and perceptions of HIV. Unfortunately, after decades of being told that HIV is primarily spread sexually, most people firmly believe that this is the case. They believe that HIV came from ‘somewhere else’ (Uganda, America, Europe, truck drivers, sex workers, men who have sex with men, etc), a widespread belief. In Bukoba, they believe (mostly) that it came from Uganda and this may be true. Alternatively, HIV may have spread from Tanzania to Uganda at the same time as it was spreading from Uganda to Tanzania. It seems likely that HIV spread in waves at various different times and its impact in a particular place depended on many of the conditions extant in that place at the time.

The problem with ignoring non-sexual transmission of HIV, through unsafe medical practices or through cosmetic or other practices where blood or bodily fluids may be involved, is that people end up not looking out for such risks. Even where they recognise their existence, they don't know how to protect themselves. For instance, people know that hairdressers should sterilize their equipment between clients but their neither the hairdressers nor the clients know what is required for equipment to be properly sterilized.

Contrary to widespread belief, HIV does not die after seconds or minutes of being separated from the host. It can live for hours or even days on instruments that dry out. And it can live for weeks if it remains wet. If a hair trimmer is used on a person with a disease that is transmissible through blood contact, it needs to be boiled. Just cleaning it in water is not enough, nor is wiping it with methylated spirits or bleach. Yet, people are convinced that this is enough. They even admit that they don't know one way or another what is done with the instruments. Manicurists just turn up with a bucket of instruments and do their work before going on to another client. They don't have the equipment necessary to sterilize their tools, nor do their clients seem to be aware that this is very dangerous.

One person we talked to said that she uses a hair relaxant that burns the skin and makes it liable to break. Hair relaxants are popular here, to produce straight hair. So combs and anything else used would need to be carefully sterilized, but the facilities for doing this are often not available. As a hairdresser, she was unaware that it is not just blood that can transmit infection. Pus is even more dangerous. She was under the impression that if people had sores on their head, this was not risky unless there was also blood. Decades of warnings about the risk of HIV infection have concentrated almost exclusively on sexual behaviour and sexual risk. So people are not adequately prepared for non-sexual risks.

Similarly, risks from unsafe medical procedures could be much more of a threat than sexual risks. People's perception of medical risks is that they will be taken care of by health professionals. This may be true in some cases, but not all medical procedures are carried out by health professionals or in ideal conditions. You can get injections, and possibly other services, from people who run 'pharmacies', often just stalls that have a few medicines. Needles may well be changed between patients. One certainly hopes so. But are syringes always changed? Many people say they don't know and they don't feel they are in a position to question doctors and other health professionals. And many injectible products are sold in multi-dose vials. But it has long been known that vials can become contaminated. This can easily lead to HIV and other diseases being transmitted to many people.

People may face threats that they don't even realise are there. And they may face threats that they have never been told how to deal with. There are ways to take precautions against non-sexual transmission of HIV (and other blood borne diseases) but HIV education campaigns concentrate almost exclusively on sexual risk. Although some people can trot out a list of other HIV threats, including shared razors, toothbrushes, cosmetic equipment and medical equipment, these are considered to be relatively unimportant compared to the risk of sexually transmitted HIV.

UNAIDS publishes a list of recent HIV related publications, along with the abstracts and some editorial comments. This list very rarely includes papers that discuss non-sexual HIV transmission, concentrating instead on the many articles that look at sexual risk or what is perceived as sexual risk. So, for example, there's an article about sex work and the 2010 World Cup in South Africa. There are warnings about the risk of becoming infected with HIV and other sexually transmitted infections, but none about the risk people may face if they have to go to a medical facility for treatment or if they visit a tattoo parlour or if they get their hair cut. And South Africa is a country with very high HIV prevalence.

Another article that UNAIDS highlights is about sexual behaviour trends in France from 1970 to 2006. Sexual behaviour became more 'risky', especially for women, during the period. The same trends in a high HIV prevalence country would have been blamed for high levels of HIV transmission. But because this is a low HIV prevalence country and European, no such pronouncements are made. Non-penetrative sex also appeared to become more often practiced, which, of course, is less of a risk when it comes to HIV or sexually transmitted infection risk. But in some African countries, sexual risk behaviours are low but HIV prevalence is high.

When the survey takes place in a country like France, people's responses tend to be believed. Similar surveys in African countries can elicit similar results, but the responses tend not to be believed if they don't correspond with the data collected on HIV. When, as is often the case, people in African countries say they have not had sex, they have not had risky sex or that they took precautions against risk, and they turn out to be HIV positive, it is assumed that they are lying, mistaken or forgetful. Yet, many of them are likely to be telling the truth but they were infected by some non-sexual route, medical, cosmetic or the like.

Similarly, women have often been infected with HIV while they are pregnant. They are tested early on in their pregnancy and initially found to be negative. But they are subsequently found to be positive when they are retested later. The earliest period of HIV infection is the most virulent. If a woman becomes infected while she is pregnant, the chances of HIV being transmitted to the infant is far higher than if she seroconverted some time before becoming pregnant. The conclusion of this paper is that couple counselling may reduce unprotected sex during pregnancy. But have the authors considered the possibility that some of the women were infected non-sexually? Did they even test the husbands to see if they were also HIV positive? Of course, if the husbands were HIV negative, the belief that HIV is usually transmitted sexually leads to the conclusion that the woman must have had sex with someone other than her husband. This is one of the reasons HIV has become so stigmatized. Husbands often accept the received view about HIV being mainly sexually transmitted. They believe the ‘experts’, not their wives.

There are many hints that a good deal of HIV is not sexually transmitted in African countries. So it's surprising that UNAIDS, WHO and others still hold on to the view that non-sexual transmission accounts for a very small proportion of all incidence. In most African countries, various prevention programmes have been run, some for many years. But these programmes are almost all aimed at influencing sexual behaviour. Very few are aimed at medical transmission and even fewer at cosmetic transmission. And these programmes have been quite unsuccessful. A number of papers have asked questions about which prevention interventions work and, on finding that none of them make much difference to HIV transmission, they keep looking for new ways of preventing sexual transmission. They don't seem to consider the possibility that at least some transmission is not sexual, though they admit that conditions in medical facilities are too dangerous to allow UN employees to risk using them! These papers are right to conclude that gender, poverty and alcohol consumption are important when it comes to sexual transmission of HIV but they are probably not so relevant when it comes to non-sexual transmission. Or, at least, they would be relevant for quite different reasons.

Similarly, a lot of research has shown that behavioural differences don't explain variations in HIV prevalence among young people in African countries. High levels of sexual risk behaviour can be found in places with low HIV prevalence and low levels of sexual risk behaviour can be found in places with high HIV prevalence.

How much evidence does it take for the 'experts' at UNAIDS to conclude that their long held view is wrong, that most HIV is not transmitted by heterosexual sex? How much evidence do they need to find it worth their effort to investigate places where many young children are found to be HIV positive when their mothers are not? If UNAIDS recognises the dangers of allowing its own employees to use medical facilities in African countries, when will they admit that Africans living in those countries also face risks?


It’s very disturbing to hear people saying that they think HIV was created in a laboratory in America and spread deliberately, for whatever reason this might have been done. But it’s hard to shake people’s beliefs in conspiracies when they are constantly being told things that don’t make sense. Many people here know that Africans are not so different from people in other countries that their sexual habits could be almost wholly responsible for the very high rates of HIV transmission you see in some countries. But those who feel they know most about the disease assure them that this is, indeed, the case.

Those who feel they are HIV experts continue to assert the racist view that some Africans have so much more risky sex than people in other countries, it’s no wonder that HIV prevalence is very high in some places. Africans are being lied to, just not in the ways they think. The people who are tasked with eradicating HIV know that the risk of non-sexual transmission of HIV is so high that they need to protect their own employees. They just don’t tell Africans that. As a result, Africans continue to take risks that they could and should avoid. When people know about the risks they face and they know how to take steps to avoid them, HIV transmission rates will go down. But as long as the sexual behaviour paradigm clouds all HIV prevention activities, several more people will be infected with HIV for every one who receives treatment.

We in the UN Have Been Lying About HIV and Now...

Myself and a friend are taking a trip around Lake Victoria to visit some of the places where HIV prevalence is exceptionally high. Countries around the lake, Kenya, Tanzania and Uganda, all have similar HIV prevalence of between 6 and 8%. But in many places on or close to the lake shores, prevalence is (or was) often well over 20%. Bukoba in Tanzania, Suba and Homa Bay in Kenya are examples, as is Rakai in Uganda.

Our first stop was in Shirati, Tanzania, where there is a Mennonite run hospital. We were made very welcome there and visited several people who have worked for a long time with HIV and health in general. Most people were happy to talk about their experiences and concerns and we were introduced to people who work in various positions in areas around Shirati.

However, even people who work closely with HIV, as well as lay people, seem to regard HIV as being mainly sexually transmitted. This is not surprising because most public education campaigns and most money are concentrated on sexual transmission. People have been listening, to a greater or lesser extent, to all sorts of advice about using condoms, having fewer partners, testing for HIV and other sexually transmitted infections and various other measures thought to reduce transmission of HIV.

But these HIV prevention interventions have had very limited success, despite exaggerated claims by some of the people behind the emphasis on sexual transmission. Perhaps, as a lot of data shows, people in these three countries already take precautions to avoid HIV, but without success. Research has shown that sexual behaviour in African countries differs greatly from place to place, just as it does in non-African countries. In fact, there is no evidence that sexual behaviour thought to be unsafe is that much higher in African countries where HIV prevalence is high. On the contrary, often, areas that have high HIV prevalence also have low levels of unsafe sexual behaviour.

So, if levels of sexual behaviour do not explain differences in prevalence within and between various African countries and non-African countries, it is possible that HIV is also being transmitted in various non-sexual ways. Two prominent examples of this are transmission through unsafe medical procedures and through cosmetic procedures. In the former group, there could be reuse of disposable equipment or failure to sterilize equipment. In the latter, again, use of equipment that is not properly sterilized.

People we talked to showed high levels of awareness of possible exposure to HIV through sexual behaviour and this is corroborated by various research that has taken place over many years. For a long time, people have been able to list all sorts of things about sexual transmission of HIV but this has had little or no effect on HIV prevalence rates in those countries. But few mention non-sexual transmission and even when they do, they don't appear to know of ways to avoid non-sexual transmission.

Some of the people we talked to confirmed that they and their children had their hair cut by a machine that breaks the skin, especially where there are sores or new scars. But they were unaware that it is necessary to sterilize the equipment properly to avoid transmitting infection to the next person who uses the same equipment. They said that hairdressers sterilize equipment using methylated spirits or water. But they didn't know that this is not enough to ensure that all possible infection has been eliminated. They also thought that HIV infection only lives on instruments for a very short period, which is a common belief, though wrong. [There are abstracts to a couple of articles on this subject on PubMed.com, here and here.]

There is remarkably little interest in non-sexual transmission of HIV among the mainstream, UNAIDS, WHO, CDC, UN and others. There seems to be a reluctance to take on board the considerable amounts of research that suggests that a significant amount of HIV transmission occurs through non-sexual means, whether in cosmetic or medical contexts. This is surprising because non-sexual transmission has been recognised by these bodies since the mid 1980s, when HIV had only recently been identified as the virus that causes Aids.

For example, regarding medical conditions in developing countries, the UN has this advice for its employees:

"Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. 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 suggests that the UN is perfectly well aware that unsafe medical practices are widespread enough to be a threat to their employees. But they and other institutions don't seem to extend the same advice to people who live in those countries and would be likely to visit available facilities more frequently. Maybe the UN is even in conflict with UNAIDS in some instances because the latter claim that medical transmission of HIV in Kenya is around 0.6% of all transmission, meaning that they think health facilities in Kenya are very safe.

The UN goes on to say:

"In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care."

Am I being oversensitive here in detecting a total disregard for the health and safety of people who happen to live in 'several regions', while paying a lot of attention to people who generally don't have to avail of the services that the general populace have to put up with? Perhaps the UN would like to reveal what this 'notable share of new infections' is and inform UNAIDS, WHO, CDC and others. In particular, perhaps they would like to inform people who live in any of the countries they are worried about. After all, 'we' are not all privileged with being UN employees.

The UN certainly knows how to avoid medical transmission when it comes to its own employees:

"None of us should ever share with another person a needle, syringe or equipment used for injection. If we receive medical care from the UN system medical services or from a UN-affiliated health-care provider, we can be confident that every effort has been made to ensure that injecting devices used to administer a shot are sterile and will not expose us to HIV. If we need to give ourselves a shot outside a UN health-care setting, we should only use disposable needles and syringes and we should use them only once. Because safe injection practices are not followed in all healthcare settings and it may not always be possible to purchase sterile injection devices, the WHO medical kit that is made available to all UN agencies includes disposable syringes and needles."

This means that we have all the information and know-how necessary to reduce non-sexual HIV transmission. Now that we know all this, it's time we went out to tell all the people the truth. We have been telling them lies for a long time now. We have spent years telling people that HIV transmission in Africa is mainly sexual and arguing that this is because Africans have so much more unsafe sex than non-Africans. We can no longer shore up this argument, nor should we. We have the means to cut HIV transmission significantly straight away, we don't need to wait for expensive vaccines or other programmes that will take years to be effective, if they ever are effective. We just need to admit that we have been lying and make amends before more people become infected and die.

Technology is the Preserve of the Rich

Every time I see an article talking up technology in Kenya and in Africa in general, I wonder which aspect of people's lives will be transformed. Over the last few weeks myself and my colleagues from Ribbon of Hope Self Help Group have been visiting families who never complain about having little access to technology. They have very little money and little access to loans. They are often surrounded by mud roads, living a long way from the sealed roads, which are often in bad repair. There is little or no affordable public transport.

Their children sometimes have very little food, no access to clean water or improved sanitation, decent clothing, books and other basic things that they need just to be able to attend school. If children become sick, their parents have to decide between taking them out of school and treating them or leaving them in school and hoping for the best. Hospitals are a long way off, they are expensive and they are poorly equipped and staffed.

Distance education would be great for children who had basic education. But only about three quarters of children even enroll for primary school, let alone finish. And just over 40% enroll for secondary school. Even at university or tertiary level, something few ever reach (despite some great official figures), elearning cannot replace teachers, books and indeed, access. Those who have got to university are already a small percentage of Kenyans who have not been denied any of the many things that poorer children will always be denied.

One of these idiotic sites that produces lots of puff about technology says "Kenyan Universities are increasingly turning to e-learning as tool to facilitate improved education". Will this improve education? It may be a new medium for some educational content but I'd like to see research that shows that education is in any way better for being delivered by electronic means. Computers are also in short supply and skills can be non-existent, especially among those who rarely have access to a computer.

Young children, especially in rural areas, where about 80% of Kenyans live, often don't have electricity or a private place to study, or even their own personal copy of the necessary text books. Some, especially girls, have to do chores around the house and farm when they should be studying. And many have to do work in the fields and in other jobs when the need arises. These are not technology related problems.

Technologies, I suspect, work when other infrastructures are in place. A farmer can, as these fatuous articles often claim, find out the market price of a commodity by mobile phone. But if there is no road, or if the road is impassible, or transport unaffordable, what's the point? Another claim is that medical stocks and medicines can be monitored electronically. The biggest problem in a lot of hospitals is the shortage or staff and medicines. Who is going to do the stocktaking and what stock are they going to monitor if there is not an adequate supply of drugs?

If the problems that most people experience can be relieved by various technologies, great. If everyone has access to these technologies and things in Kenya can change radically, wonderful. But if all these articles want to show is that some people use and like and even profit from technology, they are pointless articles, only useful to people who are already convinced that technology will pull everyone out of every problem them currently face. Technology will not solve problems of inequalities between rich and poor, between males and females, between rural and urban dwellers. Technology seems, at present, to be the preserve of the rich. And if their past behaviour is anything to go by, it will stay that way.

Some Adverse Circumstances, Some Healthy Projects

The weather in the Kenyan Rift Valley has not changed much in several months. The rainy season that was expected to end earlier in the year has not let up yet. Many people waited for the rain to ease before planting crops, trying to avoid losing them to flooding. Others took a chance and some crops are growing, some are not. But some crops will eventually need hot dry weather to ripen and dry out for harvesting. And until it dries out enough, we will not be able to finish preparing another field which has had nothing growing in it for over a month.

A lot of areas around the country have had severe flooding recently. There have been 70 or 80 deaths (there is a lot of disagreement about exact numbers) since the beginning of the year and many tens of thousands of people have been displaced. In Mogotio also, over 60 families were displaced in the December/January floods. They have since been living in UNHCR tents, partly because the areas they were in are still prone to flooding and partly because they were squatters and are not allowed to return to where they were. There is a lot of land in the area, unused and underused. But it is 'owned' by a Greek sisal farmer and a handful of other rich people. They are not known for handing over even very small amounts of land. Some of them don't even bother paying their employees most of the time.

We at Ribbon of Hope Self Help Group have had mixed luck during the prolonged rains. We planted an acre of maize and beans. The maize is doing fine, the beans not so good. We plan to harvest some of the beans while they are still green and use them straight away. It's unlikely that they will dry out enough to be harvested, dried and stored, so we have to cut our losses. The maize should be fine, especially if the rain stops, as expected, some time in June. But if the weather continues warm and wet, we could lose everything yet again. Other crops that we planted on smaller patches of ground may be threatened as well.

When it's too dry, at least we can irrigate. But when it's too wet, there's not much we can do. Instead of working on the crops in the last few days, we went to some more villages to assess orphans for the orphan and vulnerable children (OVC) programme that we are starting. But even then we were thwarted by the rain. We had walked quite a long way from the main road through Mogotio to an area called Sarambei when the rain started. We just had to sit for a couple of hours because the dirt tracks had turned to rivers of muddy water. Luckily, we were with some very hospitable people when the rain started, who plied us with tea until it cleared a bit.

All of the children we have seen, without exception, are in bad need of support. Almost all of their guardians seem to be able and willing to care for the children. But when a child is with someone who seems unsuitable, this creates quite a dilemma. When a guardian has a drink problem and seems totally oblivious to a young child's needs, that child is a lot more vulnerable than the ones who are with good carers, no matter how poor their carers are. We have almost reached our target of 20 or 21 children and we'll then have to decide how to approach each family. They will certainly all require different approaches, being dissimilar in many ways.

But some of our projects have been doing especially well. A small group of people started a rabbit breeding project with three rabbits less than two months ago. They now have 15 as two have given birth. In a few months, they should have a fine project and it will probably be split up so that each group member has their own small project. It's expensive to start off with, rabbits need good housing and other things, but it's not so expensive once it gets going. My only worry is that I have still not met a Kenyan who has eaten rabbit or who intends eating one. Apparently there is a market for rabbits but I've heard about markets before that just dried up as soon as you start trying to sell something. Perhaps I'm just too skeptical. Perhaps they will eat the rabbits if they can't sell them, they could do with the protein.

The same group also started a chicken project that was very slow to get going. I've mentioned the group before because they had a leader who seemed hell bent on making sure they never got anywhere. They got rid of him and since, the chicken project has picked up and most people in the group now have enough chickens to eat some eggs and sell the surplus. In fact, even the uncooperative former leader himself has a good flock of hens, thanks to the project. Bad weather conditions and disruptive people cause the most problems with the various projects we are involved in. But despite everything, some of the projects still produce good results, thankfully. Others will probably just take time. Many things take longer than expected here.

The Rising Tide that Floats all Goats

On a big wide plain, surrounded by hills, lived the finest herd of goats ever seen. The greatest of them were immensely hairy and roamed around, eating too much and proclaiming themselves to be the hairiest in creation. They kept the best pastures for themselves and spent a lot of time at the top of the hills, from where they could survey their minions. Anything they didn’t want would roll down the hills and on to the plain, and they considered this to be a very good thing.

Their minions were not so hairy and lived all their lives tethered to posts. All day, every day, they grazed the little that grew in the small disk around their posts. And many had to share their disk of grass with others because the posts were so close together. Sometimes, the free goats would even come and steal grass from the tethered goats, although they had plenty of their own and were free to graze anywhere.

The free goats would often discuss the conditions that the tethered goats had to live in. They would ask if the tethered goats shouldn’t have longer ropes, or even shorter ropes. They would ask if the rope should be made of different materials, perhaps cheaper ones. Once, they even tethered some of the goats with bungees, which meant that they would struggle to a little green grass only to be pulled back just as they started to eat it. This caused the tethered goats a lot of suffering but the free goats found it amusing, especially when the tethered goats hit their posts.

Every now and again, a free goat would have the temerity to suggest that all goats should be free, that none should be tethered and that the plains are subject to floods and eventually everyone will suffer, tethered or free. On such occasions, the biggest and hairiest free goat would be summoned, because he was considered to be the wisest. At least, he had the most impressive set of dried dingleberries that rattled as he walked around, a quality much prized among free goats.

This hairy goat would remonstrate with the outspoken goat and point out that great wisdom does not lie in giving the best answers to questions, or even in asking the best questions. Great wisdom lies in recognising who is the wisest and doing exactly as they do. If the wisest has long shaggy hair and a profusion of dingleberries, this is what one must emulate. As for flooding, he pronounced, the rising tide will float all goats.

And he was right, the tide rose and the goats all floated, for a while. The tethered goats were quickly submerged and the free ones ran for the hills. The water kept rising and food supplies dwindled, but the few free goats that were left ate more than ever. The one with the great dingleberries drowned because wet dingleberries don’t float. And the remaining free goats continue to live in isolated groups at the very tops of the highest hills, wondering what to do now that their hairy leader has gone.

Dingleberries are a lot less fashionable now, and even hairiness is no longer much sought after. But the ability to balance on all four feet on a very small patch of ground is considered to be a sign of great wisdom among free goats.

Health Minister Takes Aim at Own Foot

In addition to proposing a draconian law to make certain sex related crimes capital offences, the Ugandan government is also considering a law to criminalize ‘deliberate’ transmission of HIV. The ‘State Minister for Health in charge of General Duties’ (is that the same as ‘Minister of Health’?), Richard Nduhura says he is now behind the law, having previously had some reservations. President Museveni also supports the law, which never bodes well.

Naturally, human rights activists and people who have some feelings of humanity are opposed to these laws. Some of them have spent three decades trying to reduce stigma against HIV positive people, whereas laws like these will increase it. People will think twice before having a HIV test, or even going to hospital, if they think they may be HIV positive. Uganda needs more people to test for HIV, not fewer. With these laws, anyone who is at risk of being HIV positive, or even anyone who may be suspected of being at risk, also risks discrimination by neighbours, police and other professionals.

This is particularly serious in a country like Uganda because UNAIDS maintains the contested claim that most HIV is transmitted by heterosexual sex. That means that all pregnant women, their partners and those suspected of having had sex in the past could be HIV positive. After all, the majority of new infections are occurring inside marriages and steady relationships. Therefore, these are the people, along with men who have sex with men, intravenous drug users and commercial sex workers (or anyone believed to belong to these groups) who are most likely to become infected and to be spreading HIV.

But there is a rather more troubling aspect to making ‘deliberate’ transmission an offence. The law is clearly aimed at people who are already discriminated against, along with a lot of other people who will soon be discriminated against. But will it also apply to providers working in medical facilities and those working places where people receive cosmetic treatment? It has long been established that medical and cosmetic transmission of HIV is far more common than the mainstream HIV industry people will admit. But if it ever gets out that people working in these sectors are ‘deliberately’ transmitting HIV, they too will become victims of the law.
What about the esteemed State Minister for Health in charge of General Duties, himself? Healthcare personnel, I am sure, are not ‘deliberately’ infecting people. But what about the ones who reuse a needle or a syringe or fail to sterilize equipment properly? They would be well aware that this carries a big risk of transmitting HIV and other diseases. Perhaps there is a shortage of equipment, perhaps people haven’t received adequate training or perhaps someone is making money on the side by selling reused medical equipment or stealing it and selling it on the black market (I’m not necessarily talking about frontline healthcare personnel, by the way). Isn’t the State Minister for Health in charge of General Duties responsible for the conditions of medical facilities currently extant in Uganda?

Ok, the word ‘deliberately’ is in inverted commas for a reason. How can you tell that transmission is deliberate? I think the answer is simple enough: in many cases, you can’t. Some people may transmit HIV because they didn’t take adequate precautions, others may just be unlucky. Others still may not know they are HIV positive. But this applies to non-sexual transmission as much as it applies to sexual transmission. Healthcare personnel and people providing cosmetic services may not know that the last person on which a piece of equipment was used was HIV positive, before going on to use it on someone else without ensuring that it is properly sterilized.

Will people who use razors and other sharp instruments for hairdressing or other cosmetic treatments be liable for ‘deliberate’ transmission of HIV, if they and their clients happen to be so unlucky? Right now, the word on the street about HIV is that medical transmission is so low as to be almost irrelevant and cosmetic transmission is pretty much irrelevant. But once the hunt is on for people to blame, there will surely be questions about the most efficient means of transmitting HIV, that is, through blood contact.

The aim of HIV prevention policies should be to identify the people who are at risk and to deal with the sources of risk. The aim should not be to group people according to how likely they are to transmit HIV or to be infected with HIV and then to create a law which will end up discriminating against them. But by threatening to punish all ‘deliberate’ transmission of HIV, this law could also punish those who are not currently thought of as transmitting the disease at all, health professionals and those in other service sectors where blood transmission may occur.

In a country where most health spending comes out of the pockets of poor Ugandans and from donors, and very little comes from the government, things are not as neat and tidy as this proposed law may assume. If the aim is to identify all the ways in which people are becoming infected and prevent further infections and also to treat those who are already infected, the health minister and his colleagues are going the wrong way about it. They have, rather predictably, failed to control people’s behaviour as a means of reducing transmission of HIV. They will also fail to reduce transmission by threatening people in ways that result in them being very unlikely to get tested or to declare their status if they are HIV positive. The last thing Uganda needs now is more failure.

Good News for UNAIDS: We Know How to Turn Off the Tap

An article in the New York Times suggests that the "war on global Aids" is falling apart. Although drug prices have fallen dramatically and the number of people on antiretroviral drugs has risen, this effort to give HIV drugs to everyone that needs them has proved to be unsustainable. In countries like Kenya and Uganda, most of the funding was provided by donors who are now reducing funding, partly, they say, because of the global financial crisis.

But the article suggests that the financial crisis is not the only reason. Big donors are disillusioned at their lack of success, despite spending huge amounts of money on the problem. "For every 100 people put on treatment, 250 are newly infected"; prevention programmes have either been too expensive or almost completely ineffective or both. Donors are now going to turn their attention to cheaper diseases.

Using an often used metaphor, Dr David Kihumuro Apuuli, DG of the Uganda Aids Commission says that "You cannot mop the floor when the tap is still running on it". The executive director of the Global Fund to Fight Aids, TB and Malaria is "frustrated", a researcher from the National Institute of Health is "pessimistic", Obama's Aids Ambassador is "worried", the executive director of UNAIDS is "scared" and the former executive director "has seen optimism soar and then fade".

Well, David, Michel K, Anthony, Eric, Michel S, and Peter, there is a way to reduce the flow from the tap, even if we don't know how to turn it off completely. This may eventually reduce the flow to a trickle and the number of new HIV cases every year could become so small that there is no longer an epidemic. Yes, a new direction is required, but this new direction has already been researched carefully and described by a number of experienced researchers.

Here's what we need to do: we need to re-evaluate the considerable evidence that unsafe medical practices are contributing a lot more to HIV transmission than is currently estimated by UNAIDS. We also need to include in this re-evaluation unsafe cosmetic practices, especially those that, either accidentally or on purpose, draw blood and thereby contaminate instruments.

Aids spending has concentrated overwhelmingly on treatment for much of the last three decades. And much of the money spent on preventing new infections went on mother to child transmission and some rather hopeless exhortations to abstain from sex, reduce numbers of partners and use condoms. Safe sex and increasing condom use are very important for reducing sexually transmitted HIV but they are completely useless when it comes to non-sexually transmitted HIV.

To continue the rather tired metaphor, UNAIDS and many other concerned parties have been turning the tap the wrong way, because anyone infected non-sexually can go on to infect others through sexual contact. Those who are now disillusioned because the number of people becoming newly infected every year still exceeds the number receiving treatment may be inspired when they see this trend slowing down. They may be persuaded to continue paying for more treatment if they think that the numbers of new infections will go down every year from now on.

It has been obvious for a long time that the small number of countries in the world where the vast majority of HIV positive people live are not inhabited by people who have unbelievable numbers of sexual experiences with incalculable numbers of sexual partners. Indeed, only a very dedicated adherent to some long discredited and rather racist views of African people could even countenance such an explanation.

So, HIV prevention is not so intractable as some would have us believe. Yes, it's hard to influence sexual behaviour to any great extent. But if less HIV transmission can be put down to sexual transmission then a lot of money currently being spent on the programmes that are not working can be saved for something worthwhile. And money spent on health services now will result in immediate savings. Ensuring safer medical and cosmetic practices will prevent both direct infections and the indirect infections caused by those infected directly, either sexually or non-sexually.

I call on UNAIDS and all those working in the field to take the official advice, to 'Know your epidemic (or pandemic), know your response'. To understand why HIV has been spreading the way it has in high prevalence countries, we need to look at the most efficient ways of spreading the disease: blood contact. A combination of unsafe medical practices and unsafe cosmetic practices is continuing to spread HIV simply because the official view is that HIV is predominantly spread by unsafe heterosexual sex in high prevalence countries and that blood exposures are so rare as to be insignificant. You know your response has failed, therefore, how well do you know your epidemic?

More Assessments and a Visit to a Clinic

My trip today with Ribbon of Hope Self Help Group took us to Lomolo, about 40 minutes cycle from Mogotio and the main road. The conditions were not too bad, despite heavy rains recently. We visited three families, one of which has two orphans. As with the other villages, everyone seemed equally deserving and, no doubt, there are many other deserving families and orphans in all the places we visited.

There was a woman with twelve of her own children (two of whom are grown up) to take care of, yet she is also taking care of a teenage orphan who is doing very well at school. I really don't know how she makes her meagre income go so far! There was also a woman with no children of her own who is taking care of two orphans (who are not siblings). One of them is HIV positive, the other may be, but has not been tested. And there is a young mother who is so sick herself that she is finding it difficult to look after her one daughter.

Once we have done the assessments we can get a better idea of how we can help, especially in ways that will support the whole family. We need to find income generation activities that will give the family extra money and some of that money needs to be forthcoming very soon. Everyone we have spoken to has arrears of some kind, along with bills that soon have to be paid. People do a combination of borrowing and begging sometimes, but most very poor people don't have easy access to microfinance.

On the way to the village, we passed a man who had to make the difficult and expensive trip to Mogotio to see the area chief. Apparently, the microcredit organisation he went to insisted on him getting a letter from the chief. In addition to the time and money (including lost earnings), the chief will require some money, too. Asking someone in a position of authority just to do their job doesn't come cheap.

After the assessments, we went to see a client who is in a local clinic. He's very sick, either not responding to his antiretroviral (ARV) drugs or just not taking them. Neighbours say he was drinking a lot, which often results in people not adhering well to their drug regime, for whatever reason. The drugs are hard to hold down when you don't have enough food but also, probably, when you have a hangover.

Anyhow, we didn't get to the bottom of it because he had such a bad bout of meningitis that he looks like he is recovering from a stroke. He is finding it hard to talk and is difficult to understand. My colleague says he probably has other impairments in addition to his speech. He is emaciated and weak, which is not surprising. We can only hope that his current condition improves and he gets back to his ARV regime. But it's not a foregone conclusion.

On the subject of medical facilities, there was an article in the paper recently about an assistant health minister who visited a hospital in Bungoma, unannounced. I don't see the point in letting a hospital know you are coming as many things can be done to make conditions look better than they are. Anyhow, the man got many shocks. He saw how long people had to wait, some even dying as they waited, the arrogance with which people are treated, the conditions in the hospital and the tendency of people working there to try to cover up things. There were even the bodies of some children that had been left on a bed and he was told they were sleeping.

The man must have a fair idea of what things are like in public hospitals. If he doesn't, he should look for another job. Hospitals are underfunded, understaffed and cannot deal with the number of patients they get. The staff are often not very well trained, they don't get paid too well and they are underequipped. Drugs and other things are in scarce supply and buildings are old and crumbling. These are the conditions in which, UNAIDS claims, only 0.6% of HIV transmission comes from unsafe medical practices. Just how much evidence do they need that this claim should be reconsidered?

Education in a Box, Or Not

I recently mentioned the One Laptop Per Child project (OLPC), which aims to provide every child in developing countries with a low spec laptop. These laptops will cost between $190 and $200, which is a lot of money when you consider that government health spending per capita is a lot less than this (though figures vary a lot). I don't seriously believe that a project like this will have much benefit if teachers are left out of the picture. But according to a more recent article "Basic computers skills to enable children use the computers can be learnt in a day".

Having spent some time trying to help people who had never used computers before learn basic things, I would question any claim that you can teach teachers how to teach with these computers in a day. Perhaps it's just a reflection on my teaching skills, but I think people need a long time to get used to complex equipment and to go on to teach others.

But I especially wonder how these computers will "help to get children to learn how to think critically and analytically to become problem solvers." I agree wholeheartedly that children need to learn these things, so do most adults. But how till the introduction of the computers achieve this? Yet again, teachers will need time to learn how to impart critical thinking and analytical skills and to include them in the current curriculum. Laptops are neither necessary nor sufficient for this, they seem quite irrelevant, in fact.

I guess I'm repeating myself but if this project "aims to change the way children are taught" it will need to change the way teachers teach. This is not going to happen over night. Sure, some children will take on laptops quickly and perhaps put them to good use, but many children here lack the most basic skills, such as reading and writing. And they lack them because of other basic needs not being catered for. They don't learn to write properly because they don't have proper desks or three people are sharing a desk made for two. And they don't get much reading practice because they have no books or because there is no electricity at home. Many children don't attend school very often, for various reasons, many have far too many other things to do and neglect their study.

It is quite true that current classroom practice involves getting children to memorize a lot of things, but have people become more critical in their thinking since the advent of cheap laptops and computers? I don't believe so. And is the alternative to memorizing things just bearing in mind that everything they need to know is somewhere there in the laptop? If it is, then it is in danger of staying in the laptop. I think we are being conned into thinking that education in East Africa is suddenly going to improve because children are given cheap laptops.

Also, apparently the laptops are designed for 6-12 year olds. This is something I hadn't realized before. What people over the age of 12 are going to do is anyone's guess. Perhaps they are expected to still have the skills they acquire when they have access to a computer many years later. I sound like a Luddite, which I'm certainly not. But it's just one more piece of technology being thrown at a problem that is not technological. Children need good basic education, they need good basic materials and they need well trained teachers. If the OLPC project proposes providing these, great. Otherwise it will have little benefit.

Development and Sustainability

Back in Mogotio today with Ribbon of Hope Self Help Group. We have to go to five villages and identify four especially needy orphans so that we can support their adoptive families to care for them. Not that it's a difficult job to identify four, we ended up with five today and pleas for several others. Yesterday, also, we had several pleas from mothers who heard there were people assessing orphans in the area. It doesn't take long for the word to get around but it's hard to have to tell people that we only have the funding for a very limited number right now.

Today we went to Alfega (a corruption of Alpha and Omega, reflecting the Greek 'ownership' of most of the land in the area), which is about one hour of difficult cycling from Mogotio. I was given one of the very heavy but resilient Indian 'Avon' bikes and told the brakes were not too good. I would have been surprised if I had been told they were good and I've never cycled on a bike that had two brakes here. But by the time I was on a steep hill trying to check my speed, the one brake had failed. I made various attempts to slow down before preparing myself for a crash landing, which I found in a bank of clay that happened to be at just the right angle to stop me without resurfacing my face.

Without further incident, we took the least muddy route through the kilometres of sisal. It was very hot and there were several places where we struggled to push the bikes through the wet mud, but all in all, it was an enjoyable journey. The area is particularly beautiful in the present, rainy season, just a bit wet sometimes. And in the midst of all the sisal, we spotted some industrial greenhouses and some bright green fields of something other than sisal. I hoped to see food crops but, alas, there was mostly flowers (for the European market) and coffee grown there. The area is owned by one of the sons of the former president, Moi, who was quite acquisitive in his time.

Like Majani Mingi, where we went yesterday, Alfega is pretty isolated. The best roads that surround it are mud roads and impassable during and just after the rain. And it's expensive to make the journey if you really need to. So most people don't leave the village much. In spite of being surrounded by such greenery and wealth, the village is as poor as Majani Mingi and far more populous. The latter has a population of only three or four thousand, Alfega is closer to eight thousand. Of course, I never know whether the population figures we are given count the children or just the adults.

We visited four houses, assessing five orphans in all. They were all in need of assistance and the worst thing is seeing the problems that their families have to cope with. It's amazing that families that are so overstretched will still take on another child to care for, but it does seem to happen a lot. And Ribbon of Hope is fortunate enough to have members who are from the area because otherwise, it would be impossible to tell who is genuine and who is not. Even people who are clearly in need sometimes tell a few white lies to try and have one of their children assessed, which is not really surprising.

And that's another way in which we are fortunate, we have limited funding, so we have to be very careful. I've seen and heard of organisations that have large amounts of funding but they end up using it rather indiscriminately and even losing it to people who are not really in need. Organisations shouldn't have any more cash than they know how to administrate. Our biggest asset right now is the closeness of some of our members to the local community we hope to assist.

Just as it seems unfair to help people who are HIV positive when other people are suffering from all sorts of treatable and curable illnesses, it sometimes seems unfair to single out orphaned and vulnerable children for special assistance when there are others who are in equal need. And this is a dilemma that we face every time we visit such villages. Today and yesterday, we saw people, adults and children, who were suffering, but they probably won't attract the attention of NGOs. We try to do things that benefit communities as a whole as well, but we are small right now. Hopefully, things will change over time.

Incidentally, it's worth pointing out that in this area that is mostly owned by Gideon Moi, there are a lot of public toilets being built. As the houses there don't have good sanitation, this sort of intervention will have major benefits for everyone in the village. Water and sanitation related illnesses give rise to a huge share of the disease burden and deaths in developing countries. The Greek owned area around Majani Mingi didn't have any public toilets that I could see and it is likely that the overall health in Alfega in the near future will be far better as a result. I hope to see more of this kind of public intervention, despite the dominance of private (and highly exploitative) enterprise in the area.

Ideally, Ribbon of Hope Self Help Group won't get much bigger because the things we are doing now will be done by other self help groups. To some extent this is already happening. But there is a certain futility to NGOs and community based organisations (CBO) continually setting up and targeting the people and things they most want to benefit, only to be replaced by more NGOs and CBOs, without an end in sight. It would be nice to think that communities like Alfega and Majani Mingi will one day be able to support themselves, perhaps because of the support they received in the past from various parties.

In fact, if that is not what happens, if the development that we are involved in now is not sustainable, if it doesn't give rise to further development that is greater than what came before, I think it may have failed. But the possibility that what we are doing now may only have a short term benefit and that others may have to come and do the same again and again in the future is no reason to stop doing what we are doing. Unless we are doing some harm, and I hope we are not doing that.

A New Orphan Project (and Another Grumble About Pills)

I recently blogged about the tendency to medicalise problems that have very simple and cheap solutions. For example, if people are suffering from nutritional deficiencies, they need a good balanced diet and therefore access to adequate food. So many companies, especially multinationals, are weighing in with their very expensive food supplements and 'biofortified' versions of various seeds. If people don't have the money for even their meager diet, they certainly can't afford these overpriced supplements and fortified seeds.

But as myself and my colleagues from Ribbon of Hope Self Help Group sat in a restaurant having a meeting yesterday, a woman came up to us to sell us some nutritional supplements which had all manner of stuff in them, according to the colourful label. But they were to be taken three a day for seven days to relieve just about any ailment that could possibly relate to nutritional deficiency. And the course cost as much as more than two weeks of staple food for four or five people.

If people had this sort of money, they could just buy good food. They would be ill advised to spend it on pills that some woman who approached them in a restaurant tried to sell them. But people do buy all sorts of rubbish that promises to sort out all their children's or their own problems. This is a terrible form of exploitation and the stuff being sold is often produced by very big, powerful, wealthy companies. We tried to persuade her that what she was saying couldn't be true. But you can't blame her for trying to make a living in a country where most people don't have jobs. After all, she's been conned too.

Anyhow, today we went to a small village called Majani Mingi to assess some orphans so their families can be supported to send the orphans to school and look after them, along with the rest of their family. Majani Mingi is near Mogotio, about 50 kilometres North of Nakuru. In fact, you can't get to Majani Mingi most of the time and the best way to get there is by motor bike. It's about 10 kilometres from the main road but, despite this, you never leave the massive sisal estate that is 'owned' by a Greek man who can't even be bothered to pay his employees and suppliers most of the time.

With this in mind, we visited four households, taking in 5 orphans in all. All of them had lost both of their parents and all were being cared for by families that were already stretched for the means to keep providing themselves with the basics. Most people in the village have some connection, direct or indirect, with the sisal factory, either as employees or people who are dependent on employees. I think it is safe to say that pretty much all the people living in these sisal dominated villages are very needy, so it's hard to assess children and families when your finances will only stretch to four children.

We can put together the information we have received, along with similar information for four other villages and then make a decision. I suspect that families themselves will have to decide how to use any support they get because when money is in short supply, so is everything else. You can't very well ask a family of thirteen to give food, clothes and schooling to the one orphan and leave the others without. I really don't know how these decisions are made at the family level. I hope to gain some insight into this over the next few months.

There can be a tendency to associate orphans and other vulnerable children with orphanages. But thankfully, Ribbon of Hope is not interested in such institutions, they are beyond our scope. They cost so much money to run and the children do not get the sort of care they could get in a family. And so many orphanages have been hotbeds of corruption and deceit, where often children get very little and those running the orphanages make a very comfortable living. Of course, they are not all like that, but finding out which are genuine and which are not is just too time and resource consuming. As the orphan and vulnerable children project gets up and running, I'll report progress here.

Why Do Some Discount Altruism That Isn't 'Pure'?

A journalist writing in the Irish Herald ends an article on 'charity gurus' by saying "charity work is best done when it is done quietly". I assume that charity work that is done quietly is that which doesn't attract the attention of the mainstream media, press, TV, glossy magazines, the works. Because this journalist may be relieved to know that most charity work is done quietly, most people doing volunteer work or any other kind of development work, attract little or no attention. I find that gurus of all kinds are created by the very media that so loves to then condemn them once they are no longer able to control them.

This journalist, apparently, made a film about a woman who started a charity in Asia and 'hands out wads of cash to the poor'. The woman enjoys giving money to the poor and the journalist interprets this as meaning that the woman enjoys their gratitude and adoration.

Again, the journalist need not worry so much. I have never seen or heard of someone working in development who hands out wads of cash. Nor is everyone particularly grateful, nor do most people who do voluntary work expect people to be grateful. At least, that's my experience. People who receive charity may sometimes be grateful, perhaps very grateful, but their reaction may be embarrassment, shyness, contempt or perhaps a combination of things, often contradictory things.

I'm not saying this journalist is wrong or that she is misinterpreting things. I'm just saying that she is perhaps underanalysing what appears to be a rather unusual phenomenon. And I don't think she is cynical in interpreting the charity woman's enjoyment the way she does. I'm sure that among all the emotions and sensations people who work in development feel, it wouldn't be unusual to feel some enjoyment of any gratitude and adoration, if they receive such.

But supposing you were to do a survey of lots of people who worked, in any job, to find out what they enjoy about their work, or even why they work at all. I think you would find that many people work for money. They may or may not enjoy their work but the majority will do the job they do because they have to do something to pay their way. But I don't think your analysis of the survey would be very interesting or insightful if it was your main conclusion that people work for money.

Some people working in development earn money, some earn quite a lot. But most of the people I have known working in the field earn very little. Some volunteers earn a local wage and have all their expenses paid. But again, most of the volunteers I know do not earn regular wages, nor do they receive much in the way of expenses. Most of them volunteer for some of the week and do other things the rest of the time, so that they can feed themselves and perhaps their families.

I haven't surveyed the people I know who give some, often a lot, of their time for free. But one, who works as a volunteer for part of almost ever day has even pointed out to me that often when you do a lot for someone, they don't want to know you once they are better. Those were his words. This man has a sense of public spiritedness that you rarely find even among volunteers. Another volunteer, a woman, has never really discussed the subject. But she gives her time and sympathy and even some of the little money she has. And she also knows that people who receive her care can treat her with scorn later.

In fact, most of the volunteers I know don't even give out money most of the time because they don't have very much. They do work, take time, donate their skills and reach out to people who have no one. I don't know if they go home at night and bask in the glory of doing something that they may never even receive thanks for, let alone money. Nor do I care, I don't believe that altruism needs to be 'pure' in order to be altruism. People's motives for anything can be mixed, contradictory and even hidden to them.

By all means, Ms Journalist, condemn the thieves, the bullies, the smug, the sanctimonious, the extortionists and whoever else you like in the world of development, charity and the voluntary sector. But please recognise that they are probably the ones who were unusual enough to be picked out by you and your rather undiscerning and unanalytical media friends. They were picked out because they were unusual, not because they were the low key, modest people who often do things for other people without first thinking what there might be in it for them.

UNAIDS To Reconsider Evidence on Non-Sexual HIV Transmission: Only Joking!

My post was getting a bit long yesterday but it is also important to remember other blood related risks that may transmit HIV, hepatitis B and C and other blood borne diseases. For example, sharing a razor or perhaps certain cosmetic instruments, tattooing equipment and body piercing equipment that haven't been sterilized, can all be risky. Yet, UNAIDS don't mention any of these possibilities in their 2009 Aids Epidemic Update.

It seems extraordinary that, given the efficiency of transmission of blood contaminated instruments and the relative inefficiency of sexual transmission, UNAIDS should be happy to dismiss medical transmission as very small and to fail completely to mention cosmetic or other modes of transmission. Have they even checked, and can we see the data collected? We just don't know how much these phenomena could have contributed to HIV epidemics in countries with very high prevalence.

In Kenya and Tanzania, haircutting and other cosmetic processes don't just take place in hairdressers and salons. Women go to each other's homes for such things and you even see people doing their grooming in public. In Dar es Salaam, several times, I saw men shaving the head of another man with a hand held, two sided razor. They would then swap over and both would end up with a lot of cuts on their heads. It's impossible to estimate how much this could contribute unless it is properly investigated.

Yet UNAIDS can happily report the various modes of transmission and say that sexual transmission can even account for 94% of all transmission in Swaziland. That means that the extremely risky (male to male and male to female) anal sex that must take place accounts for only a few percent, at the most. Hospitals and clinics in Swaziland must be so well run that they also account for a few percent. Barbershops, tattoo parlours and hairdressers hardly ever contaminate anyone, perhaps never. And this is in a country with over 25% HIV prevalence! Come on, UNAIDS, this is just not credible.

But UNAIDS and many others just keep to the behavioural paradigm which says that in African countries, HIV is mostly transmitted by sexual intercourse whereas in non-African countries it is mainly transmitted by intravenous drug use, men having sex with men, commercial sex work and a few other things. This behavioural paradigm is one of the main sources of stigma and, despite deploring stigma, UNAIDS will not admit that the paradigm is based on a lot of guesswork and a lot of effort to ignore anything that may contradict them.

What UNAIDS need to do is admit that they are wrong, that research does not show that HIV is mostly transmitted by heterosexual sex in African countries. On the contrary, there is plenty of evidence that most people in African countries do not indulge in the levels of unsafe sex, or any kind of sex, that would be required for the behavioural paradigm to be credible. In addition, there is plenty of evidence that medical and cosmetic procedures often take place in unsterile conditions. It is simply not possible for non-sexual modes to account for as small a percentage of HIV transmission as they would have us believe.

HIV Stigma and Institutional Racism

The received view about HIV these days is that unless you are a gay man, a sex worker or an injecting drug user, you are unlikely to be infected. At least, that’s the received view in rich countries. In fact, in their 2009 Aids Epidemic Update, UNAIDS don’t even mention sex workers for North America and Western and Central Europe. They say “[i]n North America and in Western and Central Europe, national epidemics are concentrated among key populations at higher risk, especially men who have sex with men, injecting drug users and immigrants”. Despite this though, heterosexual sex appears to account for about 30% of transmission.

But in poorer countries, especially in Africa, the received view is somewhat different. Here, it is claimed that the most common way of spreading HIV is through heterosexual (vaginal) sex. UNAIDS say “[h]eterosexual intercourse remains the primary mode of HIV transmission in sub-Saharan Africa, with extensive ongoing transmission to newborns and breastfed babies.” They even claim that 94% of transmission is by heterosexual sex in Swaziland.

But the report goes on to suggest, effectively, that low risk sex is high risk sex in Lesotho and Kenya because it accounts for most transmission. “In Lesotho, between 35% and 62% of incident HIV infections in 2008 occurred among people who had a single sexual partner. Heterosexual sex within a union or regular partnership accounted for an estimated 44% of incident HIV infections in Kenya in 2006, while casual heterosexual sex accounted for an additional 20% of new infections”. However, if low risk sex is high risk, this just begs the question of how sexual behaviour could account for so much transmission in some countries but not others. Most people in every country have low risk sex but most countries don't have high HIV prevalence. UNAIDS accept that gay men and drug users are also at high risk, but that they contribute far less to the epidemic.

According to this received view, sex workers in African countries would be particularly at risk, along with their clients and their clients’ other sexual partners. So it’s easy to see how stigma creeps in. If you become infected with HIV, you are probably a prostitute, someone who frequents prostitutes or, even worse, a gay man or an injecting drug user. Because of the stigma attaching to HIV, people are often less quick to see that there are many who could have been infected unwittingly. And the issue of infants being infected by their mother can also be an inconvenience when painting a picture of rampant illicit sex and drug taking.

A former UNAIDS employee, Elizabeth Pisani, says “HIV is mostly about people doing stupid things in the pursuit of pleasure or money”. She also says “In Africa, people are contracting the virus through heterosexual, non-commercial sex”. Pisani is someone who certainly knows how to reinforce stigmatizing views. I’m surprised she ever left UNAIDS.

Of course, heterosexual sex would account for a substantial proportion of HIV transmission. But how substantial is anyone’s guess. Because, holders of the received view claim that HIV infection through accidental blood exposure in poor countries is low or negligible. Back to UNAIDS again: “A small percentage of prevalent HIV infections in sub-Saharan Africa is estimated to stem from unsafe injections in medical settings.” Also: “In an analysis of data from Kenya, medical injections were estimated to be the source of 0.6% of all HIV infections”. Though strangely enough, they admit that medical transmission is far more significant in Uganda.

They even find that in Eastern Europe and Central Asia “[i]n addition to new infections associated with injecting drug use and unprotected sex, key informants and scattered media reports suggest that a notable number of new infections may be occurring as a result of unsafe injections in health-care settings.” However, what they mean by ‘key informants’ etc., actually refers to a whole body of evidence about unsafe injections that UNAIDS are unwilling to countenance, so they ignore it.

In hospitals and clinics in developing countries, instruments that are contaminated with blood and various blood-borne diseases may be reused or inadequately sterilized. Health services are underfunded, understaffed and short of resources. There is no lack of evidence that they are risky places. So how can UNAIDS come up with these figures for medical transmission of HIV? Well, by being selective about what evidence they cite and by ignoring anything they don’t like the look of. High rates of medical transmission, and consequently, lower rates of sexual transmission, doesn’t fit with the view that, in Africa, people have a lot of unsafe sex. And institutions, politicians, churches and funders are interested in supporting sexual behaviour change programmes.

These same people are probably not interested in accepting that some of the problem may arise from unhygienic practices in the very health facilities where they are urging people to go for testing and treatment. The mainstream doesn’t want to see itself as being a significant part of the problem. So UN and WHO personnel, diplomats and other high ranking officers are issued with their own needles and syringes when they are visiting African countries. They are also given instructions to avoid treatment if at all possible.

But Africans themselves are supposed to visit whatever health facility is available to them without even a warning about the risks they face or the precautions they can take. And if they are infected with HIV, they will probably unknowingly go on to infect others.

It seems to me that racist attitudes allow members of institutions such as UNAIDS to assume that Africans have lots of unsafe sex, but that most non-Africans don’t. And racist attitudes allow these institutions to recommend that their employees avoid medical facilities in developing countries, without doing the same for people who have to live in those countries.

In Western countries, people travelling to African countries are likely to be made aware of some of the potential risks of visiting medical facilities there. They can buy information about medical safety and even kits containing syringes, needles and the like, so they can reduce the risks they face further. If it is so important for Westerners visiting African countries to take care when visiting medical facilities, or even to avoid visiting them altogether, why is it not equally important to protect Africans from being infected in these facilities?