Monday, January 31, 2011

Why is HIV Prevalence So Low in Cuba? (Hint: Health Services)

Last October Esther Murugi, Kenyan minister for special programs, called for greater acceptance of gay people in society. Her call was met with predictable righteous indignation from most politicians and church leaders. And her call stirred up a bit of debate, a small amount of which may have been constructive.

In the last few days, Murugi called for isolation of HIV positive people as a means of eradicating the disease. Does she mean Kenya should isolate all 1.5 million HIV positive people for up to ten years and longer? Isolate them where? There are not enough schools for all the country's children nor hospitals for the country's sick people.

I'm inclined to give Murugi the benefit of the doubt. After all, she is willing to stand up for one of the most reviled groups in East Africa, gay people. And I don't think she can be held responsible for believing rubbish about HIV, given that global HIV policy is governed by a bunch of racist, sexist quacks.

Ok, she thinks that Cuba has one of the best controlled HIV epidemics in the world because they isolated HIV positive people. What she is probably not aware of is that Cuba has the highest number of doctors per head of population in the world. HIV positive people were actually treated, counseled and supported in Cuba, long before they were in most other countries.

Cuba, like many other countries (the US only recently dropped its travel ban on HIV positive people), panicked a bit at first. But they had one thing that most Western countries have and most African countries do not: good health services. And they took action to make sure that HIV transmission was reduced, both sexual and non-sexual transmission.

Murugi may also be confused because at one time Cuba didn't have access to antiretroviral drugs. That was because of US trade sanctions, not because those cruel Cuban leaders didn't care about HIV positive people. In fact, Cuba is probably one of the few countries in the world that acted decisively, quickly and effectively to limit the damage that HIV caused in most other countries, rich and poor.

Indeed, Cuba still manages to keep HIV transmission low, which is more than can be said for several Western, Eastern European, Asian, African and other countries. Cuba is fortunate in enjoying relative autonomy from UNAIDS and other institutions that seem to exert such a negative influence on HIV prevention and treatment policies around the world.

The minister is seriously misinformed, but misinformation about HIV is not uncommon, rather, it's the norm. And if any Kenyans happen to agree with Murugi, the answer is no, it's not going to happen. The country hasn't even tested the majority of HIV positive people yet or got the majority of people who need antiretroviral drugs on treatment. The country's health services do not have the capacity to even account for all HIV positive people, let alone isolate them, in any sense of the word.

If the minister wishes to make herself useful, she could raise the issue of gays again and perhaps take other measures to reduce HIV related stigma, rather than increase it. For instance, she could point to the evidence from WHO that a significant percentage of HIV comes from unsterile injections (and probably from other unsafe medical procedures).

The extremely low levels of HIV transmission in Cuba, from before HIV was identified, through the earliest days of the pandemic, right up to the present, probably have a lot more to do with the quality of their health services than with the amount of sex Cubans have or the types sexual practices most commonly found there. Levels of transmission in every country probably relates to quality of and access to health services and certainly doesn't relate to sexual behavior. But only Cuba seems to have noticed that.

And if Minister Murugi wants more Kenyan people to be tested, more HIV positive people to receive treatment and more HIV negative people to be protected, she needs to ensure than health services are cleaned up first. The last thing Kenya needs is for everyone to rush to their collapsing health services in the state they are in right now. That's only likely to increase transmission.


Sunday, January 30, 2011

African Heterosexual Females Branded By Global HIV Policy

The murdered Ugandan gay activist, David Kato, was one of the victims of a piece of persecution by a tabloid newspaper, Rolling Stone. Rolling Stone published the names and photographs of people they believed to be gay. By the time a judge got around stopping publication the damage had been done.

I can't prove that David Kato was murdered because he had been exposed, I can't even prove he was murdered. But his death illustrates the sort of thing that can happen in a country where persecution of certain people is not considered important enough by the state to give them the protection they need.

The sort of hate and prejudice that lies behind the murder of David Kato exists everywhere, but some countries have laws to protect people from its worst excesses. Most gays can probably remain anomalous, or hope to. But they will all live in fear of discovery. If discovered, they could become victims of police violence, mob violence, persecution, extortion and the like.

But gays are just one group that suffers the consequences of hatred and prejudice. In some African countries, women are equally stigmatized. They can also be victims of violence and suffer injury, persecution and even death because they are a member of a stigmatized group.

Not all women are stigmatized to the same extent. But most victims of sexual and non-sexual violence are women. And the law in many countries gives them little protection, especially if the perpetrator of the violence is their husband or another family member.

In most countries, women are more likely to be poorer than men, live in worse conditions, play the biggest part in raising children, have lower levels of education, have less access to health and other social services and the list goes on. This is a result of prejudice, but of course, this is not the same kind of prejudice experienced by gays.

Women start to experience the kind of prejudice experienced by gays when high HIV prevalence is added into the picture. Fingers are pointed at sex workers and other groups. But in countries where HIV prevalence is highest among ordinary married women who only have one sexual partner, Uganda being a case in point, all women are branded as promiscuous.

Men are also branded as promiscuous, but HIV rates are far lower among men. Even people who just read what appears in the mainstream press suspect they are being lied to when they are told that it's men who go around spreading HIV and yet far more women are infected.

I often ask people for their opinion on how HIV is spread and if they think it's odd that in some places, HIV positive women can outnumber HIV positive men by 5 to one. They sometimes come up with the ludicrous suggestion that there is a small number of men who are responsible for infecting huge numbers of women. They must be very busy and such a group has never been identified.

Not for want of trying. Fingers have been pointed at 'mobile' people, either internal or external migrants, long distance drivers, armies and many other groups. But in the end, the majority of people being infected with HIV are ordinary people with ordinary sex lives. What UNAIDS refers to as 'low-risk' sex is, in fact, very high risk. I think of this as the UNAIDS paradox.

There is no paradox if you bear in mind that not all HIV is transmitted sexually, that some, perhaps a lot, is transmitted through unsafe healthcare and cosmetic practices. Most people are aware of these phenomena but there is a great reluctance to investigate. People prefer to say 'well, you're right, but I still think it's mostly sexually transmitted', or worse.

So I am not arguing that people who are HIV positive, whether they are gay, involved in sex work, injecting illegal drugs or anything else, shouldn't be stigmatized because stigmatizing people is wrong. It is wrong. But HIV positive people shouldn't be stigmatized because we don't know how they became infected. And even if they were infected sexually, that doesn't mean they have done anything wrong.

Anti-gay and other prejudices are not new and they are proving hard to reduce. But Africa suffers from an anti-African prejudice, based on the UNAIDS lie that 90% or more HIV in African countries is transmitted sexually. Effectively, heterosexuals and those who engage in heterosexual sex are the victims of prejudice and stigma.

If anti-gay stigma reduces the number of gay people who take precautions against infection with HIV, anti-African, anti-woman and anti-heterosexual stigma does the same. Few people want to be tested for HIV unless they have to because merely raising the possibility that you are infected invites suspicion, finger-pointing, ostracization, persecution and physical violence.

Like HIV itself, stigma doesn't just arise from 'somewhere else', from foreigners, migrants, Africans, women, right wingers, Muslims, or whatever. Stigma, HIV related stigma in particular, arises from the way society as a whole has come to view sex, all sex. The 'proof' that sex is bad is the existence of a HIV pandemic. But the evidence that the pandemic was driven by sex? Alas, there is none. That's why it's called prejudice.


Saturday, January 29, 2011

Concurrency: the Favorite Plaything of the Sex-Obsessed HIV Industry

For a relatively short time, the notion of concurrency became the favorite plaything of the sex-obsessed HIV industry. They hypothesized, not just Africans with rampant and uncontrollable sexual urges, but Africans with sexual partnerships that overlapped with each other.

If serial monogamy refers to the practice of finishing one relationship before going on to another, concurrency increases the chances of infecting more than one person. Given normal probability of transmission through penile-vaginal sex, those subscribing to the purely sexual theory of HIV transmission need all the help they can get.

But some have speculated about another aspect of rapid transmission, which has been well demonstrated, but never clearly tied to concurrency. The probability of transmitting HIV is highest during the first three months of infection and during the last 9 months or one year. During the latent phase, which can last 8 years or so, probability of transmission is especially low.

So, if someone acquires HIV, they are highly infectious during the first few months. Sex-only HIV transmission theorists need that person to infect several people during that short period to explain exceptionally high prevalence found in some countries. Concurrency may help explain high prevalence, but it doesn't completely explain it.

More embarrassing for these adherents of the 'behavioral paradigm', the belief that sexual behavior accounts for the bulk of infections, is that concurrency doesn't appear to be very common in many countries, even countries with high HIV prevalence.

People like Jeffrey Eaton, Timothy Hallett and Geoffrey Garnett have gone to great lengths to push concurrency, and the behavioral paradigm in general, but they have even discovered that it just can't be pushed that far. They try to model the effects of relatively low levels of concurrency that also take into account the stage of HIV infection. They even use ridiculously high estimates of transmission rates.

But they are forced to conclude that "this model produces HIV epidemics that grow more slowly than those observed in southern Africa, suggesting that factors not included here—in particular, small groups with greater number of sexual partners and cofactors that increase HIV transmission—also contribute to accelerating the spread of HIV".

This is a completely deflating argument, showing that some level of concurrency has some influence on rates of transmission, possibly. The level of influence, like rates of concurrency, is not estimated. Perhaps it's not even possible to estimate it.

Another study suggests that many people in high prevalence countries don't have very many partners (Table 2). The percentage of people who had more than one partner in the last year before the study ranged from 6% in Malawi to 25% in Lesotho. Fair enough, Lesotho is a high HIV prevalence country, but so is Swaziland, where only 10% had more than one partner.

And having more than one partner is not the same as concurrency. Eaton et al find that "increasing from 10 to 11% of individuals having concurrent partnerships increased the mean endemic HIV prevalence from 3 to 7%." We can't assume concurrency is higher in high prevalence countries without arguing in a circle (though mathematical modeling is probably no stranger to circular arguments). What the researchers say may be true, but we don't know what truth it expresses.

Even if concurrency plays a role and that role can be quantified, how do we then explain the rise, peak and decline in HIV rates in most sub-Saharan African countries before most prevention programs started and long before the notion of concurrency became the popular plaything it is today?

Eaton et al conclude that "primary infection in the context of concurrent sexual partnerships may be the factor that has enabled HIV to spread through general populations to such high levels." They are entitled to conclude that it may be a factor, not the factor. And that doesn't really get us much further.

But there isn't much further to go when your only contribution to HIV transmission theory is that it is a sexually transmitted infection. It is, but to what extent? It is also transmitted from mother to child, by injecting drug use, through unsterile health care practices and even unsafe cosmetic practices.

If Eaton et al want a model that grows like some of the epidemics found in some sub-Saharan African countries, they need to factor in non-sexual transmission. Otherwise they will continue to be in the dark and to leave everyone else in the dark. And the useless HIV prevention strategies that have dominated the field for so many years will continue to fail.


Thursday, January 27, 2011

The UNAIDS Paradox: Low Risk Sex Appears to be Risky in Africa has an article about a study carried out in Uganda which shows that there is little evidence of an increase in risky sex since the widespread rollout of antiretroviral drugs (ARV). Many people have been worried that the (relatively) easy availability of such drugs could give rise to both HIV positive and negative people disregarding principles of 'safe' sex.

It is not just in Uganda and other African countries where there are worries that such increases in risky behavior could follow ARV rollout. Wealthy countries have shown that increases in risky behavior are a reality and that this could easily wipe out some of the gains that have been made over the years. People are just not as frightened of HIV as they used to be.

But in the case of Uganda, the study gives the impression that risky sexual behavior is not such a big thing there. More surprisingly, it sounds as if it never was. After starting treatment, some people engaged in higher levels of risky behavior but later this trend reduced. In the end, they reverted to pre-treatment levels.

Well, if pre-treatment levels of risky behavior are not worrying in HIV positive people, they must be even less worrying in HIV negative people. There have been other studies like this one, also giving the impression that levels of unsafe sexual behavior are fairly low. Not that anyone has produced data showing what could count as normal and what could count as high when it comes to sexual behavior.

Not only that, even those who talk about high levels of unsafe sex don't really show that levels really are higher than elsewhere. Nor do they appear to have any reliable data to show that higl levels of unsafe sex occur more in African countries, nor in countries and regions where HIV prevalence is high.

It can be odd listening to people talking about HIV because they appear to consider the issue important, but also, in a sense, unreal. For a start, they always talk about sex, especially illicit and unsafe sex. It's as if some sex, most sex, if they are to be believed, falls into that category, while a small amount does not.

But as to what constitutes a lot of sex, no one I have asked can really say. It has been suggested that people who are HIV positive have at least one different partner a week, perhaps more, but these are just assumptions. As to why it is even assumed that some people have so many partners, and I'm not doubting that some people do, it often seems to relate to the perceived number of people who go to bars and drink alcohol.

But the Ugandan study does confirm one thing; levels of unsafe sexual behavior are not, in general, high. They probably never were. There has never been evidence of a glorious time before the HIV epidemic, when hardly anyone engaged in unsafe sex. Nor for a time when levels of unsafe sex rocketed, allowing HIV to spread rapidly. Nor for a time when all this subsided and HIV transmission rates began to decline to present levels.

Other research leads to similar conclusions. The five yearly Demographic and Health Surveys show that those who engage in risky sex are often less likely to be infected with HIV than those who don't. Trials such as the CAPRISA microbicide trial showed that the majority of people had a few sexual experiences a month and most of them only had one partner.

The Uganda study also found that use of condoms among HIV positive people increased after they started treatment. This may well be, as claimed, due to 'incraesed counselling intensity'. But condom use wasn't very high to start off with. As a minimum, you would expect people being counselled and on treatment to take some extra precautions.

However, a substantial proportion of those most likely to transmit the virus still don't wear condoms. It's hard to know if the 'intensive counselling' really has all that much effect. And when you look at sexual behavior among HIV negative people, the many years of HIV prevention interventions look even less impressive.

But the article is 100% about sex. There is never a hint that transmission may occur through any other route. Non-sexual routes to HIV infection may well have been talked about earlier on in the epidemic and, in the case of Uganda, steps may have been taken to reduce their impact. But now sex has completely taken over.

The fact that the HIV industry is attributing declines in transmission to HIV prevention programs that only started a long time after the declines suggests that they don't know why transmission declined. They don't seem to know how to reduce transmission and they don't even seem too bothered by that.

If we still don't know why HIV spread and subsequently declined, after thirty years of research, then nor do we know what to do if transmission rates begin to increase again. Don't people find that frightening? UNAIDS' claim that Uganda's epidemic is driven by low risk sex is not credible.


Tuesday, January 25, 2011

UNAIDS: HIV Industry Misinformation is their Business

The constant baying for foreskins from the HIV industry has always been difficult to comprehend. Especially considering that the few countries where HIV prevalence is lower among circumcised men are actually anomalies, rather than the norm.

These HIV experts could just as easily have advocated against circumcision if they had selected a different few countries, where HIV transmission is higher among circumcised men.

Rather than making spurious assumptions about causality on the basis of non-statistically significant correlations, the industry should abandon circumcision. There are too many arguments against it and none for it that stand up to scrutiny.

A number of arguments against circumcision have been made for countries with low HIV prevalence, but when you take into account the conditions of health services in high prevalence countries, attempted arguments for circumcision still fall flat.

But far from backing off on the basis of poor trial results for circumcision as a HIV prevention intervention, the industry insists that the results are actually very good. That if people just wear condoms and get circumcised, they will be ok.

You may do a double take on reading the last paragraph: because circumcision only works if you use condoms. But if you use condoms, your circumcision status is irrelevant. Condoms give the best currently available protection against sexually transmitted HIV.

So people in developing countries are being asked to risk all sorts of consequences, including the risk of infection with hepatitis, bacterial infection or even HIV, for an operation that will not even protect them against HIV unless they also continue to use condoms.

They could opt to use condoms all the time, and would be well advised to do so. But because they have been promised some additional protection against infections and they haven't been warned about the risks, many people have already agreed to be circumcised and hundreds of thousands of others are being persuaded to do so. They may well be told they will still have to wear condoms, but what impact will that have after they have undergone an operation?

Not content to lie about circumcision and HIV alone, others claim that circumcision protects against human papilloma virus (HPV). Yet, a recent study found that circumcision is not associated with HPV in heterosexual men. Not only that, condoms don't give complete protection either.

The study confirms that the part that genital hygiene might play in HPV transmission was not considered. But if neither condoms nor circumcision give full protection, perhaps it's time for it to be considered. There is more than a suspicion that genital hygiene could play a major role in sexual health as a whole. It would be surprising if it didn't.

However, I'm not advocating genital hygiene as a sole protection against HIV, HPV or any other sexually transmitted infection. I'm advocating access to clean water and sanitation as a human right. I'm also advocating access to good education, especially health education, decent infrastructure and living conditions, and good health services.

If people in developing countries were allowed their basic rights, diseases such as HIV, HPV, diarreal conditions and acute respiratory infections would be decimated. Picking a few choice diseases and throwing money at them has never worked. The money spent on this vertical approach to diseases (as opposed to health) would be far better spent on basic human needs.


Sunday, January 23, 2011

Global HIV Policy Too Prejudiced to End Pandemic in Africa

In an article in AlterNet, Jessi Fischer asks "Why Do We Vilify Male Sexuality"? But it's not just male sexuality that is vilified, it's sexuality in general. As a result of people's apparent desire to vilify sex, they seem anxious to seek out targets, people whose sexuality is perceived as most deserving of vilification, as opposed to their own sexuality, which is not.

When HIV was identified and thought to be exclusive to homosexual populations, many were happy to vilify men who have sex with men. Doing so was nothing new, after all. And when it was recognised that HIV also infected heterosexuals, sex workers, injecting drug users and 'promiscuous people' were vilified. They still are.

Sex was considered so important in the transmission of HIV that almost all large-scale HIV 'prevention' campaigns since the 1980s have concentrated on sex. In countries where it was possible to remove the threat of medical and other transmission of HIV, this was done, with a high level of success in rich countries. Less wealthy countries have had varying levels of success, some failing altogether.

As for poor countries, they didn't have a hope. Health services in the poorest countries were bad enough in the 60s and 70s but those countries who fell for the World Bank and IMF's 'structural adjustment' policies of the 80s, 90s and 2000s reduced health and other public services till most of their population hardly ever see a nurse, let alone a doctor or any kind of specialist.

Under international 'development' policies, health services, social services, education, infrastructure and anything else that could allow developing countries to develop were reduced, often to zero. Independently of HIV, although overlapping substantially with the pandemic, levels of health, education and overall development had already started to decline from the 1980s onwards.

It was very convenient to blame HIV for this, but the damage had already done. By the time HIV transmission rates had peaked and slowed down in the 90s and 2000s, structural adjustment and other policies, policies that continue to punish the poorest people in the world, had already destroyed whole populations.

Early on in the pandemic, it became obvious that HIV was not easily spread through sexual intercourse alone, especially not penile-vaginal sex. But those who had jumped on various political, religious and commercial bandwaggons weren't prepared to let go. The association of HIV with sex, especially promiscuous sex, was like a gift from the heavens.

HIV was, in a sense, just what development theorists had been looking for. They had been messing around with population control for decades, billions had been spent on persuading people in developing countries to use contraception, have fewer children, plan their families, etc. None of these attempts had been particularly productive, but the suggestion that they could hawk condoms as a means of protecting people from HIV, not just from unplanned pregnancies, was more than they could resist.

Billions more was spent on the same organizations which had done such a mediocre job for several decades, FHI, PSI, TFGI, and others (I assume there were some non-American institutions involved?). Unsurprisingly, they had even less effect on sexual behavior, maternal health and family planning than they had had in the past. But then, these weren't really the issues, were they?

The whole global HIV prevention effort was sidetracked by sex and has still to find its way back. This is not for lack of scientific evidence. The evidence has always pointed to the impossibility that serious HIV epidemics could be driven by sex alone. Serious levels of transmission only occur when the transmission route is highly efficient, such as through blood transfusions, mass vaccination campaigns, injecting drug use, etc.

But the international community was so enthralled by the apparent vindication of their view of Africans as animalistic, as not quite human, their policies are still completely skewed by such prejudices. African males are sexually incontinent and females are primarily victims, but also they have an insatiatable appetite for being pregnant, regardless of any danger to their own health or the health of their children. That's the story, anyhow.

And so the pinnacle of scientific endevour in HIV prevention is that we know how to prevent it; we just don't want to let go of our prejudices. Our prejudices are far more important than academic progress and, as for the lives, health and livelihood of generations of Africans, that has never been our major concern. And it probably never will be.


Saturday, January 22, 2011

Pope Makes Stupid Comments; Some People Listen

The Pope and his merry gang are tying themselves in knots again about things they know little of. They are not experts in sex, only in denying that it occurs. Outside of ostentatiously religious circles, sex is just one type of human behavior, it's certainly not an act of gross immorality. It's a highly significant type of human behavior, but it dates back long before Christians decided to prognosticate about it.

If I was sick, suffering from any disease, HIV being just one, I certainly wouldn't ask the Pope's advice on how to live my life, how to avoid transmitting the disease, etc. And if I wanted to avoid HIV, or any other disease, I wouldn't aks the Pope for advice either. Because the advice I would get would be wrong.

Not that the advice you'd get from UNAIDS or many other institutions would be any better. They would all lecture you on sex, safe and unsafe, and they would probably tell you that no sex at all is the best thing. But not having sex will not protect you from HIV, especially in high prevalence countries. And practicing safe sex will not either.

Time after time, research has shown that people who have no sex or no unsafe sex are as likely to be HIV positive as those who have lots of sex or have unsafe sex most of the time. Sometimes, they are even more likely to be HIV positive. The connection between HIV and sex is tenuous.

This is not to say the connection does not exist. Certain kinds of sex are very dangerous, such as anal sex. Certain sexually transmitted infections (STI), very common in some countries (developing and developed), highly transmissable infections, increase the risk of transmitting or of contracting HIV. But the probability of transmission through heterosexual sex is generally low.

True, STIs can be very common in some African countries. But exceptionally high rates of easily treated sexually transmitted diseases is not a sign that people there have lots of sex, or lots of unsafe sex. It is a sign that the health services are in disarray. Many people hardly ever visit a health facility and many of those who do are as likely to be infected with something they don't already have as be cured of something they do have.

In addition to the risk of being infected with HIV and other diseases in hospitals and other health facilities, people even face risks if they go to a hairdresser, a tattoo artist or a pedicurist. UNAIDS and other institutions who are obsessed with others having sex don't want to admit it but these are far more efficient transmitters of HIV than sex.

Tanzania is, according to some figures, roughly divided into three in terms of dominant religious. About one third each are Muslim, Catholic or some kind of non-Catholic Christian. HIV rates are often (though not always) lower among Muslims. But rates are very similar among the other two religions.

Similar remarks apply to Kenya and some other countries. For all their posturing, Christians, Catholic or otherwise, are no less likely to be HIV positive, to suffer from high rates of other STIs, to engage in sexual behavior considered to be unsafe, to circumcise their daughters, to beat their wives and generally indulge things that are considered to be 'unchristian'.

The fact is, many people say the right things, or what they consider to be the right things, but they do just what they want to do. So shouting about whether condoms and contraception are wrong or right, for most people, is hypocritical and potentially dangerous. There is a vast unmet need for contraception among women in developing countries.

These 'Christians' would be better advised to figure out how to change the kinds of behavior that results in some of the worst social and development problems. They could even spend a bit of time considering how to reverse the levels of gender inequality that they have spent centuries building up because that is behind some of the biggest threats that people face, especially women, mothers and girls.

Every time an article like this is published, the irrelevance of Popes, priests and religions are shoved down our throats. But when these people and institutions stand by while others become infected with a debilitating and deadly disease, it's time to tell these overfed fools where to stuff their advice. If I thought the churches had something valid to say about morality, I might listen, but they don't.


Thursday, January 20, 2011

Pregnant African Women Face Both Sexual and Non-Sexual HIV Risks

Researchers in South Africa aiming to estimate how many pregnant women were in the 'acute' phase of HIV infection, where their status would be undetectable using ordinary HIV tests, found that an astonishing 38% of women were HIV positive. They estimate the yearly rate of infection at over 11%.

It doesn't take a genius to work out that at these rates, the majority of women will be infected or dead from AIDS by the time they are in their thirties. These rates may have been found elsewhere, but they are still shocking. And yet, these researchers seem to think that they will achieve something by testing more and more people with better and better testing methods.

How are they being infected? The article assumes that most transmission is through heterosexual sex but this is just not credible. Some of the women were very young, they would hardly have had enough time to have enough sexual experience to become infected with a virus that is difficult to transmit through penile-vaginal sex.

If they are being infected by HIV positive men, who are these men? Incidence among men of similar age is often ten or more times lower. While it is argued that young women have sex with older men, who are more likely to be infected, are there even enough older HIV positive men to explain incidence figures among women? And are these women having sex with them? These have never been demonstrated.

Earlier research in South Africa has suggested that the probability of transmission is often 1, that a woman can become infected despite having only one partner and possibly even only having unprotected sex once. Would the researchers like to claim that there is a different strain of HIV in South Africa? Has the possibility of such transmission rates through heterosexual intercourse ever been demonstrated?

I don't believe so. I believe a lot of things are assumed, despite evidence to the contrary. And the authors of this paper go on making those assumptions. But HIV transmission will not be prevented if we don't even know how it is occurring. Rather than establishing how they may have become infected, it is assumed that most African women were infected sexually and conveniently forgotten that the chances of this happening to a few women, let alone to many, are extremely low.

Non-sexual HIV transmission must be considered. Most women, African and non-African, even young women, do not take stupid risks when they are pregnant. Most women don't take stupid risks even when they are not pregnant. Many HIV infections among pregnant women occur once they are already pregnant, often long into their pregnancy.

Transmission rates may well be higher among pregnant women, but so is the number of risks they face from being infected through unsafe injections or other medical procedures. And interestingly, the percentage of women in South Africa who visit an ante-natal clinic several times during their pregnancy is in the 90s. Compare that to a country like Tanzania, where some may visit once but the majority never visit at all, and where rates of transmission are many times lower than in South Africa.

Is it just a coincidence that HIV rates are often lower in areas where people don't have access to health services? Perhaps it is. But it is vital to find out if it is a coincidence. If it isn't a coincidence, then health services could be busy spreading the very virus they are supposed to be preventing.


Wednesday, January 19, 2011

When Will UNAIDS Be Abolished?

When people find used hypodermic needles in areas where children play in Western countries, they are upset. Quite rightly so. They don't like the thought that their children are being exposed to injury and diseases, possibly even serious or deadly diseases.

But even many Westerners seem to believe that HIV 'dies' within seconds, minutes or some fairly short period, outside of the body. This is not what the US Center for Disease Control (CDC) says on the subject, although it may have said that at one time. Their current answer to the question 'How well does HIV survive outside the body?' is difficult to interpret.

But no matter how you interpret the risk, no one wants a possibly contaminated needle piercing their skin or that of their children. As well as the physical injury, there is also a risk that the needle is contaminated with hepatitis and it is almost certainly contaminated with bacteria.

So the CDC's comment about 'incorrect interpretations' of risk causing 'unnecessary alarm' seems injudicious. I know the question is about HIV but the answer really needs to address risk as a whole. Potentially, HIV can survive for days and even weeks, under the right conditions. Contact with contaminated needles and other instruments should be avoided and where this is not possible, medical advice is required.

However, the idea that the HIV does not live outside the body is widely held, by professionals and lay people. And in countries like Kenya, Tanzania and Uganda, it is far more dangerous to be unaware of the risks. The chances of medical or cosmetic equipment being contaminated in countries with high prevalence of HIV, hepatitis and other diseases can be very high.

You might think that there would be a lot of awareness of these risks and how to avoid them but I have rarely spoken to anyone who has considered the risks they face from contaminated instruments in health or cosmetic facilities.

UNAIDS dismisses the importance of any form of non-sexual HIV transmission, let alone transmission in health facilities. They grudgingly accept that a few percentage points of HIV transmission in East African countries may come from such routes. But they hardly mention cosmetic instruments, razors, tattooing equipment and the like, at all.

As a result, such transmission may be occurring at high rates and people are doing nothing about it. When they take their child to the hairdresser, or go themselves, they could be picking up scabies, hepatitis, HIV or some kind of bacterial infection. To help people avoid these risks, the best thing to do would be to inform them.

Risks in health facilities are more difficult to handle. Doctors, nurses and other health personnel can be pressed for time and it is not easy for patients, or those accompanying patients, to intervene. At best, personnel will be annoyed, at worst, they will refuse to treat the patient, give them poorer quality treatment or make them wait a long time.

The WHO has published data showing that as much as 14% of injections in developing countries are contaminated with HIV and they have unpublished data showing that this figure can be a lot higher. A large proportion of hepatitis B and C is transmitted through contaminted needles. And an estimated 70% of all injections are not even necessary.

When there is even the hint that someone in a Western country may have come into contact with contaminated equipment, there is an investigation to establish how procedures could have resulted in such a risk. And anyone who may have been affected, even going back years, and through thousands of records, is contacted and screened.

Not only does this sort of investigation and screening of possible use of contaminated equipment not take place in developing countries but UNAIDS and others seem keen to deny that such things, which happen in the best resourced health systems in the world, could possibly happen in the worst resourced health systems in the world.


Monday, January 17, 2011

HIV Policy Needs to Follow Health Policy, Not Vice Versa

Following my last post, I received a comment raising the issue of the role of sexually transmitted infections (STI) in HIV transmission. This is a vital issue so I gave a brief response but promised to answer more fully in a blog post.

Firstly, health is not just a matter of absence of disease, so health policies should aim to prevent diseases where possible, as well as treat them.

This has clearly not been done with STIs. Preventable and treatable STIs are endemic in many developing countries and, regardless of whether they play a role in HIV transmission, sexual health is in urgent need of prioritization.

Very high levels of STIs, and of all easily preventable or curable diseases, are a symptom of poor health services, services that have been declining for decades. Concentration on HIV has often meant that STIs and other diseases have been ignored, so this has added to the serious STI epidemics that have developed.

However, the role of STIs in HIV epidemics has not been clearly demonstrated and there have been conflicting reports, especially where tests with treating STIs as a HIV prevention intervention have been carried out.

There is an interesting article on this subject called "Confound it: latent lessons from the Mwanza trial of STD treatment to reduce HIV transmission", by David Gisselquist and John Potterat. This is about the STI treatment trial in Mwanza, Tanzania which, according to the researchers involved, showed that reducing STIs could reduce HIV transmission.

The researchers' claim is odd because STIs were not reduced much during the trial, yet HIV transmission did seem to be reduced. Also, similar trials were carried out in two other locations and neither of them demonstrated any benefits for STI treatment.

Gisselquist and Potterat have two suggestions as to why the trial results in Mwanza differed so much from the two in Uganda. For a start, those taking part in the Mwanza trial appear to have received safe health care, which is something most East Africans don't receive. And there happened to be an injection safety initiative taking place at the same time as the STI trial.

The authors warn that continuing to target STIs without also improving health services by making it far safer, especially in relation to injection practices, there is a risk that transmission of HIV and other blood borne viruses will increase.

In the mid 1980s in Nairobi, HIV rates were found to be over 80% among sex workers at a time when they were extremely low among males in the city. The hypothesis, still the dominant hypothesis about HIV transmission in African countries, was that these women were infected through sexual intercourse with HIV positive men.

But if few men were infected, that seems unlikely. To explain such high transmission rates among women, even though they were engaging in high risk sex on a regular basis, the possibility that they were infected through health services must be investigated.

After all, there was an STI reduction program in Nairobi targetting sex workers in the early 1980s. As far as I know, this program did not target sex worker clients, which may well explain why HIV prevalence among men, in Nairobi and most other parts of Kenya, has never been as high as it has been among women.

Not only is it possible for HIV to be transmitted rapidly through unsafe health care, it is far more likely than transmission through unsafe sex. The transmission probability for many health practices is many times higher than the transmission probability for penile-vaginal sex.

Blood transfusions, for which the transmission probability is extremely high, may well have been made safer very early on in the epidemic. But most people don't have transfusions, whereas many people do receive injections and other invasive procedures. And the safety of these procedures has never been adequately assurred.

If these comments are even partly correct, not only is current UNAIDS policy allowing many people to become infected with HIV and other diseases; but it is also ensuring that many people become infected who might remain healthy if they ignore the health advice they are likely to receive. That's if they even have the option to ignore the advice.

Targeting STIs is a good thing in itself and may even reduce sexual transmission of HIV. But there is little point in reducing sexual transmission while at the same time increasing non-sexual transmission, especially that through unsafe injections and other procedures. HIV policy needs to follow health policy, not the other way around.


Sunday, January 16, 2011

What Do UNAIDS Call a HIV Positive African? Promiscuous

To continue yesterday's theme about the difference between HIV in Western countries and HIV in high prevalence countries, most of which are in sub-Saharan Africa (SSA):

Treatment with antiretrovirals (ART) is widely touted as a type of HIV prevention because if people are responding to ART their viral load should be low and they should be far less likely to transmit the virus.

In Switzerland, in particular, HIV positive people on ART have been told that they could have unprotected sex and that the risk of transmission would be very low.

However, in SSA countries, people are not given the same advice. But also, it has been suggested that people who are on ART could experience 'disinhibition'. They could engage in higher risk sex because they think their treatment means they are less likely to transmit the virus.

Conditions in SSA are very different from those in Switzerland. For a start, perhaps a majority of people, certainly a lot of people, don't know their HIV status. When it comes to preventing sexually transmitted HIV, the more precautions people take, the better.

Even those who promote the rather unconvincing 'treatment is prevention' strategy admit that if treatment results in significant disinhibition, the modeled reductions in transmission will not occur.

So far, so good. It could be argued that conditions are so different in SSA and in Switzerland that the advice given to HIV positive people on ART should also differ.

But many articles have come out about how disinhibition doesn't occur in SSA countries. And at the same time, articles have also come out about how it does occur in Switzerland.

It would be very convenient if levels of disinhibition in SSA were not high enough to cancel out gains, but it also sounds a lot like wishful thinking. Especially if, in practice, disinhibition does occur in Switzerland.

The orthodox line about HIV, a virus that is difficult to transmit sexually, is that over 80, perhaps over 90% of it is transmitted through heterosexual sex in African countries.

In wealthy countries, the virus is usually transmitted through anal sex or through intravenous drug use. It is not much transmitted through heterosexual sex.

We are supposed to believe that, despite the difficulty of transmitting HIV through heterosexual sex, Africans do so because they have such exraordinary sex lives. But if they have these extraordinary sex lives, why is disinhibition so unlikely?

As I say, probably wishful thinking. Which is not really a good basis for a HIV treatment strategy, and even less so for a prevention strategy.

In countries where hundreds of thousands or even millions of people are infected with HIV, so many will not know their status and so many will not be on treatment even if they need it, treatment and prevention need to continue to be driven by separate initiatives.

There is little point in putting more and more people on treatment and hoping that they will adhere to the drug regime as they need to, supposing their supply of drugs even keeps up with their needs, unless efforts are also made to reduce the incidence of new infections. Drugupplies are often too unreliable to ensure that viral load will always be kept low.

But many people, also, are not being infected sexually. This means that they will not know what risks they are facing when they visit health facilities or anywhere else they may be exposed to contaminated blood or bodily fluids.

It is popular to talk about the need to test as many people as possible and to test people as often as possible. Despite this, most people have never been tested and the ones that have been, have only been tested once.

Testing on its own is not enough. It also needs to be established, for each person who becomes infected, how they are infected. The fact that they are sexually active does not mean they were infected sexually. Many people are sexually active and some of them become infected with HIV, but their partner is not positive. This means they were probably not infected sexualy.

It may take a bit of work to establish how people were infected, especially as most people will blame their own sexual behavior because they have the heterosexual theory of African HIV transmission drummed into them. But it is vital to take appropriate steps to reduce HIV transmission. Assuming that most transmission is sexual does not lead to appropriate steps.

In addition to testing and retesting, there needs to be an honest and creadible assessment of the risks people face and of all the likely routes to transmission. Those who are positive need to be assessed for treatment and those who are negative need to be made aware of all the HIV transmission risks they face, sexual and non-sexual.

HIV transmission rates are still very high in many countries. Transmission needs to be reduced. Treatment of those infected alone is not likely to reduce transmission enough. We have to keep our eye on non-sexual transmission as well as sexual transmission. Concentrating on sexual transmission alone, for example, by targeting discordant couples, is not going to protect them from non-sexual transmission.

All that remains now for HIV epidemics to be turned around is for UNAIDS and their HIV industry friends to lose their highly prejudiced views of African people and to treat Africans as they do their own employees and Westerners, who seem to be considered far more important than Africans.


Saturday, January 15, 2011

Apparently, the Truth About HIV is Relative to Nationality and Wealth

A typical article about HIV reads "Cheating spouses have always caused problems for their marriages." That may be so, but it does not mean that 'cheating' drives HIV epidemics in high prevalence African countries. Data about sexual behavior and HIV prevalence show that many people engaging in 'safe' sex become infected with HIV and many engaging in 'unsafe' sex remain uninfected.

It has long been recognised that the majority of HIV infections in several countries, Uganda, Kenya and others, come from people in long term relationships who only have one partner, many of whom take adequate precautions against sexually transmitted HIV.

Of course, you could engage in unsafe sex and become infected non-sexually. You are unlikely to ever find out because if you live in a resource poor country, especially an African country, it will be concluded that you were infected sexually.

Whether you are infected sexually or otherwise, it's good to take precautions against infection of any kind. But it would be pretty stupid to protect yourself against sexually transmitted HIV, for example, and turn a blind eye to the fact that your children are all receiving invasive medical treatment with unsterilized equipment.

Who would be stupid enough to do that? Perhaps people who have been bashed over the head for years about their sexual deviance. Indeed, their sexual deviance is considered so bad that the possibility of their being infected non-sexually by a virus that is difficult to transmit sexually is rarely mentioned.

The article in question, as they usually do, rants on about a discordant couple, where one partner is infected and the other is not. There is no mention of how the one partner became infected nor of how the other is in danger of being infected non-sexually as well as sexually.

Well, UNAIDS and the AIDS orthodoxy are not going to change their tune in a hurry. But they haven't even managed to persuade very many people to use condoms to protect themselves from infection or to get careful advice when they wish to become pregnant. They are even failing in their favorite field, sex.

So underinformed are the majority of people that they know as little about the dual role condoms play in reducing transmission of sexually transmitted infections and preventing unplanned pregnancy as they knew many years ago, before most people had heard about HIV.

The entire process of HIV prevention seems to consist of misinforming people. And the article even refers to a 'myth' about HIV negative people being protected when their partner is on antiretroviral drugs (ARV).

But this is not a myth, even according to the HIV orthodoxy. Big pharma and HIV Incorporated are trying to sell the idea that treatment is prevention; that because those on treatment have a low viral load, they are less likely to infect their partner.

Well, like the myth in the first paragraph, it's more of a half truth. The HIV/AIDS industry has been trying to sell the idea of taking ARVs instead of bothering to carry out any real prevention programs that they might not be able to make huge sums of money out of.

In some Western countries, discordant couples are advised that they can have safe unprotected sex as long as the infected partner has a low viral load as a result of successful ARV adherence. But this is not the advice given in African countries.

And it would be very stupid advice. If we haven't established how most people are becoming infected with HIV, we cannot advise them about what is and what is not safe behavior, about what they can do and what they must avoid.

And that underlines the biggest risk regarding HIV: being African. If you are African, you will not be  told that you face serious risks in health facilities and cosmetic facilities, not just through your sexual partner.

If you are African, you are almost condemned to being infected without anyone noticing until it is too late, especially if you are a woman who is foolish enough to get pregnant.

And when you are found to be HIV positive, because you are African, it will be assumed that you were infected sexually, regardless of how well you may have protected yourself, whether you have had sex or not or anything else. To be African, in the eyes of the orthodoxy, is to be promiscuous.

The most illogical thing is, just because people are promiscuous, and some are, everywhere, that doesn't mean you will be infected sexually. Therefore, the fact that you are infected does not mean you are promiscuous. UNAIDS and the rest of the industry may be obsessed with your sexual behavior, but they don't actually know anything about it, their frequent pronouncements notwithstanding.

An interesting feature of HIV myths is the fact that both those who are in danger of being infected with HIV or of infecting others, and those who are supposed to be responsible for reducing transmission, all have their own myths. And what is a myth in poor countries may be the orthodoxy in rich countries, and vice versa.


Friday, January 14, 2011

Giving Up Sex Will Not Protect You From HIV in Africa

All the HIV/AIDS industry has to do is put out a press release and the global media reproduces it over and over again, without question or analysis. It's hard to believe that such slavish repetition is what counts as journalism.

Even, with their pretentions of offering something different, just pick up whatever is thrown at them. A recent article, typical end of year stuff, rehashes all the hypes of the year about HIV, how it is all going to be sorted out in the end by technology.

The main worry about this sort of article is not that technology will never develop to the extent that it can treat, prevent and even cure HIV one day. The worry is that we don't have to wait till that happens before we do anything to prevent a lot, perhaps the majority of HIV infections in high prevalence countries. Yet, we are still waiting.

UNAIDS and their pharmaceutical industry chums have been putting about the idea that if only people would have less sex, everything would be ok. But some people don't have sex, or they are very careful when they do, and they still end up HIV positive. Others have lots of sex, even unsafe sex, and they generally do not end up HIV positive.

We even know who is likely to be infected. If they are female and living in a handful of mainly African countries, between one third and half of them will be HIV positive or dead before they are 40. Doesn't that strike people as a bit odd?

If they are not from one of those countries in question, they can have as much sex as they like, as long as it is penile-vaginal sex. Outside of high and medium prevalence countries, where epidemics are 'generalized', that is, not confined to high-risk groups, HIV is transmitted by intravenous drug use and anal sex, generally.

Unless you subscribe to the racist and sexist 'oversexed African' view of HIV transmission, and you're in the esteemed company of the entire HIV/AIDS industry if you do, you have to conclude that there is something we are not being told about HIV.

How can it be an almost exclusively sexually transmitted infection in a handful of countries and almost exclusively transmitted by anal sex and intravenous drug use in all other countries?

Even the HIV/AIDS industry knows that HIV is not exclusively, perhaps is not even mainly, sexually transmitted. They don't like to admit it, but sexual transmission of HIV is not very efficient.

However, non-sexual transmission modes, such as unsafe healthcare, are higly efficient. UNAIDS and the UN as a whole are well aware of this and they warn their own employees to avoid medical facilities in high HIV prevalence countries.

For some reason, they don't think it necessary to warn people living in high prevalence countries. Every tourist coming to African countries can read warnings about using health facilities in these countries. It's just people living in them who are not warned.

Worse still, UNAIDS denies that unsafe healthcare plays a significant role in transmitting HIV. They estimate that it may account for 2-5%, but that is certainly not enough for them to consider warning people who have to use health facilities that lack trained personnel, basic equipment and even soap and water.

Testing is of little value to populations as a whole if no attempt is made to find out how people are being infected. And no attempt is being made to find out. If someone is African, it is assumed they were infected sexually, even if they don't have sex, don't have unsafe sex or have a partner who is not infected.

Never mind the technologies that so many billions of aid money is going into, or the technologies that may one be developed. People are being infected, suffering, infecting other people and dying because they are being told half truths and outright lies.

HIV is tranmitted non-sexually, especially through unsafe healthcare. We need to tell people that so they can protect themselves and protect their partners and families. People will not be fully protected if they have 'safe' sex, take various drugs, use condoms or take any other precautions against sexual transmission. They also need access to safe healthcare.


Wednesday, January 12, 2011

HIV Stigma Doesn't Come from Ignorance, it Comes from Lies

UNAIDS' and the Aids industry's stigmatizing of HIV positive people has many consequences. If you resolutely claim that HIV is almost always transmitted sexually in African countries, people in African countries who are HIV positive will continue to be stigmatized. Telling everyone that HIV is driven by promiscuity means that everyone who is infected is considered to be promiscuous.

Some of the most vulnerable victims of the industry's stigmatization are sex workers or those assumed to be sex workers. Of course, according to UNAIDS, a huge precentage of African women are sex workers, even if they don't know it themselves.

Many women, whether sex workers or not, are aware of sexually transmitted HIV. Most women attend antenatal clinics when they are pregnant, if they can reach one. Those who do engage in transactional sex visit clinics if they can. In fact, the majority of women probably follow the strictures of the HIV industry, especially where they think they might be at risk.

Most women are not, however, aware of non-sexual HIV risks. Those visiting antenatal clinics or giving birth in health facilities are unaware that the majority of injections given in developing countries (70%) are unneccessary. A huge amount of HIV and hepatitis is probably transmitted in such facilities due to reuse of injecting or other equipment.

In some countries, HIV prevalence among sex workers has been found to be as high as 70 or 80%. How can this be? Especially when prevalence among men in the same areas is 5% or less. It is not possible for three quarters of heterosexual women to be infected when such a small percentage of men are infected.

Prevalence among young women of child-bearing age in some countries is 30 or 40%. It is nowhere near this level among men of any age. Who is infecting these women? The Aids industry doesn't even bother checking the status of partners of all these HIV positive women, let alone find out how they became infected.

Even if African women are as promiscuous as UNAIDS and the rest of the industry tell us, we don't know how they are becoming infected sexually, unless a sizeable percentage of men are also infected. There simply is no small group of HIV positive men who sleep with almost all the sexually active women in a particular population.

Sex workers face risks, there's no doubt about that. They have been stigmatized by UNAIDS and the industry to the extent that many of them are afraid to visit health facilities, though they know they have to. And they may be right to be afraid. Perhaps the massive rates of HIV prevalence found among sex workers and others attending sexually transmitted infection (STI) clinics face more serious risks in the clinics than they do from their clients.

But sex workers also face stigmatization and persecution from their clients, who often refuse to pay or demand more abusive or dangerous types of sex. They face stigmatization from police and security people and often have to pay bribes, in cash or by sexual favors. And they are stigmatized by the public, who have been told by UNAIDS and the industry that sex workers spread HIV.

Nauseating articles about how sex workers are so badly treated, when the same articles simply spread the industry stigma, do little to help. Sex workers need to know the truth: that HIV is not spread by sex alone. Indeed, everyone needs to know the truth. Sex may well spread HIV but so does unsafe medical treatment, cosmetic treatment, tattooing, traditional medicine and any other practices that may involve contaminated blood or other bodily fluids.

One of the biggest threats to reducing HIV transmission seems to be the very HIV researchers who don't bother investigating non-sexual HIV transmission, especially in health facilities for sex workers and for pregnant women. They seem utterly oblivious to the possibility that sex is not always transmitted sexually, even when it happens right under under their noses.

It's time to investigate the massive levels of HIV among sex workers whose clients are almost all HIV negative, the mothers whose husbands are HIV negative, the babies and children whose mothers are HIV negative.

Of course sex workers are treated badly and that needs to stop. But articles that simply repeat the half truths about HIV almost always being sexually transmitted is simply adding to the neglect of their health and welfare. The very stigma the Aids industry claims to abhor comes from the industry itself.

Of course the poverty that so many people have to suffer is terrible. But it is not poverty or lack of education, terrible things in themselves, that are driving the epidemic. HIV is a virus that is sometimes transmitted sexually, but not always, probably not even often. We can't continue to refuse to investigate the relatively simple question of the extent to which HIV is transmitted non-sexually.

It's not just sex worker clients, police and others who abuse sex workers and non-sex workers alike: it's researchers and academics who claim to be helping but who don't seem to be able to see Africans as ordinary human beings. Perhaps if they take that first step, the rest will be easy.


Tuesday, January 11, 2011

Flawed HIV Transmission Models Beget Flawed Strategies

A researcher called Jeremy R Magruder has written an interesting thesis about 'marital shopping' or 'spousal search' patterns being behind high and medium prevalence HIV epidemics in African countries. According to his model, when people are searching for a partner, they have unprotected sex with several different people in a relatively short space of time.

The factor that really increases the probability of HIV transmission is that people who have recently been infected are most infectious. Their HIV positive status may not even be detected by tests, so regular testing would be unlikely to help much. Therefore, this brief period of rapid partner change is likely to result in more transmissions than other scenarios.

This model is interesting because Magruder suggests that advising people to use condoms for the first three months of a new relationship could provide very high levels of protection. Better still, evidence has suggested that people respond better to behavior change strategies that are more feasible.

Unsurprisingly, being told to abstain for an indefinite period, even if it is until marriage, is a lot less feasible than abstaining until the end of secondary school. And using condoms for a few months into a new relationship is a lot more feasible than using condoms, not just until marriage, but throughout marriage.

Magruder also notes that efforts to reduce sexually transmitted infection prevalence and male circumcision are unlikely to have much effect on transmission rates. He even dismisses the benefits of looking at antiretroviral treatment as prevention, something some technology fanatics have suggested as their magic bullet of choice.

But the model becomes less credible when you start to ask why prevalence in some African countries is only 1%, in others it is over 5% and in the worst affected countries it is over 25%. Prevalence is over 40% in some demographic groups and many people who never have sex, or who always use protection, are also infected.

Within countries, prevalence also varies greatly, with less than 1% in some areas and figures that are 10 or 20 times higher in other areas. Variation between tribes can be equally high and the ratio of male to females in some tribes range from 17% to 120%. Could this really be explained by differences in spousal search patterns?

Magruder could explain these differences by reference to differences in levels of 'unsafe' sexual practices or in levels of protective behavior. But this is one of the great mysteries of sexually transmitted HIV: transmission rates can be higher among those who practice 'safe' sex. Attested levels of safe and unsafe sexual practices don't correlate with HIV prevalence.

Also, is Magruder suggesting that spousal search patterns changed some time in the 1970s and 1980s, a phenomenon which might explain why the virus was spread so rapidly during this period and not before? And is he suggesting that this search pattern changed again some time in the 1990s, when HIV incidence, the yearly rate of new HIV infections, peaked and declined in most African countries?

Magruder has assumed the truth of a version of the behavioral paradigm, the view that HIV is almost always transmitted sexually. He simply ignores the possibility that some, perhaps a lot of HIV, is transmitted non-sexually.

But Magruder doesn't subscribe to the view that African people engage in inordinate amounts of sex with little concern for the consequences for themselves or their families. And that is refreshing. But it may not help him gain acceptance for his thesis. The HIV orthodoxy is very committed to its racist and sexist views of HIV transmission.

Magruder may have shed some light on how sexually transmitted HIV could be spread by people who are only human and can only engage in humanly possible levels of sexual behavior. But until some light is also shed on what proportion of HIV is transmitted sexually and what proportion is transmitted non-sexually, his strategy will bring only limited benefits.


Saturday, January 8, 2011

Unethical Tuskegee Style Trial Being Re-run in African Countries

The issue of male circumcision has cropped up on this blog because of claims that it can reduce HIV infection in men. It is not claimed that it reduces infection in women, though there is often that implication. In fact, circumcised men may be more likely to transmit HIV to women.

However, here's what one of the 'experts' and flag-waving proponents of mass male circumcision, Dr Maria Wawer, has to say: "Circumcision removes the foreskin of the penis, which is rich in immune system cells targeted by HIV and perhaps other viruses. Taking off the foreskin likely makes the penis less likely (sic) to carry a range of microbes."

The lack of certainty that I express using the word 'likely' stems from the fact that I am not a scientist, nor am I collecting and analyzing data directly. There is conflicting evidence, to a large extent because much of the research has concentrated on demonstrating the effectiveness of male circumcision, rather than considering if it is really going to reduce HIV transmission.

But 250,000 Kenyan adult men have been circumcised because Dr Wawer and her colleagues think the operation is 'likely' to be effective. They have no idea why it might be effective, if it really is. Worse still, the best that can be hoped for in terms of transmittion reduction is really nothing to get excited about.

The claimed 60% reduction in HIV transmission was achieved in groups of people who were 'counseled' (indoctrinated) at length on 'safe' sex, urged to use condoms and monitored regularly for a relatively short time. What was really established was that if people, circumcised or uncircumcised, used condoms consistently every time they have sex, HIV transmission issignificantly reduced.

Far from publishing critical analyses of these rather poor results, much has been made about the protective benefits of circumcision against other sexually transmitted infections, such as human papilloma virus (HPV), which can cause cervical and other cancers. Yet again, the figures are not that impressive. Their '28% lower rates of transmission' in field trials could be far lower in practice.

But supposing the protection was real and male circumcision does give some protection against some STIs, or even just one? Would this mean that those who seem so vehemently opposed to mass male circumcision, and that includes me, need to backtrack?

I'm not opposed to proven interventions that reduce HIV transmission, such as prevention of mother to child transmission (PMTCT). What I am opposed to is half-baked interventions that may appear to give some small benefit but may also be doing a lot of harm.

The trial Wawer is involved in like the Tuskegee syphilis trial, where the ultimate outcomes for those taking part is not the concern of those doing the research. They are not worried whether participants become infected with HIV or anything else, they just want to know the circumstances so they can develop interventions for Western countries.

Why circumcision is still of so much interest is not clear, it of no use among men who have sex with men and unless people use condoms during heterosexual sex, it is of no use to them either. It's big in the US and must make a lot of money for the healthcare industry.

But it doesn't appear to protect people much in the US, either. HIV prevalence in the US, especially in some cities, is far higher than in European countries, where circumcision is not very common. Other STIs are also more common in the US, sometimes 10 or 20 times higher than in many European countries.

In African and other developing countries, though, the risks associated with circumcision are far higher than they are in Western countries, with their good health services and fairly numerous health personnel. Countries like Tanzania, Kenya and Uganda have deplorable health services, chronic shortages of skilled personnel, inadequate supplies of equipment and a serious lack of safety and infection control processes.

Going for an operation, even getting a tooth pulled or receiving an injection in many African and other developing countries is a serious risk. The Tuskegee syphilis style trials mentioned above don't bother checking what non-sexual risks people face in their day to day lives, so obsessed are they with sex.

Those taking part in circumcision, vaccine, microbicide, pre-exposure prophylaxis (PrEP), treatment as prevention and other trials, many of whom eventually become infected with HIV, are not warned about non-sexual risks. Researchers don't check to see if those who become infected were infected non-sexually or sexually.

In short, most of these trial results are not even valid and certainly do not justify the green light that mass circumcision campaigns have received. Circumcision has not been shown to be of benefit and its safety has not been assurred. The health and even lives of millions of African people are being put at risk by a bunch of well financed Western researchers. Doesn't that bother anyone?


Wednesday, January 5, 2011

Circumcision: 1.1 Million Kenyans Tricked Into Being Human Guinea Pigs

Some of the highly dubious pronouncements about HIV programs can be taken with a pinch of salt and I certainly hope that's true of the mass male circumcision program taking place among the Luo tribe in Nyanza province, Kenya. About a year ago they were claiming to have circumcised about 100,000 men. Now the figure has risen to 250,000, 40,000 of them said to have taken place over the last few weeks.

The argument is that men are less likely to be infected with HIV if they are circumcised. There is little evidence for this and how, exactly, the process may work, is unknown. But on the slight chance that it may work, the program is going ahead. Aside from the fact that the HIV industry really wants to do it, it is not clear why this program was ever started.

We are constantly told it is 'cost effective' and will prevent hundreds of thousands of infections over the next 20 years. However, this projection depends on a lot of assumptions that are completely unsupported by evidence. And lots of things are 'cost effective', such as reducing diarrhea and intestinal parasite rates, which infect far more people, kill more people and cost even less to prevent and treat. But cost effectiveness doesn't seem to count in those instances.

Male circumcision is rare among members of the Luo tribe and HIV prevalence is high, so this is seen as a good argument for circumcision. However, female genital mutilation (FGM) is also rare. I don't hear anyone calling for mass FGM just because of this correlation. Not that I think FGM is a good thing, I don't. I think it is an appalling form of gender based violence that has none of the benefits claimed for it.

However, two other tribes in Nyanza province, the Kuria and the Kisii, have low HIV prevalence. And most of the men are circumcised. But many, perhaps most, of the women are victims of FGM. And the lowest HIV prevalence found in Kenya is among the ethnic Somalis, who also practice male circumcision and FGM widely.

Clearly, there are other circumstances that surround low HIV rates and high rates of FGM. FGM is most commonly practiced where levels of education are low, people are exceptionally poor and they are isolated from health and other public services. But there are other circumstances high rates of HIV and low rates of male circumcision, too.

Are these arguments for reducing education and health and increasing poverty? I wouldn't have thought so. But if you make projections using the figures for the Northeastern province, which has the lowest HIV rates in the country, you might find that such measures are 'cost effective' when it comes to reducing HIV rates.

Recent research in Tanzania has found that HIV rates are, indeed, lower among women who have undergone FGM of some kind. Indeed, the level of 'protection' given by FGM is curiously similar to that claimed for male circumcision. So if this is not a valid argument for FGM, maybe it's time to reconsider male circumcision?

Given current data, Kenyan Luos are being used in a large scale public health experiment that is undoubtedly unethical. As to the consequences of the experiment, it's too early to say. But if I was a Luo I'd be careful of people wielding scalpels. Just use condoms. You'll still have to do that when you are circumcised, anyway.


Monday, January 3, 2011

Global HIV/AIDS Policy for Africa: Mass Denial of Human Rights

Rumor and myth continue to dominate academic writings about HIV/AIDS, especially when it comes to explaining why HIV prevalence has declined in many countries which have experienced a very serious epidemic. In brief, HIV academics don't really have a clue why the virus spread, peaked and declined in the first place. Therefore, they don't know which prevention programs work and which don't. Some of them may have worked, or they may just have appeared to work because they began shortly before the high death rate stage of the epidemic.

Leaving aside the somewhat risible strategies of abstinence and partner reduction, which were never as vital as the literature claimed, nor as successful, that leaves the one strategy that could have had some impact on sexual transmission of HIV. Using condoms could have been successful if people used them, consistently. But in most places, they didn't. Many people have used condoms, some even use them several times a year. But this is not enough to have much impact on sexual transmission.

A fairly typical set of results comes from Kilifi, in Kenya's Coastal Province. The "mean number of condoms used was 2.2 per person per year among all sexually active individuals". Usage was lower in rural contexts. The majority of people in all East African countries live in rural areas. And not only is condom use lower in rural areas, so is HIV prevalence. There is more than a hint that the extent to which HIV is a mainly sexually transmitted virus has been seriously exaggerated.

Uganda is one of the few countries credited with playing an active part in reducing HIV transmission. The country may have achieved all sorts of feats, it's hard to tell, because rates of transmission there peaked and declined just as mysteriously as they did in other countries. It's just that in Uganda, the epidemic arrived, spread, peaked and declined earlier than it did in Kenya, Tanzania and most of the very high prevalence countries of Southern Africa.

Knowledge about condoms, HIV, unplanned pregnancy and other matters is not nearly as widespread as all the hype suggests. People in urban areas, people with better education and people in higher income brackets know a lot more than people in rural areas. HIV rates being higher in less isolated areas and lower in more isolated areas tends to make popular reduction strategies look a bit pointless.

But I wouldn't like to suggest that higher condom use or knowledge about sex, sexually transmitted infections, unwanted pregnancy, etc, are associated with higher HIV rates, just that they are not particularly relevant to HIV rates. Nor is it to suggest that using condoms to reduce HIV transmission, the transmission of other sexually transmitted infections and unplanned pregnancies is not a good thing.

It's just that HIV is not, as UNAIDS and other 'experts' keep claiming, almost always heterosexually transmitted in African countries (but not in non-African countries). WHO admits on their web site that up to 14% of infections may be spread by unsafe injections and they have unpublished data that suggests such infection rates are even higher. As for the proportion of HIV transmitted by other non-sexual routes, none of these authorities have bothered to check yet.

Given the rates of transmission among intravenous drug users, men who have sex with men and mother to child transmission, the proportion of HIV transmitted through heterosexual sex is in urgent need of investigation. Otherwise there is a danger that these highly inefficient, expensive and deceptive 'prevention' interventions will continue to deflect attention away from the health services that may be causing more infections that they have ever been able to prevent.

A recent paper shows that 50% of the 500,000 people currently infected with HIV in Uganda are under 25. The study also shows that young people know very little about sex, condoms, HIV or pregnancy, despite the hundreds of millions of dollars that have been spent. HIV rates in the area are high. Sadly, young people appear to have picked up many of the rumors spread about condoms by religious leaders, journalists and others who seem to prefer to maintain high rates of STIs and unwanted pregnancies (and the consequent high rates of unsafe abortions).

Firstly, young people need sex education and it needs to be an integrated part of their overall education (not an afterthought tagged on to an already under-resourced system). If religious and political leaders are hell bent on filling people's heads with rubbish (in addition to the bunch of lies they get from the HIV industry), at least with a good education they have some chance of working things out for themselves.

But their education needs to include information about non-sexual HIV transmission routes, such as unsafe healthcare, unsafe cosmetic practices and perhaps some traditional practices that involve exposure to contaminated blood. And in order for this information to be of any use, people need accessible and safe healthcare.

Countries with continuing high rates of HIV transmission can not afford to depend on luck. It is lucky that HIV transmission rates declined. But current rates of transmission are still too high. The HIV industry harping on about sexual behavior and the religious and political interests contradicting every piece of advice given is not going to lead to a reduction in current rates of transmission. As Uganda and other countries are finding, HIV rates can also start to rise again.

In places where very little HIV is transmitted non-sexually, fine, as long as steps are taken to eradicate these forms of transmission altogether. However, it looks as if non-sexual transmission is far from trivial in most African countries. This is in urgent need of investigation and this work can take place at the same time as the work on sexually transmitted HIV. But ignoring non-sexual transmission is probably doing more to spread HIV than continuing the many failed sexual prevention interventions.

The consequences of the lies and inaction from UNAIDS, many HIV/AIDS academics and various institutions are almost too terrible to contemplate. But we can not allow this mass denial of human rights to continue.


Saturday, January 1, 2011

UNAIDS Happily Stoke Up HIV Epidemic Using Public Money

Someone recently raised the question in a Kenyan newspaper of whether a negative HIV test result in one partner implied that the other partner is also negative. The answer is a resounding 'No', but the person replying was not quite clear enough on the matter: "There are instances where one partner is HIV-negative and the other is HIV-positive".

In many African countries, half of the couples infected with HIV are discordant, meaning that only one partner is infected. And about half of those in such discordant relationships are female. People in discordant relationships can and do have unprotected sex, often for years, without transmitting the virus. And in couples where both partners are infected, it has often been found that they were both infected by a different source.

More worryingly, you can not imply the HIV status of a woman from the HIV status of her children. Not only can HIV positive women have HIV negative children but HIV negative women often seem to end up with HIV positive children. UNAIDS and others deny that this phenomenon is significant and very little research has been carried out to find out if they are right.

Indeed, the very mention of terms like 'nosocomial', 'iatrogenic', 'hospital acquired' (all meaning roughly the same thing) is something of a taboo. In the same way that people all over the world see talk about sex as taboo, the highly paid and overqualified people who make up the AIDS industry see talk about non-sexual HIV transmission as taboo. Perhaps it's a cultural trait or some kind of institutional tradition, who knows.

Things in Mozambique may be different. Most of the relevant publications are in Portuguese, but Dr David Gisselquist recently sent me some figures for HIV positive children with HIV negative mothers. It was kindly translated by a researcher who knows Portuguese. I just wonder how much other vital data is available but only in a language I don't know. I suspect there's a lot.

Anyhow, the proportion of HIV positive children with HIV negative mothers is around 30%. This is an alarming figure, suggesting that infants and children, as well as mothers (and the population as a whole), face serious risks of HIV transmission from unsafe healthcare.

The AIDS industry has always tried to diminish the likelihood of any form of non-sexual HIV transmission and a similarly embarrassing revelation a few years ago, that time in Swaziland, was dismissed as being a result of babies being raised by someone other than their birth mother. This unconvincing argument is quite telling, too; the industry is not interested and will not investigate.

Cock-ups in health services are not confined to dirt-poor countries with disasterous infrastructures and extreme shortages of skilled personnel and equipment. They also occur in countries that have very high quality, accessible healthcare systems. There have been numerous scares about healthcare transmission of HIV, hepatitis and other conditions. And recently there was a scare about a mother in the UK who was given the wrong (expressed) breastmilk for her infant, several times.

The figures for Mozambique are unlikely to reveal the full picture. Women with HIV positive children who are HIV positive themselves may not have infected their children. And it is also possible that some children may have infected their mother. Or they may both have been infected through different routes. Many women are found to seroconvert late in their pregnancy or just after giving birth. The AIDS industry assumes that this is because they continue to have unprotected sex, probably often with strangers, during their pregnancy.

This is an appalling attitude towards African people and, as it is not the received view of non-Africans, it must also be considered racist, institutionally racist. The picture that is painted of women is similarly bigoted and entirely sexist. In Western countries, if a HIV negative woman is found to have a HIV positive child, there is an investigation, not an outpouring of racist bilge.

To misrepresent HIV as a purely sexually transmitted virus (in African countries, alone) is to condemn people to a lifelong, debilitating disease that will likely reduce the sufferer's lifespan. It also condemns many people to a life of stigma, persecution, isolation and violence.

To stand by and watch people being needlessly infected with HIV is bad enough but to brand them as stupid, careless, ignorant, and even as evil, is beyond belief. The HIV industry, especially UNAIDS, need to be recognised as being more than just ineffective; they are also playing a significant part in fuelling the HIV epidemic.