Wednesday, September 29, 2010

Will Kenya Challenge UNAIDS Over Health Care Transmitted HIV?

Despite resolute denial from UNAIDS and other parties that a significant proportion of HIV transmission could be from medical procedures, injections in particular, there is at least one Kenyan politician who disagrees. And he is the Medical Services Minister, Anyang' Nyong'o.

Mr Nyong’o is quite frank about problems in health care provision, especially for poorer people. He points out that between 33 and 50% of Kenyans are taking the wrong drugs and up to 75% of antibiotics in Africa are prescribed inappropriately.

The minister has drawn attention to shortages of nurses, with only about one quarter the number required to meet WHO guidelines. There are also shortages among other health care personnel and overall standards are deteriorating.

Of particular importance, the minister said that there is “widespread use of the injection and prevalence of unsafe practices which put communities at risk of blood-borne diseases like Hepatitis B and C and HIV.” This is a courageous remark to make in the current climate of denial about blood-borne infections, in particular HIV. If UNAIDS could excommunicate, they would surely excommunicate the minister.

This is not the only courageous statement I have heard recently about blood-borne HIV. A Ugandan journalist, James Lutaaya, said in relation to criminalization of HIV transmission “The deliberate infection Uganda wants to prosecute…would not involve sexual relations as it is relatively unlikely that sex will lead to HIV infection...hence sex would be a very ineffective method of passing on HIV if someone was really intent on doing so.

Lutaaya is right, but this is not the orthodox view. According to the orthodoxy, HIV is almost always transmitted sexually in African countries, despite there being little evidence supporting this view.

Interestingly, Lutaaya refers to the case of Nadja Benaissa, who was given a two year sentence for knowingly spreading HIV. Lutaaya feels that both Benaissa and the man she is said to have infected (the court didn’t have to prove that Benaissa infected him) share equal responsibility. That may be so, but the case also highlights another serious problem with prosecuting in such circumstances. The man Benaissa is said to have infected could have already been infected and he could have been fully aware of this. He could have been guilty of the same crime for which Benaissa was given a suspended sentence, yet he wasn't tried for such an offence.

Because the orthodoxy assumes sexual transmission and Benaissa, who knew she was HIV positive, had unprotected sex with the partner, it is also assumed that she infected him sexually. She may not have infected him at all, or she may not have infected him sexually. He could have been, as mentioned, already infected. Or they could have shared injecting drug equipment or some other form of exposure may have taken place. Certainly, the probability of her infecting him sexually by having unprotected sex with him a few times is very small indeed.

A woman is far more likely to know her HIV status, especially if she is or has been pregnant. It is also harder for her to hide her status, especially in countries where testing is routine for pregnant women. A man is less likely to know his status and more likely to be able to keep his status confidential. This doesn’t exonerate Benaissa, but it shows that the law is counterproductive if it aims to reduce HIV transmission. And its negative impacts will affect women far more than men.

The insistence that HIV is almost always sexually transmitted in African countries, or anywhere else, is quite illogical. Non-sexual transmission of HIV and other blood-borne viruses is not uncommon, even in countries where health spending per head of population is very high.

In African countries, per capita expenditure on health is about $10, on average. In Kenya, it’s about $6. The least UNAIDS, WHO and other institutions could do is investigate the extent to which HIV is transmitted non-sexually. Their claims about HIV almost always being transmitted sexually are no longer reassuring for the many people who have been infected and know they could not have been infected sexually. Perhaps Minister Nyong'o will take up the matter and challenge the ruling elite of the HIV/AIDS world?


Tuesday, September 28, 2010

The Choppy Logic of HIV Politics

"Circumcising infant boys could become part of Kenya's voluntary male circumcision programme...if an ongoing pilot project in the western province of Nyanza recommends it." Can infant boys become part of a voluntary program? Perhaps the author meant that parents could choose to have their infants circumcised, which is quite a different matter.

The pilot project is looking at the ability of medical staff to run an infant circumcision program that is acceptable to parents and safe for the infants. At least, that's how I interpret this rather garbled account. Words like 'successful', 'promising' and 'viable' also occur in the article (though some of the optimistic words are later qualified by words like 'reasonably', 'variable' and 'comparatively'), though the program hasn't finished yet.

The people being trained, apparently, are clinical officers and nurses, not doctors and surgeons. Kenya doesn't have anywhere near enough doctors or surgeons to take care of existing health problems, let alone get involved in tens of thousands of additional operations and follow-up care. Not that they are oversupplied with nurses or clinical officers, either.

The whole exercise involves what is sometimes referred to as 'task-shifting', whereby less well qualified, even completely unqualified people, are trained to do work that in wealthier countries would only be carried out by a highly qualified person.

Task-shifting may be safe enough when it involves doling out drugs and the like (though that also has its risks), but carrying out operations? I can't see it being popular in a Western country. There are hairdressers who have more training than some clinical officers but no one is suggesting that hairdressers should circumcise anyone.

The article suggests that infant circumcision is 'preferable' to adult circumcision, for various reasons, including being more cost-effective. But does that make it ethical to decide on behalf of infants that they should have an invasive and potentially dangerous operation, rather than waiting till they reach an age where they can give their informed consent? And purely because it may give them some protection against HIV?

Does the fact that parents make the decision on their behalf make it ethically sound? What sort of information are the parents being supplied with in order to make the decision? This operation may, the argument runs, reduce the risk of the children being infected with HIV when they become sexually active, but the evidence is slim and needs very careful manipulation to make circumcision sound like a good idea.

Even if circumcision were guaranteed to protect against HIV, or give a high level of protection, I would still question the ethics of carrying out such an operation on infants. They could decide whether or not to have the operation when they are adults. After all, there are many things these children will face, most of them preventable or curable and many of them deadly.

Up to 20% of the children will die of water-borne diseases and another 20% of respiratory problems. The majority will suffer from some form of intestinal parasite, possibly all their lives, and a large percentage will endure various forms of malnutrition and vitamin deficiency, the effects of which will almost definitely last for the rest of their lives (if they live). Most will, at some time, suffer from malaria and a host of other controllable diseases.

Indeed, quite a large number will be infected with some disease or other, hepatitis B, hepatitis C, possibly even HIV, as a result of their contact with a health facility. Some will even die from the disease, or suffer severely compromised health as a result. Health resources are not just scarce in Kenya, they are also potentially dangerous. The risk of HIV and the protection that circumcision may give seem quite diminished compared to the realities of Kenyan health care.

The trend towards 'treating' healthy people with drugs and other procedures is extremely worrying. Health is not just the absence of disease. Although sick people need drugs and other things, healthy people do not. Especially in a country where the most basic needs, clean water, sanitation, food, housing and education, are lacking. If the country doesn't have the wherewithal to treat all its sick people, why do some appear so anxious to use up scarce resources on those who are not sick?


Monday, September 27, 2010

Some Statistics Are More Equal Than Others

I recently wondered out loud why those who were baying for mass male circumcision in high HIV prevalence African countries didn't seem to be as interested in the possibility that washing with soap and water might be just as effective. Well, one Thomas J Coates has received 800,000 dollars to evaluate the feasibility of a "post-coital genital hygiene study among men unwilling to be circumcised" (compared to an estimated $50 million to circumcise just over a million members of the Luo tribe).

If this 'genital hygiene' involved something as basic as soap and water, that might be worth celebrating. But I doubt if it is. It's more likely to involve 'penile wipes' or some other technology. (Nothing wrong with technology, but let's just keep it appropriate.) And the study is not to establish if such measures would protect as well as circumcision, better or less well. It is to establish if men would find the practice acceptable, convenient, practicable and if adherence is high.

The project information says "If we find that men are able to practice consistent washing practices after sex, we will plan to test whether this might protect men from becoming HIV infected in a later study." It's surprising that they are going ahead with the plan to circumcise a million people, even though penile hygiene may be all that's required!

But I am not sure what they mean by 'able'. I assume most men are able to wash their penis, whether circumcised or not. I'm also wondering why pre-coital hygiene is not also being observed, with a view to reducing male to female transmission of HIV (and other sexually transmitted infections), not just female to male transmission, which is often less of a risk.

If "adherence is high" (and if men are 'able'), genital hygiene might then undergo randomized controlled trials to be considered as a HIV prevention intervention. If adherence is not high, some serious questions would need to be raised about the way the research was carried out. Personal cleanliness is considered extremely important everywhere I have been to in Kenya, Tanzania and Uganda, whether running water is available or not. But by the time the results are available, many more men will have been circumcised, possibly unnecessarily, possibly at considerable risk to their health.

Male circumcision is, all things considered, an odd HIV prevention intervention in a country with relatively low health care standards and low levels of access. Outside of the Luo tribe, circumcision rates are between 90 and 100%, yet HIV prevalence ranges from 0.8% among the ethnic Somalis to 7.9% among the Luhya and Maasai. That's nearly 10 times higher. And among the Embu, Somali and Meru tribes, men are just as likely to be infected as women (see table below).

In contrast, men are far less likely to be infected with HIV than women in most other tribes. Only three Luo men are infected for every four Luo women. But only 1.6 Luyha men are infected for every 10 Luyha women. So circumcision may protect men, but to widely varying degrees.

In some tribes, circumcision may not be giving much protection at all. It's hard to compare, because there are very few uncircumcised sexually active members of most tribes, but that information would hardly increase confidence in the effectiveness of circumcision, would it? In fact, it has never been clear what sort of protection male circumcision gives, if any. There is even evidence that Luos are more susceptible to HIV infection for reasons unrelated to their circumcision status.

But the passion with which mass male circumcision is advocated as a HIV prevention intervention smacks of an almost religious fervor. After all, lower HIV rates are found among those who practice female genital mutilation (FGM), too, mutilation of the worst sorts. Thankfully, none of the circumcision enthusiasts are advocating for FGM. But the highest rates of HIV are found among the people who don't practice FGM in any form (Luo and Luhya). Perhaps we shouldn't be so easily swayed by the promise of 'up to 60% protection' against HIV, or any other opaque statistics.

Female HIV Prev
Male HIV Prev
HIV+ Male
Male Circ'd

*FGM rates almost 100%


Sunday, September 26, 2010

The Limits of Human Promiscuity

In response to a raft of articles challenging the view that heterosexual transmission is by far the major mode of spread of HIV, 15 academics penned a paper that concluded that “there is no compelling evidence that unsafe injections are a predominant mode of HIV-1 transmission in sub-Saharan Africa”. One of their ‘main arguments’ is that “Unsafe injections are not sufficiently common to play a dominant part in HIV-1 transmission in Africa”.

But how common do unsafe injections need to be? Even the WHO accepts that up to 40%, and in some areas, as much as 70% of medical injections are unsafe (also that as much as 70% could be unnecessary). They accept that 30% of hepatitis C (HCV) and 40% of hepatitis B (HBV) is transmitted through unsafe injections.

Another of their arguments against medical transmission of HIV is that “Transmission efficiency of HIV-1 for injections in African health-care settings is overestimated and is far less than 2·3%”. Ok, but what is the figure and how does that refute the significance of the WHO’s findings? And what about other procedures, aside from injections? UNAIDS has acknowledged that little is known about unsafe injections, yet they seem very confident in dismissing their contribution to HIV epidemics in African countries.

This group of academics suggest that “Analyses to assess the association between a history of injections and HIV-1 infection do not adequately take into account reverse causality and confounding”. And what analyses have they and their colleagues in the HIV industry carried out? There is such a thorough lack of papers on nosocomial and/or iatrogenic HIV transmission, anyone would think that the industry was afraid of what such research may reveal. If analyses to date have been lacking, they don’t seem in a hurry to fill the gap in our knowledge.

The authors seem to be suggesting that those who receive a lot of injections may already be infected with HIV and, therefore, suffer from a lot of illness. But this simply underlines the need for further investigation. They claim that people who get a lot of injections may be receiving treatment for sexually transmitted infections (STI), so they are already at risk of being infected with HIV. But there is still a danger that people receiving injections for any reason, including STIs, are at risk of being nosocomially infected with something they don’t already have.

Many people receiving injections for STIs do so in clinics that specialize in STIs and have a lot of clients who have multiple risks for STIs and other blood borne viruses. This doesn’t mean they must all have been infected sexually. Rather, it could point to clinics being even more hazardous than previously recognized. They have a tendency to concentrate those most likely to be infected with HIV in the one place and thereby increase their risk.

Their argument that “Apart from mother-to-child transmission, HIV-1 infection is rare in children” is swiftly dealt with in a paper by Savanna Reid, who points out that childhood prevalence does not increase with age because many HIV positive children die. Indeed, the number of cases of infants and children who are HIV positive and their mothers are HIV negative has long been a cause for concern. Yet it has gone uninvestigated by the industry.

They have a few other ‘main arguments’ but almost everything they claim seems to follow from the ‘behavioral paradigm’, the belief that almost all HIV transmission in African countries is through heterosexual sex. Every piece of evidence that appears to challenge the paradigm is dismissed as being impossible by reference to the paradigm itself.

One must ask, what level of HIV transmission from unsafe injections would be acceptable? When the mere possibility of nosocomial infection occurs in Western hospitals, such as in the UK, the US or Australia, tens of thousands of people are recalled and tested for blood borne infections of various kinds. This never happens in African hospitals, despite there being ample evidence that such infections occur. Even UNAIDS' 'estimate' of 0.6% transmission still represents thousands of preventable infections.

Although I think the (predominantly) heterosexual transmission theory of HIV in Africa is grossly under-supported by evidence, this is not the only objection. There seems to be a complete lack of fellow feeling among those who cling to the theory, a lack of humanity. I believe that some people all over the world have a lot of sex, but most don’t. And I don’t believe anyone, let alone the majority of people in a handful of countries, can possibly indulge in levels of sexual activity that would explain HIV prevalence levels found in these countries. But such perverse views as the behavioural paradigm are the orthodoxy.


Saturday, September 25, 2010

The ‘Unknown Knowns’ of HIV Epidemiology

In his book ‘The Black Swan’, Nassim Nicholas Taleb distinguishes between two realms, Mediocristan and Extremistan. The law of Mediocristan is: when your sample is large, no single instance will significantly change the aggregate or the total (p32). The law of Extremistan is: inequalities are such that one single observation can disproportionately impact the aggregate, or the total (p33).

An example from Mediocristan that Taleb gives is of sex workers, who can’t scale up their workload beyond a certain number of clients per hour or day (p27). Their earnings, no matter how high, are limited. In contrast, a successful financial trader can earn (or lose) more in one day than in their entire career. The financial trader’s job is scalable and is from the realm of Extremistan.

Wars used to belong to Mediocristan but modern technology makes it (theoretically) possible to wipe out whole populations, cities or even humanity in a single act (33-4). I would argue that it is also possible to infect huge populations with a virus through modern technology. There have been many documented instances of this.

Therefore, HIV, being difficult to transmit heterosexually, is stuck in Mediocristan. Despite the best attempts of UNAIDS and others to claim that sex workers can become infected and infect many others in a short space of time, a HIV epidemic driven by sexual transmission alone would never reach very high levels. The HIV epidemics of most countries, UK, Germany, USA, Australia, etc, are safely inside Mediocristan.

But there are countries where levels of HIV transmission can not be explained by heterosexual transmission alone. Prevalence figures in these countries, especially in certain groups within these countries, are extreme. In fact, they appear to be from the realm of Extremistan. There is a limit to how high they can go and, thankfully, none have reached 100% yet. But the highest prevalence figures can be hundreds of times higher than the lowest.

An example that stands out comes from Nairobi in the mid 1980s, only a few years after HIV was identified and not long after the virus probably reached Kenya. Prevalence among sex workers was found to be 4% in 1981 and it had increased to 61% by 1985. By what means were these women infected? In order for four sex workers to (indirectly) infect 61 sex workers (to keep the numbers simple) in the space of four years, how many men would they have to infect? Because the 61 would have been, according to the sexual transmission theory, infected by HIV positive men.

In 1980 in Nairobi, a particular sample of men being treated for a sexually transmitted infection was found to contain no HIV infections. In 1985, a similar sample had a prevalence of 15%. Unless the sex workers were all having enormous amounts of sex with a handful of men, these findings are completely inexplicable. Even over a longer period of time, such as fifteen or twenty years, such high sexual transmission rates are not credible. And over that length of time, most of those originally infected would be long dead.

Even less explicable are the HIV prevalence figures for people who are neither sex workers nor sex worker clients. Prevalence for Swaziland as a whole is in the mid twenties. For young, sexually active women, figures are in the thirties and forties, though they remain consistently lower for men at any age. What kind of amounts of sex could these women be having? And with whom could they be having so much sex? In order to become infected sexually, they don’t just need to have lots of sex, they also have to have lots of sex with HIV positive men.

Rather than imputing inhuman feats to Africans, as UNAIDS and their friends have been doing for many years, it is worth looking at where very high rates of transmission could come from. And the obvious source for transmission rates that could only come from the realm of Extremistan is unsafe health care (and possibly unsafe cosmetic practices).

A clinic could give hundreds of injections a day. Vaccination programs can cover tens of thousands, even hundreds of thousands of people, in a very short period of time. It could take years, even decades, for one HIV positive person to infect a few more, and for them to go on and infect others. But unsafe injections could, potentially, infect hundreds or thousands in far less time.

I’m not claiming that current HIV epidemics in African countries are Black Swans, because the risk is not incomputable. It’s just very high. The knowledge required to prevent these transmission events from happening does not consist of ‘unknown unknowns’. Far from it, the knowledge required consists of ‘unknown knowns’, information about the efficiency of transmission through unsafe health care, coupled with information about the quality of health care available in high HIV prevalence countries.

UNAIDS and their collaborators have gone through a process of ‘unknowing’ things that have long been well-established, sometimes by their own employees. But rather than investigating the many instances of health care transmission of HIV, they have built up a literature that simply ignores the very possibility of such transmission. Occasionally, nosocomial and iatrogenic transmission are mentioned, only to be dismissed as very slight and unimportant.

Documented outbreaks of HIV from medical procedures have identified hundreds, even thousands of infected people. Disturbingly, most of these outbreaks have never been investigated to find out how many people have been infected. One of the most infamous outbreaks occurred in Romania in the 1980s, thought to have infected about 10,000 children. No search was made to identify all those infected. An estimated 100,000 were infected in China but again, no effort has been made to identify all those infected.

There are plenty of other outbreaks like these. A number of African countries have estimated the proportion of incident HIV infections caused by unsafe injections. The median is 19% but Malawi estimated in the early 2000s that 54% of HIV infections in women were attributable to injections. That’s a lot higher than the UNAIDS estimates of 2.5% or less for Kenya and other countries.

Where HIV prevalence figures are extreme, as they are in many African countries and regions, transmission rates must also be extreme. It is not possible for such extreme rates to occur from even the highest levels of sexual transmission imaginable. But such high rates could come from unsafe medical practices. And this is what needs to be investigated.

It may be a mammoth task to investigate and eliminate such practices. But it is a mammoth and pointless task to shake a warning finger at half a billion Africans and tick them off about their sex lives when sexual behaviour is clearly not the main problem.

Such investigation is vital because the one or two people that a sexually active HIV positive person might infect in their lifetime is dwarfed by the hundreds or thousands that health facilities may be causing or may cause some time in the future. Everyone infected, whether sexually or non-sexually, can go on to infect others sexually or non-sexually. If they infect others sexually, the resulting number may be low. But if their infection becomes part of a health facility based outbreak, as any single infection could, the numbers infected as a result could be very high.


Friday, September 24, 2010

Unsafe Health Care and Risk of HIV Transmission

Frederik Joelving, in an article entitled ‘Did Doctors Jumpstart the HIV Pandemic?’, looks at the recent research which finds that public health programs carried out 50 to 80 years ago may have played a part in spreading HIV. I mentioned this research recently. But it’s interesting to hear what the scientists involved have to say to a journalist.

According to Joelving, “What is still a matter of debate is how a blood-borne disease infecting one or a few individuals in a remote area could ever spread to the more than 33 million people who were infected by 2008, and kill two million of them.”

However, Thomas Strickland, one of the researchers, says "Everybody now is getting infected from having sex”. This is not the case. HIV has never been entirely sexually transmitted and the extent to which it is sexually transmitted is not known.

Worse still, Strickland goes on to say that sexual transmission is not very efficient and that “You can have heterosexual sex ten or fifteen times without getting infected.” Heterosexual HIV transmission is far less efficient than that. Transmission risk is very contentious but estimates run into hundreds or even thousands of sex acts (Risk of transmission of HIV varies from 1 in 200 to 1 in 10 000 coital incidents, depending in part on the integrity of the vaginal epithelium.)

Strickland is right in stating that “if you get injected with a contaminated needle, the risk is much higher”, but he seems to assume that the chances of being injected with a contaminated needle nowadays are pretty low because standards of hygiene are high. Standards are not high in many countries, Kenya being just one.

It’s a pity that this research has been interpreted so narrowly but there are even narrower views. One Michael Worobey blames urbanization and prostitution for the eruption of HIV from a rare virus to a global pandemic, whereby “an infected villager made his way to the city, setting off the HIV epidemic like a spark falling on a dry savanna.” Worobey goes on: "I think a train is a much better way to get a virus to a city than a needle".

Somehow, I think a needle is of far more danger than a train when it comes to spreading viruses. As for the urbanization explanation, this just doesn’t wash. In a paper entitled ‘Spatial phylodynamics of HIV-1 epidemic emergence in east Africa’, the authors conclude that migration, population growth and warfare contribute marginally to the spread of HIV.

The authors do show that transport infrastructure was vital to the spread of HIV over long distances. But they don't show that once the virus arrives in distant places, that it must have been spread sexually.

Jacques Pepin feels that both reuse of needles and sexual transmission are compatible and that both probably contributed to the pandemic. But he argues that “single use needles are now commonplace” and that “unprotected sex is the major reason people get HIV”. Perhaps he doesn’t read publications from the WHO (though who could blame him?).

Sexual transmission is, as mentioned, not very efficient. There is a limit to the amount of sex and sexual partners a person can have. Their chances of having a HIV positive partner may increase as an epidemic spreads. But even if someone had hundreds of sexual partners a year, the risk per sex act is still low. In other words, most people will only transmit HIV a small number of times through heterosexual sex, if at all.

In contrast, if a hospital or clinic is giving injections with unsterilized equipment, the risk of infecting patients is many times higher than the risk of sexual transmission. Not only that, a single health practitioner can potentially infect many people per day, week or year. People infected through unsafe health care can also transmit HIV sexually, though they are no more likely to do so than those infected sexually. And every HIV positive person treated in a health facility that engages in unsafe practices can give rise to more HIV transmission. The potential for health care transmission is of a different order of magnitude than that for heterosexual transmission.

Research to quantify the contribution that unsafe health care makes to HIV epidemics in African countries would not require groundbreaking techniques. Normal infection control investigations should be able to establish levels of unsafe practices in hospitals and clinics and measures to reduce such practices are well known in Western hospitals. But even researchers doing groundbreaking work seem unwilling to upset the orthodoxy.


Thursday, September 23, 2010

Reification of a Racist Paradigm

The President of Zimbabwe has been reported as saying that compulsory testing for HIV should be introduced on the grounds that the pandemic is a health emergency. He is right, in the sense that if it were possible to test all or most people, this would allow unprecedented progress to be made in reducing transmission. But as long as HIV is seen as the sexually transmitted infection that evil Africans spread through their selfish behaviour, I don’t see whole populations meekly lining up to be tested.

If treatment were to be guaranteed for everyone found to be in need of it, that might work as an incentive. But people might ask if the promise will be kept, especially if they look at countries where antiretroviral programs have been started but continue to miss out on or let down many people. And even the promise of some kind of treatment might not tempt some people, who are only too aware of the sort of stigma that is associated with HIV and other diseases. They will also be aware of the consequences of such stigma.

One of the most unethical aspects of the use of testing data so far has been the failure to establish how people become infected with HIV. UNAIDS and their chums in HIV related industries and academic institutions have decided that, in Africa, they don’t need to collect data on how HIV is transmitted because they, for reasons known to themselves, believe that it is already obvious; that HIV in Africa is almost always transmitted sexually.

This ‘behavioral paradigm’ is completely undermined by evidence but, being a paradigm, it is never questioned. It is frightening to think that scientific findings are judged by their possibility of supporting the paradigm, rather than the other way around. But there is something more frightening; that is when the paradigm itself becomes replaced by something far more tangible, almost a reification of the paradigm. That’s the infrastructure that has been built up around the paradigm.

This infrastructure consists of huge supplies of drugs, equipment, consultancy, programs and other paraphernalia, and a vast array of government, non-government, commercial, non-profit, religious and other institutions, which might genuinely be required for the eradication of a sexually transmitted infection. Except that some HIV transmission, how much is unclear, is not sexual. Some is undoubtedly transmitted through unsafe health care and perhaps unsafe cosmetic practices. But because the HIV infrastructure that has been built up over more than two decades is designed for sexually transmitted HIV, it has little or no effect on non-sexual transmission, perhaps even a negative effect.

Mugabe himself may well accept the behavioural paradigm. The same article says, as newspaper articles are wont to do, “United Nations agencies have for years lauded Zimbabwe's HIV and Aids intervention models, which have seen the prevalence rate declining from a high of around 25 percent a decade ago to present levels of below 14 percent.” What the article doesn’t mention is that for national prevalence to drop by this amount, an awful lot of people need to die. And that is what has happened. This is not evidence of the country’s successful ‘intervention models’, whatever form they might have taken.

The article concludes “Cuba has a system of compulsory testing that has seen the largest island in the Caribbean recording miniscule infection rates.” Testing, on its own, doesn’t reduce HIV transmission. It’s what happens as a result of testing that (possibly) reduces HIV transmission. Who is to say that in many countries, once tested, most don’t go on to infect others, or become infected or die? Much may be learned about HIV transmission by looking at Cuba’s HIV epidemic in detail, but the fact that it involved compulsory testing doesn’t tell us anything. Most countries in the world didn’t have compulsory testing and most of them also have very low infection rates.

I sympathize with the sentiment that more HIV testing would be a good thing. But the biggest problem is the prejudice of UNAIDS and others, whose insistence on a paradigm that doesn’t fit gives rise to stigma and discrimination which makes widespread testing programs unlikely ever to be realized. So if Mugabe wants to see HIV transmission reduced he should start by questioning the assumption that the people of his nation, and the people of all other African nations, have inordinate amounts of sex. Right now, this would be a hell of a lot easier and cheaper than trying to test everyone. But it could turn around the epidemic.


Saturday, September 18, 2010

HIV Incidence Has Been Declining Since Before UNAIDS Was Established

A couple of recent studies lend considerable support to the theory that HIV was originally spread widely throughout Africa via unsafe injections (cited in this article). In the first half of the 20th century, syringes and needles were frequently reused without being sterilized, with the result that various blood-borne viruses were transmitted to very large numbers of people.

The article also claims that medical procedures are now safer, which may well be true. There has certainly been awareness among health professionals since HIV was first identified that the virus can be transmitted through unsafe injections. As a result, some countries introduced strict health care guidelines, some even enforce them.

But countries with underfunded and declining health services, like Kenya, may still be transmitting HIV and other viruses in this way. It's difficult to be sure or to say exactly how much this may be contributing to the country's epidemic because UNAIDS and the rest of the HIV industry have little interest in investigating. But the state of Kenya's health services, according to a Service Provision Assessment, suggests that many people are probably not accessing health care services at all; and the ones that are could be receiving low quality and unsafe health care.

One of the big mysteries about HIV is how it quite suddenly went from being rare and difficult to transmit sexually to becoming a pandemic, reaching extremely high levels in some African countries. And this is without becoming any easier to transmit sexually.

This led to some pretty racist theories about African sexual behavior which now form the orthodox view of HIV in Africa: that 90% of transmission is through heterosexual sex. The orthodox view sometimes cites high rates of urbanization as giving rise to increased levels of 'unsafe' sexual behavior.

However, urbanization trends started before HIV emerged and it's still happening. There are plenty of places where urbanization is high, even in Africa, but HIV prevalence, the number of people living with HIV, is relatively low. Yet HIV incidence, according to UNAIDS, has been dropping for some years. Having said that, even in countries where urban rates of transmission have gone down, rural rates can be going up.

Of course, holding such views as they do about African sexuality, UNAIDS and the industry claim that incidence has been declining because unsafe sexual behavior has gone down. And they claim that their policies and prevention interventions have been behind the decline in unsafe sexual behavior.

In reality, there is no evidence that African sexual behavior is extraordinary enough to give rise even to a relatively low rate of HIV transmission, let alone the high rates of transmission that have been seen in some African countries. Nor is there evidence that sexual behavior has changed significantly. And there seems to be little correlation between knowledge and behavior relating to safe sex and HIV transmission rates. In fact, it has long been clear that most HIV prevention interventions don't have any impact on HIV transmission.

Recent press releases by UNAIDS, the marketing and publicity wing of the HIV industry, widely copied and pasted by the world's press, now claim that incidence, the yearly transmission rate of HIV, has declined. And this is very likely to be true. Except that incidence rates have been declining since long before any of the current rash of prevention interventions had begun.

Incidence rates in Kenya peaked in the early to mid 1990s and have never returned to levels seen then. Among sex workers in Nairobi, HIV incidence peaked in the mid 1980s. Incidence peaked earlier in Uganda than Kenya because Uganda's epidemic started earlier. Again, incidence levels have never returned to those seen at the peak of transmission. Why? We just don't know.

The Kenyan government hadn't even got around to accepting that there was a HIV epidemic in the 1990s. The various prevention programs, such as they were, didn't get started until some time in the 2000s. By this time, prevalence had been falling for years. It would do, given that incidence had peaked and declined about ten years previously. And prevalence rates kept falling because death rates were peaking at about this time.

Embarrassingly, the time that Kenya started plugging the various prevention programs paid for by the global HIV industry was also the time that the rate of decline in incidence probably reduced. Prevalence now is at the same level as it was at in the early 2000s. It could be claimed that prevalence remains high because many people are on antiretroviral (ARV) treatment and so are living for longer. But death rates of people on ARVs are probably quite high, too. It's hard to tell because so many are lost to follow up. Health record keeping is not one of the health service's strong points.

But then, despite using words like 'evidence', 'evidence-based' and 'evidence informed' a lot in their publications, UNAIDS doesn't seem to distinguish between genuine evidence and something published by people who get paid very well to say the right thing. It would be unfair to suggest that all UNAIDS policy is based on prejudice and research of dubious provenance, and I wouldn't want to give that impression. They also rely heavily on not talking about anything that may undermine the orthodoxy. In this respect, most academics and all the global media support and defend them vigorously.

(For discussions of Pre-Exposure Prophylaxis, seem my PrEP Blog.)


Thursday, September 16, 2010

HIV Has Always Been Good News for Ambulance Chasers

I recently mentioned that there is some evidence that the aims of the mass male circumcision campaigns currently taking place in some African countries might also be achieved by provision of soap and water. But yesterday, I mentioned that soap and water are not even available in most health facilities in Kenya. Those findings are pretty shocking, but some researchers recently found that fishermen operating in Lake Victoria are reluctant to ensure their own genital hygiene for various reasons, including that they don't wish to wash their genitalia in public.

This is quite understandable. Few people would wish to wash their genitalia in public. But the authors of the paper recommend penile microbicides, which they can apply in the 'privacy of their bedrooms'. People who do not have the privacy to wash themselves properly probably do not have privacy in their own bedrooms, either. Many people, by no means the poorest, live in one and two room houses, shared with other members of their family.

If the problem is lack of hygiene, and soap and water is adequate to solve the problem, why bring in penile mcirobicides (unless you are trying to promote them for commercial reasons)? UNAIDS review the article in their weekly 'Good News for Ambulance Chasers' and note that penile wipes have been used in the past. Great. But if people can find a private place to use a penile wipe, with or without a microbicide, then they can also apply soap and water.

Lack of penile hygiene is cited as an argument for mass male circumcision. But this research claims that there is also a traditional proscription against fishermen washing with soap and water. I don't really see how this would make the case for penile wipes or topical microbicides. But there is also a traditional proscription against circumcision among the dominant Luo population.

If the stories about the success of mass male circumcision campaigns in Luo areas are true, the proscription against use of soap and water can also be overcome. But the HIV industry seems very keen on circumcision, regardless of how little it may affect HIV transmission in the long run. The Ugandan government is now also offering 'free' circumcision. Rates of circumcision are even lower in Uganda than they are in Kenya, but conditions in hospitals are similar.

Would you go for an operation on your penis in a country where health services don't guarantee running water, soap and adequate supplies of latex gloves, injecting equipment, sterilizing equipment, disinfectant and pain killers? Consider the question rhetorical. But the point that needs to be made (apparently) is that people are in need of things like water and sanitation more than they are in need of pharmaceutical products and trendy cosmetic operations.

As for privacy, this points to a need for improved housing conditions. But that need, like the need for water and sanitation (education, infrastructure, health and other social services), long predates the need for HIV interventions. Indeed, they are all prerequisites for the success of HIV interventions and it is their lack that has resulted in many HIV interventions having no impact on HIV transmission. The more technical solutions can wait. In fact, they have to wait until far more basic rights have been provided for.

(For discussions of Pre-Exposure Prophylaxis, seem my PrEP Blog.)


Wednesday, September 15, 2010

Concentration Clinics for the Usual Suspects

The WHO have just finished a forum on medical devices and they note the lack of access to such equipment in developing countries. However, developing countries have a far bigger problem than that. There are also too few medical facilities, too few trained personnel and too few drugs. As a result, in many developing countries the majority have little access to health care. And in some countries, access to health care is relatively high but the quality of the health care is very low.

Anyhow, the WHO does conclude that up to 40% of injections are unsafe in developing countries, probably around 6 billion or more injections. This is a particularly interesting figure for a country like Kenya, where UNAIDS insists that HIV transmission through unsafe injections only accounts for between 0.6 and 2% of all transmission. If you thought that 40% of injections were unsafe, you might avoid health facilities altogether, as UN employees are advised to do. But if it's the only health care available, many will probably risk it, especially when the alternative is far worse.

But there is a difference between UN employees and Kenyans (and most other Africans). Not only is there no alternative to poor quality care in most African countries but Kenyans and other Africans are generally not aware about the risks they face when they visit a doctor, dentist or other health care practitioner. Even among health professionals there appears to be little awareness of the risks. Therefore, neither health professionals nor patients will take any of the relatively straightforward steps required to reduce the risks.

Making health facilities safe could significantly improve overall health in countries like Kenya. HIV transmission through unsafe health care could be avoided, probably entirely. But also, transmission of hepatitis C and B (HCV and HBV), which are very commonly transmitted in health care facilities, could also be reduced. Kenya's health services are not going to become top class over night, not after decades of neglect, but they could become safer.

But at the rate things are going, even safety is not considered a priority. The percentage of spending allocated to injection safety in Kenya's latest National Aids Strategic Plan is small, less than one percent. And there is an even bigger question mark over where, exactly, this money will be spent. The country doesn't have a very big health infrastructure. More than half of the health providers sampled (supposedly a representative sample) in Kenya are either private pharmacies or otherwise limited to a handful of services.

Kenya's Service Provision Assessment Survey looks at what is available at 440 facilities and reports data on, among other things, 'elements for preventing nosocomial infections', that's infections that are due to unsafe health care. Included are running water, soap, latex gloves and facilities for disposing of 'sharps' (needles and the like). The majority of facilities, about 90%, don't provide all of these basic facilities. More than half the hospitals don't have running water. Similarly shocking figures apply to stocks of things like disinfectant, needles, syringes and latex gloves. In fact, only 3% of hospitals have all three. Most providers don't even have guidelines for infection prevention or sterilization.

The Kenya Modes of Transmission Analysis rather confidently states "It is unlikely that there is much medical injection transmission these days, given the raised awareness (both amongst health professionals and the general public) of the importance of clean needles." The confidence seems particularly unwarranted when they say, much later in the document, "[there is v]ery little information on injections safety - [it is]...hard to get baselines". That's a contradiction that even UNAIDS would be proud of.

Putting the various documentation together, sketchy as it is, the picture of health services in Kenya and other African countries is that they pose a lot of risks for blood-borne infections. Research earlier this decade showed that over 32% of HCV and over 40% of HBV were being transmitted through unsafe injections. In clinics where many of the clients are infected with some blood-borne virus, the probability of nosocomial HIV or other blood-borne infection would be even higher.

Consider, for example, clinics that deal primarily with sex workers and intravenous drug users, even clinics for pregnant women. Current HIV strategies herd together those most likely to be infected with HIV and play a barbaric form of Russian roulette with them and all their other less 'high risk' clients. It's no wonder that HIV is unbelievably high in STI (sexually transmitted infection) and ante-natal care clinics. These clinics are probably the source of much of the prevalence in countries with such deplorable health services.

Some evidence may point to sexual transmission of HIV. But some evidence points to nosocomial transmission, too. Without investigating the considerable evidence for nosocomial HIV transmission, targeting sexual behavior and not bothering about unsafe health care is condemning an unknown number of people to disease, stigma and early death. Given the weight of evidence, it's becoming more and more difficult to understand why UNAIDS and the HIV/AIDS industry continues to insist that, in African countries, HIV is almost always transmitted sexually.


Sunday, September 12, 2010

Stealing People’s Land Can Only Impoverish Them Further

The World Bank, an institution devised to divert aid money on its way to developing countries back to the rich and powerful, seems to have woken up to the sort of negative impact that its policies have been having on developing countries. I wouldn’t get too excited, though, because the negative impacts they are concerned about follow from their policies, which they haven’t changed in any way. And no matter how they appear to equivocate, it’s always worth bearing in mind who ‘international’ financial (and other) institutions are intended to benefit.

Grabbing land goes back a long way, hundreds of years, as does using people and resources in developing countries for the enrichment of people in developed countries. The monumental disaster, the Tanganyika Groundnut Scheme, which started in the late 1940s and was abandoned in the early 1950s, is just one out of many examples.  Like all of today’s land grabs, the grabbers were quick to claim numerous advantages for those who were being dispossessed of their land; employment, food security, development, mechanization, efficiency, modernization, etc. Such terminologies have changed little since the 1950s!

The flaws of the Tanzanian scheme were many and obvious from very early on, but there were those who thought they would make a lot of money from it. So vast tracts of land were destroyed and lots of equipment and other resources were wasted. Someone did make a lot of money out of the scheme, though it’s not certain who. But the losers were Tanzanians, the Tanzanian economy and the Tanzanian environment.

Land grabbing schemes of the last few years have already appropriated tens of millions of hectares, at very low cost. It is difficult to estimate how many people have been displaced and dispossessed but the number affected by the process will be enormous. ‘Investors’ will not be counting those costs, that’s for sure. They are anxious that we think of ‘feeding the starving’, even though 80% of the land hasn’t yet been used for anything. Ultimately, much of it is destined for non-food crops and for export to rich countries, though. What else would it be used for?

The World Bank has been talking about how to protect people in developing countries and their land. But they have been talking about a lot of things throughout their history. International agreements about accountability and transparency are a great idea, even better if there is some guarantee that they are upheld. But we know that all sorts of agreements are discussed, fewer are made and hardly any are ever upheld.

Land grabbing on a scale that is taking place presently is not happening despite the existence of institutions like the World Bank. On the contrary, such institutions were set up by rich and powerful countries so that they could stay rich and powerful. So we need different institutions, not the same ones saying the right thing while continuing the policies that have brought developing countries to their knees. The institutions are doing what they were intended to do, that’s why the World Bank needs to be abolished and replaced by something that genuinely represents the interests of the world.

The kind of land grabbing that is occurring at the moment will further devastate the most vulnerable communities, economies and environments in the world. People in rich countries may not be able to witness these phenomena as they occur, and the corporations currently enriching themselves are certainly not going to record them or make them publicly available. But by the time a handful of sound bites and photo opportunities are considered to be newsworthy by the world’s media, it will already be too late to reverse the damage.


Friday, September 10, 2010

HIV Drug Resistance is a Consequence of Irresponsible Drug Use

The availability of antiretroviral drugs (ARV) for HIV treatment, especially in high prevalence countries, has been welcomed by many, and rightly so. Only an estimated one third of people who need treatment are currently receiving it in Kenya and accurate figures about how many people are being successfully treated are probably not available. But the situation is a lot better that it was in the early 2000s, when drugs were still unaffordable (to donors, they will probably always be unaffordable to most Africans) and only a few thousand people were able to access them.

There have long been warnings about careful management of ARV rollouts. One of the main worries was about resistant strains of HIV developing in large numbers of people where the treatment program was not being administrated well. Because, while the cost of ARVs is high, the cost of second line ARVs, needed when resistance develops to first line drugs, can be five to ten times higher. But eventually, a lot of resistance will develop because people are not responding to treatment it or are not taking it according to requirements.

Even in countries with relatively well established treatment programs, drugs of all description are in short supply. Uganda is now depending on emergency funding just to supply existing patients with ARV drugs, let alone dealing with new patients or ones who are affected by resistance. Taking the drugs in accordance with requirements can be impossible for many people.

However, a related worry is that of transmitted resistance. Those who are not on ARVs can acquire a strain of HIV which is already resistant to first line drugs. A study in Zambia has found that almost 6% of HIV positive people who are in need of treatment are resistant to first line drugs. It's all very well to say the people involved can be treated with second line drugs. But in addition to the massive increase in costs involved, second line drugs are just not as widely available.

The trouble with resistance, whether acquired or developed, is that it will eventually reach high levels. In countries where ARV programs have long been available, resistance can be as high as 20%. Coupled with this, recent WHO guidelines recommend starting ARV treatment at an even earlier stage in disease progression (though some question the wisdom of this). That sounds great but, not only are numbers of people on treatment in African countries very high, health services and health infrastructures are weak, very weak.

Similar circumstances have already given rise to resistant, multi-drug resistant and extensively drug resistant TB. The problem doesn't get resolved by the production of stronger drugs unless the circumstances that gave rise to resistance are also resolved. Many people in Kenya who are HIV positive also have TB. But many who don't have HIV do have TB. 50% of people with TB are not HIV positive. These are two separate epidemics, despite considerable overlaps. Resistance in either TB or HIV treatment will fuel at least one, perhaps two devastating epidemics.

Monitoring and testing for poor adherence to treatment and resistance are expensive. African countries are struggling to implement the most basic treatment services, let alone such advanced facilities. Some of the costs may go down, but unless broad health systems are developed, the lack of adequate facilities, trained personnel and equipment will mean that the majority of people are still vulnerable.

You can't expect weak health services to implement massive, high technology programs. Yet, this is what seems to be expected of African health services. The majority of people have little or no access to primary health care, water and sanitation, adequate food and levels of nutrition, some of the most basic aspects of health. People die of diarrheal conditions and respiratory problems. What chances have they with HIV and TB?

The HIV agenda has been driven by the desire of pharmaceutical companies to sell drugs at the highest price they can get to the largest number of people possible. Not only is resistance, acquired and developed, a consequence of allowing Big Pharma to drive the HIV agenda. Resistance is also an excellent way of increasing their profits further. But what about the epidemics? What about people who are HIV positive and those who are in danger of becoming infected?

If donors, governments and the HIV industry can accept that preventing and treating HIV is not just a matter of distributing ever increasing quantities of drugs, the agenda should include other items, such as the need for more and improved hospitals, more and better trained and motivated personnel, better equipment and supplies. People must be able to access primary health care, not a bunch of kiosks that give out drugs, almost willy-nilly. And good health also requires good infrastructure, education, food security and a whole lot of other things.

It's the job of Big Pharma to sell drugs but it's not the job of UNAIDS, the WHO, national governments, academic institutions and other parties to support them and their excesses. Prevention of further transmission of HIV is getting lost in the process of selling drugs. Some even believe that prevention of HIV transmission will be effected by greater consumption of drugs. This is not the case. Countries that are devastated by epidemics are not just markets; epidemic and endemic diseases will not be eradicated by treating them as commercial opportunities. Use of drugs for HIV treatment must be responsible, which it is not at present.

(For a discussions about pre-exposure prophylaxis (PrEP) and resistance, see my other blog.)