Thursday, March 31, 2011

Ups and Downs of Volunteering and Development

Miriam (thanks to Danielle Jenson for photo)

It's a long time since I have blogged about what I do from day to day and that is because I'm working in an office now. The work may be interesting enough, but it is not something I could write about with enthusiasm on a daily basis. And it is not really relevant to my blog, which is about HIV, development and East Africa.

But I don't just spend my free time looking for articles about development and HIV that make me grumpy. I spend most evenings researching and weekends enjoying being in a place as beautiful as Northern Tanzania, which is friendly and secure, after the less friendly and less secure atmosphere of Nakuru, Kenya. I hang out with various people, some Tanzanians and some fellow ex-pats.

One of the best times of the working week is visiting a children's home that is in the same compound as my home and my work. It's called Cradle of Love and the 45 or so children are all under the age of three. The children can be as young as a few weeks. Most are in some way vulnerable or sick, some have been abandoned, some have no parents and some, we have no idea about their history.

Several people have said that they think the work I do and the things i involve myself with must be very depressing. Others have asked about the frustrations of working as a volunteer in situations that can involve making little or no noticeable progress most of the time. Some even ask if anything good can come of voluntary and development work, and shouldn't we all just mind our own business and stop thinking we know best.

I sympathise with such views, especially from people who have done voluntary work, and even from those who have considered it. But I never have to question whether any of the children I see in Cradle of Love or other similar homes are well off for being there. Their physical needs are looked after, but they also get constant emotional stimulation, from a combination of highly experienced nannies, devoted long term volunteers and shorter term volunteers.

The more time you spend with young children, the less you see development as being depressing or cynical or misguided. This is not to say there is nothing bad about NGOs, volunteering or development. But things are by no means all bad. There are plenty of things that can be done that are not currently being done everywhere. And seeing negative things in the development industry, and it is to a large extent an industry, is not a reason for dismissing everything done in the field.

I notice the New Internationalist has an article on how most volunteers work without any thoughts of a quid pro quo. It is particularly galling when fatcat banks and multinationals are the only ones who get the 'quid' and this is quite disincentivizing for volunteers. Some people spend their adult life enriching themselves at the expense of others, and some people don't.

I've noticed a tendency in development to compartmentalize parts of projects into short term consultancies and professionalized functions, which cost a lot for what you get and can be of very low quality. Often the same work can be done by indigenous people but the work usually goes to ex-pats, not volunteers; ex-pats who charge Western rates even though they live in a developing country.

Recently, I heard of a large sum of money, what the average Tanzanian would earn in two and a half years, being handed to someone for three days of work that could have been done, would willingly have been done, by a volunteer. Work done by volunteers can often be dismissed simply because they are not charging anything for it, and this too is disincentivizing.

Seeing large amounts of money being given out for goods and services that could be a lot cheaper, and could represent far greater gains for people in developing countries, is hard to stomach.

But, as I say, it is never a wast of time or effort when you are working with the right people, whether they are children or not, who show very clearly how they thrive, how they prosper as a result of your efforts. That is never depressing. It is always a pleasure.


Wednesday, March 30, 2011

Uganda's HIV Epidemic: Mystery or Myth?

I have always worried about the way Uganda is held up as an example to other African countries on account of its early experience with HIV. What happened in Uganda earlier on is not the same as what happened later.

Early on in the epidemic, everything possible was done to reduce HIV transmission, both sexual and non-sexual transmission, in all their forms. Later, non-sexual transmission became more and more excluded and a set of myths about the efficacy of the ABC (abstain, be faithful, use condoms) strategy replaced any semblance of a coherent strategy.

The epidemic in Uganda took off earlier than in most other countries. HIV incidence, the rate of new infections, then declined and several years later, prevalence (the percentage of HIV positive people between the ages of 15 and 49) also declined.

It is not clear exactly why the epidemic took off when it did, nor is it too clear why incidence then peaked and declined. Measures to control the epidemic are likely to have played some part, of course, but how big a part has long been a matter of debate. Prevalence would have declined because of high death rates.

Once global HIV policy was thrown off course by ABC, or even AB or just A, it never got back on course. The burgeoning HIV industry's obsession with sex still rages and non-sexual HIV transmission, for example, through unsafe healthcare or cosmetic practices, is rarely talked about, let alone researched or investigated.

This leaves Uganda in a vulnerable position. The country receives a lot of HIV money, most of which is spent on drugs and care for HIV positive people. And the little left over for preventing new infections is spent on interventions that obviously don't prevent new infections.

Prevalence declines that resulted from high death rates have been reversed by a high rate of new infections. Those on treatment are likely to stay alive for longer, adding to increases in prevalence. But many HIV positive people still die, usually from treatable illnesses.

Not only is Uganda far from eradicating HIV, there is still a very serious epidemic in the country. Prevalence is bumping along, lower than it was during the worst years, true, but it has hardly changed for the last 10 years.

Infection rates in young people is often seen as a proxy for incidence because it's hard to measure incidence directly. But if young people who are just becoming sexually active are infected in large numbers, the epidemic is still very much alive. And 1.5% of people between 15 and 19 are HIV positive, 2.6% among girls and 0.3% among boys.

Of course, many of these teenagers could have been infected by mother to child transmission. But it's unlikely that they all were, unless this type of transmission is a lot more common that has been realized.

We are told that the highest burden of HIV, though, is now among married couples between 30 and 40 years old. In fact, it has been realized for some time that the majority of transmissions in Uganda appear to be a result of sex that is not 'unsafe' by any of the HIV industry's definitions.

HIV is common among those who don't have sex very much, are not likely to have several sex partners, and most of whom only have sex with a long term partner. Many, also, are in discordant relationships, their partner is not infected (or they did not infect each other). And half of the infected partners are female, so there goes the 'all men are promiscuous' theory of HIV transmission.

And that's the problem. If HIV is not primarily transmitted through unsafe sex, interventions that target unsafe sex will have little effect on transmission rates.

Yet the conclusion of Uganda's Ministry of Health is that they should encourage male circumcision, increase use of female condoms and awareness about HIV/AIDS. This may or may not reduce sexual HIV transmission. But after so many years watching HIV transmission stagnate, so many people becoming infected and so many dying, perhaps they could think about changing tack.

HIV is difficult to transmit sexually, yet it seems to be transmitted very rapidly in Uganda. Young people who are just starting to have sex are being infected quickly, which suggests that we are way off when it comes to our knowledge of transmission probabilities. Or perhaps not all HIV is transmitted sexually? Either way, we need to find out why transmission rates are so high in Uganda. Otherwise it will not be the only country with stagnating HIV prevalence figures.


Tuesday, March 29, 2011

The Futility of Criminalizing HIV Transmission

Yet another blog posting that demonstrates the futility of criminalizing having sex with someone without disclosing one's HIV status. It's quite simple. If you don't want to risk prosecution for the offense, don't get tested. Or make sure you get tested anonymously.

In this case, a man, who says he was infected in the late 1980s (but appears to have survived without antiretroviral drugs until about 20 years later) has unprotected sex, once, with a long term sex partner. How do we know that she wasn't already HIV positive at the time? That doesn't exonerate him, of course, but if she had kept her status secret from anyone, his behavior is punishable and hers is not.

The more people get tested the better. And better still if people get tested regularly if they think they continue to run risks of infection. But if knowing that you are HIV positive means you might accidentally infect someone with whom you haven't discussed your status, it's better to test anonamously.

People are not being criminalized for being HIV positive, they are being criminalized for being tested openly, in a manner that can be traced, should someone wish to trace it. Instead of getting people to test as early as possible, this makes it preferable for them to test as late as possible and to disclose their status as little as possible, perhaps never.

For people in developing countries, it's fairly obvious who is most likely to be punished by such laws. Women are under a lot of pressure to test when they are pregnant, sometimes more than once. For various reasons, it is often difficult, perhaps impossible, for them to keep their status confidential. And there is always the danger that someone else could reveal it.

In fact, if a woman needs any health services, especially before, during and after pregnancy, it is very unlikely that she can remain untested, or that her status can remain confidential, should the matter be scrutinized later.

Women in developing countries are more likely to be infected than men, often substantially more likely. They are more likely to have to test in local facilities (because of relative lack of mobility), where they are known by others.

Far from reducing stigma, this kind of criminalization would increase stigma. People would be under suspicion just because of things that may be known about them, or even because of characteristics that are merely attributed to them.

The orthodox view of HIV in developing countries is that HIV is almost always transmitted through heterosexual sex. But it is people who are felt to be engaging in more sex that will be most stigmatized, sex workers, pregnant women, perhaps young women, because prevalence is so high among them.

In the case mentioned above, both the woman and the man are intravenous drug users. They are both at high risk, far higher than people who engage in a lot of heterosexual sex. If the woman did know her status, it would probably be difficult to prove that.

And if she didn't know her status, perhaps, being an intravenous drug user, it might be suggested that she should have been tested a long time ago. It is claimed she was not tested till 2006, though the unprotected sex act was said to have occurred in 1999.

But why would anyone test if it's safer not to? If there was any chance that criminalization could reduce HIV transmission, there might be some justification for it, though it's hard to imagine what that could be. But in fact, it only makes things worse. It risks punishing people who may have been a lot more careful, or honest, and risks exonerating those who keep their test results to themselves, or don't even bother testing.


Monday, March 28, 2011

Beware of Reassurances About Genetically Modified Organisms

In what may be an attempt to reassure the public, an article in Tanzania's Daily News says "Only South Africa and Egypt have potential to handle cultivation and consumption of genetically modified organisms (GMO) [in Africa]". But this message comes from Dr Tesfai Tecle, a spokesman for the Alliance for a Green Revolution in Africa's (AGRA) Kofi Annan.

Another of AGRA's token Africans, Dr Namanga Ngongi, goes further and says that GMOs are too complicated and sophisticated for countries like Tanzania to adopt. Tecle claims that AGRA's position is clear, that they "don't support genetically engineered seeds".

But this does not fully characterize AGRA's position on GMO because their own website says they "do not preclude future funding for genetic engineering as an approach to crop variety improvement when it is the most appropriate tool to address an important need of small-scale farmers and when it is consistent with government policy".

AGRA is the joint spawn of the Gates Foundation and the Rockefeller Foundation, neither of which are in any way averse to GMOs. The former has invested millions in Monsanto and the latter, despite making some claims to be sceptical at one time and funding some 'research' into the subject, are 100% behind GMOs.

Proponents of GMOs often talk about 'feeding the world' and 'food security', yet these two particular proponents are also very keen eugenicists. They are particularly in favor of people in developing countries having fewer children, since to their institutions, development means little more than population control.

So, there is no contradiction between between supporting GMOs and being a eugenicist, despite the fact that successful eugenics would lead to fewer mouths to feed. Because GMOs are, ultimately, for those who can afford them. Whether they are paid for by public or private money is immaterial. The claim that GMOs can actually play a part in improving the lives of the poor is just a popular myth used by the industry.

The advantage of GMOs is not that they are cheaper, they are not. Yields are not better. They cannot, despite the publicity material, grow in sup-optimum conditions, they are not more nutritious, they do not have special qualities, such as drought or salinity resistance, or anything else.

The sole advantage is that they are owned by a handful of the world's most powerful food multinationals. If the world's seeds, or as many of them as possible, could be replaced by GMOs, these multinationals would control the world's food supply. Proponents of GMOs may mention small-scale farmers, the poor and starving, Africans and what not, but GM seeds are not owned by any of these groups and they never will be.

Which leads to another reassuring story that doesn't seem so reassuring when you look at it closely, the US Government's Feed the Future program, about to decend on Tanzania. The literature is too polite to mention GMOs but wait till you see the list of private partners:

Archer Daniels Midland, BASF (Zyklon-B), Bunge Limited, Cargill, Coca-Cola, DuPont, General Mills, Kraft Foods, Metro AG, Monsanto Company (Agent Orange), Nestle (Baby Milk), PepsiCo, SABMiller, Syngenta, Unilever, Wal-Mart, and Yara International.

This is not a list of the world's best known bleeding-hearts. And in among the bloodless hearts, in addition to its large investment in Monsanto, the Gates Foundation can be found listed as a donor and AGRA gets a few honorable mentions. Reassurances that GMOs will not be unleashed on unsuspecting and defenceless developing countries should be interpreted to mean something quite contrary to what they say.


Sunday, March 27, 2011

Could HIV Policy Be Driving HIV Transmission?

Early on in the HIV pandemic it was thought that if people were to be told about the risks for HIV infection and how to avoid them, they would do so. Those involved in public health, professional and non-professional, took steps to inform people about both sexual and non-sexual modes of transmission and what they could do to reduce their personal risk. Improvements in health facilities were also made to eliminate accidental infection through various invasive practices as much as possible.

In a paper on knowledge of blood-borne HIV transmission risk, Dr Devon Brewer comments that "many Ugandans adopted injection practices that likely reduced their risk of HIV acquisition following the 'massive anti-AIDS education campaigns that began in 1985 [that] warned people about the dangers of sharing unsterilized needles and syringes'" (citing a paper by H Birungi). Brewer notes that "these behavior changes were accompanied by concurrent declines in HIV transmission".

Things changed later and non-sexually transmitted HIV risk is now said to have been taken care of. The entire HIV orthodoxy is built on an assumption that is covertly recognised to be incorrect: the behavioral paradigm. This is the view that HIV is almost always heterosexually transmitted in African countries and that non-sexual transmission, which is not uncommon in non-African countries, hardly ever happens in Africa.

Brewer found that in countries where it was known that certain behaviors carried a risk of HIV infection, sharing razor blades in this instance, HIV prevalence was lower. It is not clear to what extent sharing razor blades contributes to HIV epidemics and there are many other such risky behaviors, for example, the use of contaminated injecting and other medical equipment, contaminated cosmetic equipment, such as tattoo needles and ink, and various others.

But Brewer also found that "countries with high proportions of respondents endorsing condoms also tended to have higher HIV prevalence than countries with low proportions endorsing condoms." This is difficult to explain and, if you accept the behavioral paradigm, you might suggest that it means people do not avoid risks that they have been told how to avoid.

My take on the phenomenon is that those in areas with the highest risk of HIV infection, cities and more populated, accessible areas, are also those most likely to have heard the constant messages about condoms. And apparently they even use them more than those in rural, less populated and less accessible areas. But as HIV is less likely to be transmitted through sex and is very likely to be transmitted through unsafe healthcare and the like, those endorsing condoms also face risks not faced by people in rural areas.

Well, 'safe sex' messages may not have had much of an impact in high HIV prevalence countries. But this is not a reason for not advising people of the risks. In the same token, the fact that most people do not have much influence over those who provide them with health services is not a reason for failing to advise them of the risks involved, and the risks of sharing razor blades, for that matter.

People are entitled to know that HIV is far more likely to be transmitted through contaminated blood than through any kind of sex and that there are steps they can take to reduce risk to themselves and their friends and family.

The HIV orthodoxy think nothing of stigmatizing entire nations, a whole continent, blaming massive levels of HIV transmission on massive levels of unsafe sexual behavior. Yet they balk at the suggestion that those providing health services need to be reminded to avoid any risks of transmitting HIV and other blood-borne diseases. They accuse anyone questioning the behavioral paradigm of branding health care providers, while at the same time branding every HIV positive African as promiscuous, stipid and cruel, as mere spreaders of disease.

Brewer concludes, "Health officials have an ethical duty to warn the African public about blood-borne HIV risks. Where such efforts are currently absent, they should be started immediately; where such efforts are underway, they should be emphasized further and sustained. Public education campaigns should not only highlight blood-borne HIV risks comprehensively but also communicate practical strategies for avoiding the risks."

Public health professionals in African countries are in very short supply, underpaid, overworked, undertrained and underequipped. Conditions in public health facilities wouldn't even be approved for veterinary use in Western countries. Warning about health care transmission of HIV is not pointing the finger at health professionals.

If anything, it is pointing the finger at the over-qualified and extremely well paid policy 'experts' at UNAIDS and other institutions. This doesn't answer the queston of why so many people in the HIV industry have failed to do anything about non-sexually transmitted HIV; perhaps they can answer that themselves. But progress in eradicating HIV transmission will not be made until the truth about HIV transmission is acknowledged.


Thursday, March 24, 2011

'We Haven't a Clue, But We're Doing a Great Job', Say Academics

With a population of only about 800 million, sub-Saharan Africa (SSA) has 22.5 million HIV positive people. The rest of the world, with a population of about 6 billion, has 10.8 million HIV positive people. While 2.81% of SSA is infected, only 0.18% of the rest of the world is. In that sense, SSA's epidemic is 15.5 times worse and that of the rest of the world and Lesotho's (an exceptionally high prevalence country) is 75 times worse.

So how do we interpret these enormous differences? If we accept UNAIDS' and the HIV industry's claim that about 80% of HIV is transmitted heterosexually in African countries, does this mean that people there have more sex than non-Africans? And how much more? Ten times more? Fifty times more? Or is it more dangerous? Ten times more dangerous? Fifty times more dangerous?

In a kind of a sort of a way, they do mean this, or something like this. But they don't mean anything very specific. So if most sexually active people had sex four times a month, perhaps Africans have the time, energy and inclination to have sex at least once a day, every day, and often more than once. Actually, they would need to have a lot more sex with this, or it would need to be unbelieveably dangerous, to account for some of the very high prevalence figures found in SSA.

But the industry clings to its behavioral paradigm, the belief that HIV is mostly transmitted sexually in African countries. Some representatives of the industry recently published a paper wondering what kinds of sexual behavior change resulted in substantial declines in Malawi in recent years. The concluded that it may have been a reduction in the number of sexual partners among (heterosexual) men. They weren't sure about this, though, nor are they sure what could give rise to such a reduction.

I'd like to know what caused sexual behavior in Malawi and other SSA countries to increase to non-humanly possible levels in the first place. And why is it that it's always men who engage in the highest levels of 'unsafe' sexual behavior, but always women who outnumber men, often vastly, in numbers infected? And if it wasn't quantities of sexual behavior, but rather increased risks, why did these increase and then decline?

The authors note the lack of success so far for most interventions. They even cast doubt on the potential effectiveness of mass male circumcision, pre-exposure prophylaxis (PrEP) and immediate initiation of antiretroviral therapy for all HIV positive people, without these being accompanied by substantial changes in behavior. This is almost anti-establishment.

Perhaps they would like to reconsider their adherence to the behavioral paradigm? Because in the case of Malawi, it is possible that more than 50% of HIV infection comes, not from heterosexual sex, but from unsafe healthcare. With the appalling health facilities found in many SSA countries, it is plain arrogance to insist that 80% of HIV transmission is heterosexual and that most of the other 20% is a result of mother to child transmission.

In fact, if nearly 20% of infections are said to be from mother to child, it is very likely that many of these are, in reality, also a result of unsafe healthcare. And far from all these infants being infected by their mother, some mothers may be infected by their infants during breastfeeding.

The authors of the paper conclude, as they did in a recent paper on Zimbabwe, that there was the 'funeral factor', the fear of contracting, suffering from and dying from HIV/AIDS that may have given rise to changes in male sexual behavior. It's always good to have something to attract journalists, but this doesn't explain why so many more women are infected than men. If HIV is not all being transmitted through heterosexual sex, then some interventions that address non-sexual transmission are urgently needed.

The HIV industry has been kicking around the oversexed African theory of HIV transmission for almost thirty years. In addition to being insulting to Africans, especially African women, it does not stand up to scrutiny. This paper is just one more in a long line of travesties. These researchers claim that behavior change has averted tens of thousands of deaths. On the contrary, the number of infections and deaths that have resulted from the failure of HIV research is incalculable.


Wednesday, March 23, 2011

Will Reduced Funding for UNAIDS Mean Less Prejudice?

My first experience of a HIV voluntary counselling and testing (VCT) clinic in Kenya was memorable for the fact that, among the bustle of people coming and going from the public hospital, those wanting anything to do with HIV turned left before the hospital gates. The would sit outside the standalone clinic, in full view of passers by.

This phenomenon, which is still the norm, is just one aspect of HIV exceptionalism and it clearly puts people off going to VCT clinics. It compounds the stigma that surrounds HIV, the fact that anyone who sees you at the clinic will know that you may be HIV positive. Those who are HIV positive face the even greater stigma of having to go to a Comprehensive Care Clinic, dedicated to those with HIV.

Now a pilot program in Western Kenya is trying out the idea of integrated care, where people turn up to see a health professional without being segregated into HIV and non-HIV groups. And aside from reducing the fear people had of being sneered at by other patients and even by health professionals, some are saying that it also frees up scarce resources.

It is good to hear that efforts are being made to see HIV as just one of many illnesses, because people also suffer from and die from so many diseases, often preventable and/or curable conditions. Those who defended the exceptionalization of HIV claimed otherwise, but it is widely felt that resources, including personnel, tended to be deflected away from less prominent conditions.

In fact, one of the groups most vulnerable to HIV, young women of child-bearing age, were unlikely to get much care aside from HIV related care. If they turned out to be HIV positive, they might get just enough care to ensure than their baby was not infected. But then they would be left to their own resources, ignoring the fact that the best way to ensure the health of an infant is to ensure the health of their mother.

Those who turned out to be HIV negative were even less likely to get the care they needed. But recently, there has been talk about putting a greater emphasis on maternal health. Some have even talked about strengthening health systems and improving health facilities, without reference to one, or a handful, of diseases. This may just be a way of reducing funding, but it may also be a genuine attempt to right the balence. I'm accepting that the two could be compatible.

Another of the effects of the exceptionalism of HIV was the way it was never really seen as the business of national governments in high prevalence countries. It was always something that donors controlled. The only interest that health (and other) departments would take seemed to be in the vast sums of money that HIV seemed to attract.

If it is true, as defenders of exceptionalism like to claim, that much of the HIV money was additional, on top of health funding, that's great. And if it is true, as they also claim, that HIV money has also helped strengthen health systems, that's great too. Though I have to say, I don't believe those claims for one moment. But all the better for health systems if they are right, because it's very likely that they will have to get by on a lot less if the pilot is scaled up across the country.

My worry is not that less money will be spent on HIV prevention. Very little is spent on prevention now and most of it is being spent on useless exercises. But if health facilities do not give some attention to levels of infection control, there is a danger that they will continue to expose patients to diseases such as HIV itself, as well as many others.

Conditions in Kenya's hospitals are appalling. Nurses in Pumwani, one of Kenya's busiest state run maternity hospitals, have gone on strike to complain about conditions, extreme shortages of personnel, equipment and medicines. Maternal, infant and under five mortality rates in Kenya are among the highest in the world as a result of these conditions. And yet UNAIDS still claim that HIV is almost never transmitted in health facilities. This is an area of HIV prevention that is in urgent need of attention.

Treatment and care for HIV positive people may suffer if funding for this is reduced. After all, though this amounts to little more than funding for drugs, they are inordinately expensive. But a reduction in donor money for HIV drugs may result in a reduction in the sort of prices that the market has never been able to sustain. And many HIV positive people don't even die of AIDS. They, in common with those suffering from AIDS, often die of preventable and/or curable conditions, despite levels of donor funding for AIDS drugs.

If HIV becomes less exceptionalized, perhaps it will also start to be looked at more realistically. The experience in Kakamega and other districts is, apparently, quite encouraging, especially in the way it has reduced stigma. If HIV is seen as just one of many diseases, it may also be recognised that it can be spread in health facilities, just like hepatitis, MRSA and lots of other diseases. And this would represent a paradigm shift in HIV prevention.


Tuesday, March 22, 2011

HIV in Lesotho: The Unpopular Questions Are in Most Need of Answers

Yesterday I blogged about HIV in Lesotho and the finding that clusters of high HIV prevalence for women and clusters of high HIV prevalence for men do not overlap very much. I wrote to the corresponding author of the finding, Myong-Hyun Go, to ask if the extent to which HIV is transmitted sexually might thereby be in question. His reply was a definite no, but without any argument or evidence.

And that's pretty much how the HIV industry works. The view that HIV is mainly transmitted heterosexually in African countries is sometimes called the 'behavioral paradigm'. And it is not really amenable to evidence, for or against. It is, let's be frank, a prejudice. So it is worth looking a bit more closely at some figures for HIV in Lesotho.

The study in question uses data from the 2004 Lesotho Demographic and Health Survey (DHS), but as the 2009 survey is available, I'll be referring to it instead. After all, the authors expect their work to influence health policy, so it would need to apply equally to both early and later data.

In common with many other African countries, women usually report very low levels of multiple sex partners, with less than 10% having more than one partner in the previous 12 months and a mean number of lifetime partners never exceeding 3. And while HIV prevalence differs a lot spatially, levels of multiple sex partners and mean number of lifetime partners does not.

Men usually report far higher levels of multiple partnership, double or even triple the levels for women. Their mean number of sexual partners is also up to three times higher. Such differences are equally pronounced among young people. Yet far more women than men are HIV positive in most age groups and in most areas. This is also the case in other African countries.

HIV prevalence by sexual behavior figures show that orthodox thinking about age at first intercourse is in need of review. For women, those who first have sex at less than 16 years old have the same HIV prevalence as those who start at 20 years or over. For men, prevalence actually rises with age, with those starting early having lower prevalence. Prevalence for men and women who use condoms is about the same as it is for those who don't.

But the most remarkable thing about the figures is not that HIV prevalence does or does not correlate with sexual behavior; in some respects it does and in some it does not. What is remarkable is that rates of sexual behavior considered to be unsafe are no higher than other countries with far lower rates of HIV, countries in Africa and elsewhere. People in Lesotho are at higher risk than almost anywhere else in the world, but no research has shown why this is so.

The study authors also claim that their findings provide a 'concrete basis' for male circumcision. Well, there are countries where male circumcision status may be correlated with HIV prevalence. In some countries, circumcision appears to be protective, for example, Kenya. But Lesotho is one of the countries where the opposite may be the case. Of course, these correlations may point to something else entirely.

About half of all men in Lesotho are circumcised. But while uncircumcised men are a bit more likely to be HIV positive in some age groups, overall, circumcised men are far more likely to be HIV positive. It could be argued that many circumcised men were infected before being circumcised, but there is then the problem of explaining how they were infected with a virus that can have as little as a 1 in one thousand chance of being transmitted during heterosexual intercourse.

I would argue that both the spatial data created by Myong-Hyun Go and Co and the DHS data show that Lesotho has extraordinarily high HIV prevalence figures and both sets of data suggest that a substantial proportion of HIV may be transmitted non-sexually. But the disturbing thing about each set of data is that neither really shed light on the possible extent of non-sexual and sexual transmission. Without knowing this, the way forward is no clearer than it was before the data was collected.


Monday, March 21, 2011

GPS Data Analysis Upholds Stork Theory of Where Babies Come From

A story is told about a grumpy conductor who said to a cellist (I'm paraphrasing): 'You have between your legs one of the most sensitive instruments known to man, and all you can do is scratch it'. The story comes to mind sometimes when reading the latest findings about HIV epidemics.

Many researchers come up with great data, data that should change the way that HIV prevention programs are targeted. A lot of recent data, and even some not so recent, clearly shows that HIV transmission is not nearly as closely related to sexual transmission as has been assumed so far. But this never seems to have any influence on prevention programs.

UNAIDS and the HIV industry in general take it as read that 80% of HIV transmission in African countries is a result of heterosexual sex. They claim that almost all of the remaining 20% is accounted for by mother to child transmission. This leaves very little for intravenous drug use, men who have sex with men and various forms of non-sexual transmission, such as unsafe healthcare.

A recent piece of research by Myong-Hyun Go, B Coburn, J Okano and S Blower uses GPS coordinates to depict HIV clusters or hot-spots in Lesotho. Lesotho has one some of the highest HIV prevalence figures in the world. They range from 8.5-46.6% for women and 4.1-39% for men.

Remarkably, the hot-spots for high female prevalence do not overlap with those for males very much. Those for females are mainly located in two lowland urban centres, the most heavily populated areas in the country. Those for males are mainly located in two less heavily populated mountainous areas, quite distant from the urban centres.

The research also finds that travel between most parts of Lesotho is not too efficient. Even travel between areas of high female prevalence and high male prevalence, according to the maps provided, could be quite challenging. These findings are referred to as 'spatial heterogeneity', which sounds rather quaint, under the circumstances.

Do most of the inhabitants of one of the poorest countries in the world expend most of their time and income on travelling to and from different parts of the country for the sole purpose of having sex, with as many different partners as possible, if official HIV lore is to be believed?

I think many people whose minds are relatively unbiased, especially by said official HIV lore, might question the 'behavioral paradigm', the view that almost all HIV is heterosexually transmitted in African countries. There must be something else to these incredible rates of transmission.

Not only must people be having immense numbers of sexual experiences, with immense numbers of people, but if the heterosexual sex theory is true, there must also be something else accounting for the increased susceptibility of this population.

After all, HIV prevalence among sex workers in India is only about 7% and the disease, according to the official story, is something of an occupational hazard for them. National prevalence in Kenya, Tanzania and Uganda is around 7% or less, which is itself shocking when compared to the figure for India.

But even if we embrace the extreme prejudices of UNAIDS and their accomplices, we must still wonder what it is about the Basotho people that accounts for almost unprecedented rates of transmission (and, of course, their superhuman feats of mobility and sexual prowess).

The researchers, however, don't even raise such questions. They merely conclude that prevention programs must be gender specific ones, such as circumcision for men and microbicides for women.

Even if it is true that most transmission is through heterosexual sex, these interventions will have only a relatively small impact, if any. Neither intervention has been shown to reduce transmission very much outside of some highly questionable trials.

But the data screams out for thorough investigation of how HIV could be transmitted heterosexually when so many HIV positive men and women live so far from each other. There is also an urgent need to find out if there is some additional factor that could explain how a virus that is difficult to transmit sexually affects such an enormous number of people. And it would be a further disgrace to the HIV industry if it just lets this data go by without it having any influence on global HIV prevention policy.


Sunday, March 20, 2011

What if HIV Drug Pricing Depended on 'the Market', Rather Than Subsidy?

Are HIV programs in developing countries really in danger of collapsing because donor funding is being cut? This would result in the HIV drug subsector suddenly having to do without public money, which has supported it almost entirely so far.

Antiretroviral drug (ARV) research and development was carried out by publicly funded institutions. And the bulk of the finished products have always been bought and paid for by public money, so called foreign aid.

The price of ARVs has so far stayed too high to rely on any 'market'. The majority of HIV positive people live in developing countries and would never be able to afford to pay for ARVs for the rest of their lives, even if they were a fraction of the current price.

I doubt if the ARV industry, that has been built up so carefully, will be allowed to collapse. Like the financial institutions around the world that have been propped up with public money, this industry is also 'too big to fail'.

The ARV market is also changing. Up to now, the drugs are usually given to HIV positive people who have reached a certain stage of disease progression. As part of a larger care program, ARVs can keep people alive and healthy for many years.

But more recently, there has been talk about putting people on ARVs regardless of what stage of disease progression they have reached. This could increase the number of potential customers by several hundred percent.

And there are plans to put as many HIV negative people as possible on ARVs of some kind. Of course, the potential recipients of these drugs for prophylactic uses are referred to as 'most at risk' or something similar. As if the HIV industry have any idea who is at risk; as if they give a damn.

If you ask UNAIDS who is most at risk of being infected in African countries, they will say that anyone who is sexually active is at risk, and those who are most sexually active are most at risk. But who is most sexually active, and are they really more at risk than those who are not particularly sexually active, or who are not sexually active at all?

Surprisingly, the answers to these rather obvious sounding questions is not so clear. Because UNAIDS then point to those who are most infected by HIV and conclude that it is because they are most sexually active. The circularity of this argument has very serious consequences.

So as the pharmaceutical lobbyists want more HIV positive people to be put on ARVs earlier, and also want more HIV negative people to be put on them as well, much of the work will be completely misdirected. Rates of drug resistance will be rife and death rates will probably also rise.

But a hell of a lot of drugs will be sold. And resistance will mean many tens, perhaps even hundreds of times more money per patient. Developing countries will be drowning in a sea of drugs, yet most of them will be of little benefit and many could be doing a lot of harm.

A recent IPS article asks when national governments of countries with serious HIV epidemics will become major funders in HIV treatment and prevention programs. But were they ever intended to become involved? What exactly could they do?

It would be interesting if these countries could have a say in how HIV positive people were treated and in how HIV prevention policies characterized risk. Would they reject the current racist and sexist assumptions about African sexuality, or would they simply play along?

There would certainly be no incentive to play along if they had to pay for treatment and prevention themselves, if any of these countries were even able to do so. But if they were allowed to play a part in HIV programming, perhaps they would do what no Western country or institution has yet done: question the assumption that all Africans are sex maniacs.

The article concludes with some rather trite nonsense about negotiating through the World Trade Organization (WTO) to get a better price, using the TRIPS (Trade Related Aspectes of Intellectual Property Rights) agreement, but these were never developed to benefit developing countries. On the contrary, they were developed to support the pharmaceutical industry and others based in rich countries.

If a reduction in donor funding means that people currently being kept alive by ARVs will just be allowed to die, this would be a humanitarian disaster. But if it means that countries with the worst epidemics, all African, get to decide what would really have an impact on HIV transmission, this might be the first step in turning around the pandemic. This could avert the even bigger disaster that is the status quo, which condemns millions of people to HIV infection, illness and premature death.


Thursday, March 17, 2011

Are Racism and Sexism Lessened by Being Passive-Aggressively Pursued?

Following yesterday's blog post I had a brief email conversation with Dr David Gisselquist during which he pointed out that higher levels of education, to some extent, and greater wealth, to a large extent, tend to correlate with higher HIV prevalence in African countries. Researchers are not sure what to make of these correlations, though they are well attested.

Anyhow, neither of us find the World Bank claims particularly credible and they seem to go hand in hand with a purely sexual view of African HIV transmission, the so called 'behavioral paradigm'. The view is both racist and sexist. Imagine a similar handing out of money to Western women aimed at influencing their sexual behavior, and particularly their reproductive intentions.

Anyhow, giving girls money and paying their school fees could be expected to result in higher HIV prevalence among the recipients, unless transmission patterns have changed substantially, and only since all previous population based surveys of the last 15 or 20 years have been carried out.

The same article refers briefly to a Tanzanian study, which gave cash incentives to adults who tested negative for certain sexually transmitted infections (STI). But public health experts are well aware that STIs are more than just a reflection of sexual behavior. They also reflect broaderhealth conditions in a country, that's why certain STI rates are very high in some US and other Western populations.

The idea of handing out money to people in an attempt to influence their behavior or lifestyle is not confined to sexual behavior, nor even to young people in developing countries. Money has also been used to persuade women (and some men) to use birth control of some kind, or even to be sterilized, because an institution called 'Project Prevention' has wished to intervene for one of several reasons.

Project Prevention aims at female drug users in Western countries, because they are said to play a significant part in HIV transmission there. But it is HIV positive women who are targeted in Africa (Kenya, specifically). The aim is not really prevention because if HIV transmission had been prevented in the first place, there would be no need to prevent the possible vertical transmission of HIV from the mother to their children. And Project Prevention aim to eliminate the child, hence, no prevention if they achieve that aim.

Ironically, one of the favored methods of birth control employed by Project Prevention is the intrauterine device (IUD). If Project Prevention gave a damn about the safety of women at all, they would check out the sort of conditions found in health facilities in Kenya and other high HIV prevalence countries. Getting an IUD inserted in Kenya will carry many risks, including the risk of infection with diseases such as HIV.

And that's only if things go reasonably well. If women have any future problems with an IUD they will face further, similar risks and perhaps some additional ones. Many will continue to have little access to adequate health care after Project Prevention have handed over their few dollars a head and, in common with most African women, will probably just have to put up with whatever injury that results.

Whether it is right or even effective to hand over a few dollars to influence people's behavior is one thing. And there is a lot of discussion about these questions. But even if the answer is that it is both right and effective, it will not work, because HIV is not, and never has been, purely a matter of individual behavior, sexual or otherwise.

Some commentators are correct in referring to Project Prevention's agenda as pure eugenics or 'racial hygiene'. But then, so is the bulk of prevention work carried out by the big players in HIV prevention, including Population Services International, Family Health International, The Futures Group International, the Guttemacher Institute, the Rockefeller Foundation, the Gates Foundation and many others.

Most of the billions contributed to the multi-billion dollar HIV industry has gone to treating HIV positive people. But most of the considerable fraction that has gone into prevention, very unsuccessful too, has been frittered away on trying to influence people's sexual and reproductive behavior. Project Prevention's strategy is extreme, but that's really only a matter of degree.

The various commentators abhorring the work of Project Prevention are all rightly concerned about preventing HIV transmission from mothers to their babies and they are also right in pointing out that this is a well developed and relatively successful area of HIV prevention. The problem is that too few women who are about to become pregnant, or are already pregnant, or even who have just given birth, are in any way protected from HIV infection.

It is the very assumption that HIV is almost always sexually transmitted that results in the stigma that these commentators also abhor. Project Prevention is contributing to the stigma, but so are these well-meaning critics. If the HIV industry could lose its obsession with the sexual and reproductive behavior of people in developing countries, they would be able to prevent HIV transmission that is clearly not coming from heterosexual sex.

HIV in poor countries is commonly associated with pregnancy. But this does not mean it is therefore also caused by sexual behavior. Many women are infected when they are in the later stages of pregnancy, or even after they give birth. And this is often the case when they have a HIV negative partner and they have only had sex with this HIV negative partner. At least some of these women were infected non-sexually.

Some HIV negative women have HIV positive babies and, despite the excuses of UNAIDS and others, all of these babies were infected non-sexually, probably through unsafe healthcare of some kind. HIV positive babies can even infect their mothers during breastfeeding.

Project Prevention may be racist and sexist bullies, who prey on vulnerable people in developing countries. But what they are doing is not that different from the more passive aggressive forms of racism and sexism that constitute global HIV prevention policy. HIV is not just another sexually transmitted infection, though it may sometimes be transmitted sexually. Eradicating the virus depends on accepting that and investigating the extent to which it is transmitted sexually and non-sexually.


Wednesday, March 16, 2011

Could the World Bank be Lying About Conditional Cash Transfers?

Perhaps we should all be kicking ourselves. According to an article in Bloomberg Businessweek, you can reduce HIV infection among young females by giving them some cash every month and paying for their school fees. That's according to the World Bank, anyhow, and they can afford to know such things.

But would that be the same World Bank that has insisted for decades that developing countries, in addition to getting themselves into irreversable debt, need to reduce public service and infrastructure spending, close health and educational facilities, reduce public sector employment levels, including teachers and health personnel and generally place young females, and everyone else, in a position where their health, education, economic and other circumstances suffer?

Denying hundreds of millions, perhaps billions of people, their basic human rights is bad enough. But then handing out a few dollars to some of them and offering to pay the school fees for the same schools that you wanted closed down does not seem like a great way of cleaning up the mess that you have been creating for so many years.

Frankly, I don't believe the results claimed for this exercise. Yes, there are young women and men who sell sex for money, goods, services and other favors. This is intolerable and everything should be done to make sure that it stops. But this phenomenon does not 'drive' (or even 'fuel') high prevalence HIV epidemics like those found in Malawi, Zimbabwe or Tanzania, no matter how much we enjoy the righteous indignation we feel when reading about 'sugar daddies' and the like.

The claim is that several thousand young women were recruited on to the trial and one group received an average of $10 a month and 'payment for school fees' if they attended class. The other group got nothing. And one and a half years later, infection rates were 60% lower among who those received the cash and school fees.

That really would be a remarkable result if it were true, but I think the person producing these results is not being completely frank. But we'll have to wait until the full program results are published. Apparently they are currently being peer reviewed. Although that doesn't seem to prevent the release of their headline figures.

Remarks from the World Bank's Mayra Buvinic sound particularly naive: “It is obvious, but it never occurred to anybody to give girls cash to help prevent transactional sex”. But it has occurred to development theorists to provide girls with education. It is well known that girls who are enabled to attend school have far better health that those who are not; this is not just about HIV.

The expert continues: “They needed money and, you know, since they got money, they didn’t need to interact with older men.” So now that you've made this great discovery about the value of education, perhaps your employers will consider its long running structural adjustment policies; I'm not sure of the current nomenclature, but you know what I mean.

Another expert smugly remarks that cash may be the "ethical policy instrument" of the 21st century. Where the hell do they get these idiots from?

Several others chip in with their stories about some of the terrible things that people in developing countries have to put up with. But these are things that existed before HIV was ever heard of and will continue to result from Western foreign policies, which concentrate on taking what they can get and even causing, or at least exacerbating, many of the problems that these 'experts' seem to think arise spontaneously.

Even if HIV epidemics such as those found in Malawi, Zimbabwe and Tanzania were driven by heterosexual sex, I don't believe you could significantly influence sexual behavior by handing out some money and paying for school fees. But nor do I believe that any severe HIV epidemic could possibly be driven by heterosexual sex, so I don't believe the claims of this article. If I hear otherwise, I'll be sure to blog about it.


Tuesday, March 15, 2011

'Promiscuous African' Explanation of HIV Falls Flat Again

It seems odd to compare Botswana with Sweden and to conclude that, because cross-generational marriages, usually referring to marriages between teenage girls and much older men, are common in Botswana but not Sweden, that must explain why HIV rates are high in Botswana and low in Sweden.

For a start, I expect there are many stark differences between Botswana and Sweden, including ones that may shed light on why HIV rates are so high in Botswana and so low in Sweden. But why compare those two countries? And why pick out cross-generational marriages, in particular?

Well, cross-generational marriages are just one of the many factors that have been said to increase HIV transmission over the years. Part of the reasoning is that teenage girls are unlikely to be very sexually experienced, but older men are, and so they are more likely to be HIV positive. The hypothesis on its own seems to be enough for the phenomenon to be the culprit.

But in most high prevalence countries, rates of discordance are very high. In other words, many HIV positive people have a HIV negative partner. And, although men are often said to be the main drivers of HIV transmission, especially in long-term partnerships, women are just as likely to be the HIV positive partner.

This means that, where both parties are infected, it may have been either the male or the female partner who became infected first. And this raises questions about how the female partner was infected, if she wasn't infected by her partner.

UNAIDS and the HIV industry have a ready explanation: if the female partner is African, then she is promiscuous. According to the orthodox view, this is just a fact. It may not stand up to scrutiny, but it is the lynchpin of pretty much all HIV prevention policy: Africans are promiscuous, and that's it.

Why so many more women than men are infected is not really clear if HIV is, as the orthodoxy claims, mainly sexually transmitted. HIV researchers often say that women are usually infected earlier and men later, often because of cross-generational marriages. But the figures just don't add up.

Men, on the whole, are far less likely to be infected, so there still remains a question as to who infects all the women where the ratio is something like 1.5 men infected for every 10 women, as is the case among the Luhya of Western Kenya.

Kenya's eight provinces were originally divided on ethnic lines and cross-generational marriage rates vary considerably between provinces. But the province with the highest HIV prevalence, Nyanza, doesn't have the highest rates of cross-generational marriage, not even the second highest. And the province with the second highest HIV prevalence, Nairobi, has almost the lowest rates of cross-generational marriage.

In contrast, the province with the highest rates of cross-generational marriage, North Eastern, has the lowest HIV prevalence. Prevalence there, at less than 1%, is lower than that found in many US cities. The diagram below is rough, but it shows that cross-generational marriage does not correlate with HIV prevalence. Interestingly, in North Eastern province, male and female prevalence figures are also very similar.

A lot more work needs to be done to show why some females in African countries face such high risk and why most males do not. Women may be more 'susceptible' to infection, as the industry never tires of telling us, but who is infecting them? It is unlikely to always be men, even if the promiscuous African 'theory' (in reality, a crude prejudice) so beloved by the industry is even vaguely true.

Rather than focusing on sexual behavior and marriage patterns, the author should have considered the relative quality and accessiblity of health services in Botswana and Sweden. He might have noticed that in places where many pregnant women visit hospitals and clinics in high prevalence countries, they seem to be far more likely to be HIV positive. If men tend to be infected later in life, perhaps women infected in hospitals are infecting them, another possibility not raised in this or most other articles.

The idea that HIV prevalence is higher in places where access to health services is higher and that HIV prevalence is lower in places where access to health services is lower is well attested and has been for some time. Indeed, Kenya's North Eastern province is a very good example. And elsewhere, urban and peri-urban areas have far higher prevalence figures than the most isolated areas, which often have very low rates indeed. Perhaps Dr Flamholc would like to develop his 'observations' a bit further.


Monday, March 14, 2011

UNAIDS' Subterfuge Puts Gadaffi's in the Shade

Mike Elkin gives a rather predictable 'analysis' of Libya's relatively well documented nosocomial (health care related) outbreak of HIV, which began to be uncovered around 1998. But Elkin would do well to distinguish between Gaddafi's dictatorship and the outbreak investigation that took place, and eventually revealed that hundreds of children had been accidentally infected with HIV because hospital equipment had been contaminated by one former HIV positive patient.

Libya's is not the only nosocomial outbreak in the history of HIV. It's not even the biggest. But it was more thoroughly investigated than many others and resulted in changes to the whole health care system in Libya. The fact that all sorts of horrific political excesses also resulted from the outbreak does not detract from what could be learned from such an investigation. Yet, evidence that such outbreaks have occurred in many other countries at various times has been virtually ignored.

I refer to the Libyan incident, but really it was a whole series of incidents. The investigation revealed that hundreds of HIV positive children with HIV negative mothers began to be infected in the mid-1990s. Some mothers were also infected through breastfeeding their babies. No doubt, others have been infected since. There must have been many health professionals involved, over a period of several years.

The point is that one outbreak like this in a very low HIV prevalence country like Libya (about 0.3%) can result in very high rates of transmission. The 400 or so transmissions amount to about 4% of Libya's entire epidemic. Just one infected person in an underfunded health care system can do untold damage. So think how many times this kind of thing could happen in high HIV prevalence countries with even less well funded health care systems.

My frequent rants about nosocomial infection and heterosexual HIV transmission are about the fact that the former is a very efficient transmitter of the virus and the latter is not. A few nosocomial outbreaks in high prevalence countries could explain the extraordinarily high rates of transmission often found, especially among young, pregnant women. But even the most (certainly non-mammalian) animalistic rates of heterosexual behavior cannot account for epidemics found in Swaziland, Botswana, South Africa and many other sub-Saharan African (SSA) countries.

If Gadaffi's regime is as brutal as Elkin paints it, and I believe it is probably a lot worse, what about the regime of the global AIDS industry, which insists that nosocomial HIV infection accounts for a very small fraction of HIV transmission in SSA countries, despite evidence to the contrary? And the same industry insists that 80 to 90% of HIV transmission in SSA countries is through heterosexual sex, despite plenty of evidence that this is not true, is not even possible?

Many heterosexual HIV positive people are unlikely to infect anyone else. At least, the speed at which HIV is transmitted among heterosexuals is slow enough to make a massive HIV epidemic impossible. Yet there are massive epidemics in many countries and in parts of many countries. The only explanation is that 80 to 90% of HIV transmission is most definitely not through heterosexual sex.

The question of what could account for high HIV prevalence rates is even asked by those who probably know well what could account for them, and who probably know well that heterosexual sex could not account for them. And if they don't know these things, they should not be receiving the massive amounts of public money that supports this multi-billion dollar industry.

Those working for UNAIDS and various other institutions don't need to be bullied into silence about how many people may be exposed to HIV infection, infected and even killed though unsafe health care. They seem to see it as their job to take the money and keep their mouths shut. Gadaffi's regime may have blamed the whole outbreak on some innocent health care workers who were in the country at the time (though probably not at the right time to have been responsible for the infections). But UNAIDS and the HIV industry blame those who become infected.

Whatever Gadaffi did to cover up the outbreak and silence anyone who tried to speak out, it's nothing to the way the HIV industry refuses to investigate why so many children in some countries are HIV positive when their mothers are negative, why so many women are infected when their only partner is negative, and many other anomalies in the sexual behavior story of HIV transmission.

When you think about it, the UN doesn't even have as credible a democratic mandate as Gadaffi himself. They may have a touchy-feely reputation (or do they still?) but, by pretending that nosocomial HIV infections barely exist, UNAIDS and the HIV industry may ultimately be responsible for more deaths than some of the most infamous dictators in history. Elkin may be justifiably outraged, but when it comes to HIV infection Gadaffi's Libya is small fry.


Sunday, March 13, 2011

Africans Slowly Start to Question the Popular View of 'African' Sexuality

It's nothing new for a Kenyan minister to opt for foreign medical services rather than settle for the best their own country has to offer. Never mind that non-whites in the US currently get the worst medical services their country has to offer, if they get anything at all. Kenya has some high quality, private facilities, but the country's political elite are not tempted.

However, when the Minister for Medical Services, Professor Anyang' Nyong'o, heads to the US for prostate work, people may do well to sit up and take notice. Does the Minister know something about Kenyan health services that leads to those in the best position to judge their quality choosing to head off elsewhere? Of course, he is hardly going to face the sort of hazards faced by non-white Americans, but there surely must be something available in Kenya for those able to pay, or for those who don't have to pay?

Well, in early October of last year, the same minister pointed out that there are many problems with health care provision in the country. Quite an understatement. I blogged about it at the time and there are a couple of links to some further information.

But Nyong'o is remarkable in drawing attention also to the possible contribution that unsafe health services could make to the HIV epidemic and various other blood borne viruses. Politicians normally don't even come close to considering this possibility, that at least some HIV transmission in countries with appalling health services may result from unsafe health care practices.

The closest I have heard has come from former South African President Thabo Mbeki, who pointed out that Africans face numerous health risks that could just as easily explain what the rest of the world calls the HIV epidemic. Mbeki infamously went a lot further than that and refused to accept that there was a HIV epidemic. He made the biggest blunder possible, despite his valuable insights into the plight of Africans and other developing peoples.

But people like Mbeki, and even Nyong'o, are shedding more light on the drivers of HIV than whole teams of highly qualified scientists from the Johns Hopkins School of Medicine and various other elite academic institutions. There are some Africans who sense that the deeply racist explanation of HIV being driven by some notional African sexuality is not going to help eradicate the virus.

Nyong'o also raises other interesting points, such as the lower quality of health care found in rural areas, compared to urban areas. But he doesn't go far enough. Most rural areas have no health care facilities whatsoever, the majority of facilities being located close to or in urban centres, or at least close to surfaced roads, another thing that is in short supply in Kenya.

And he could have gone further still: in areas of Kenya where access to health facilities is lowest, HIV prevalence is also lowest. Yet, it is clear that people don't have less sex, or less unprotected sex, in these areas. In the North Eastern province, where health and other social services are lowest, birth rates are highest, early marriages are most common, female genital mutilation is most common, intergenerational marriages are most common, etc.

Mbeki was wrong in concluding that HIV affects the poorest disproportionately; it affects those who are just rich enough to access what are very poor health services. Of course, many such people are poor and suffer from numerous other health hazards, but the richest of the poor suffer the highest rates of HIV. And that probably means that even the best health facilities are not too reliable and Nyong'o is better off taking his chances with the health facilities of a country that would normally discriminate against him.


Saturday, March 12, 2011

Why Poor Access to Health Facilities May Save Lives in Africa

"Hospital Births Still Unpopular" in Ethiopia, writes IRIN, the UN development news agency. But is this a good or bad thing? Ethiopia has never managed to provide the majority of its inhabitants with health services. Yet HIV prevalence, like in many other countries with low health service usage, is relatively low, at just over 2%.

In South Africa (and several other Southern African countries with high health service usage), HIV prevalence is staggeringly high. These are not just two countries where HIV prevalence and health service usage happen to be negatively correlated, there are many others. Zimbabwe has had high health service usage at times in its history, as have Swaziland, Botswana and Zambia, all in the top ten for HIV prevalence.

Where health services are of high quality, things are quite different. Take Cuba, for example, which has some of the best health indicators in the world and the lowest HIV prevalence in the Carribean. Similar remarks apply to many other Western countries and even a few developing countries.

Even the US has good health services for those who can afford them. But sadly, those who can't afford the best experience the highest HIV rates in the country. Most of them also happen to be non-white. And before you ask, yes, HIV and other viruses can be transmitted in US health services too. Do you think that doctor specializing in late abortions had any more respect for adults than for children?

To conclude that countries need fewer health services would be crazy, though it is the direct aim of the World Bank and the International Monetary Fund, through their structural adjustment programs, or whatever they call them now. And it is the indirect aim of the WHO and UNAIDS, through their insistence that grossly disproportionate amounts of health spending goes to HIV.

Despite the barbaric health agenda of global economic health institutions, African countries, like all countries, need good health services. They also need decent levels of education, good infrastructure, economic and employment opportunities, in other words, a future. But that is what they have been denied for many decades. Human rights that have been denied many countries for so long don't appear to be any more forthcoming now that they were in the past, either.

The argument that HIV spending puts all other health spending in the shade is not even the most important issue here. The most important issue is that the billions of dollars that have gone into HIV so far have done little to reduce transmission enough to see the virus being eradicated any time soon.

Not that much of the money has been spent on prevention anyway, and what has been spent was frittered away on pointless exercises, which will probably continue for some time, because the 'experts' simply don't have any idea what else to do. They don't know how to reduce HIV transmission, or they don't wish to suggest that the health industry itself may be part of the problem.

You could argue that the multi-billion dollar per annum global HIV industry is run by a bunch of buffoons and you'd probably have some supporters. Like any professional group, there are buffoons. But there are also people who are the best in their field. And then it sounds as if things get done or remain undone because that's what the whole lot of them, buffoon or otherwise, want.

For example, a bunch of people of some description found that 'only' 1.4% of HIV positive children had HIV negative mothers. They speculated about these children being infected by contaminated breast milk, which is a possible explanation. But they hesitate to conclude that infants and mothers may be at risk of infection through unsafe health care practices.

This is surprising because the same researchers found that 47% of instruments were contaminated with blood, many of these instruments being used for invasive procedures. They also found that many of the HIV positive children with HIV negative mothers were breastfed by a non-biological mother. So there are several possible sources of non-sexual HIV transmission, but this research is just scratching the surface.

HIV negative mothers can be infected by their babies if their babies are infected nosocomially. This has been demonstrated many times, especially in Romania, which experienced a massive outbreak of nosocomially transmitted HIV, one of the biggest ever brought to light.

Also, both mothers and babies can be independently infected, though various routes. The fact that many mother and baby pairs were both infected does not tell you how either of them became infected. Researchers might need to do a bit of work to establish that.

As for the HIV positive women, with or without HIV positive babies, how were they infected? Were their partners tested? Partners tend not to be routinely contacted and tested and it seems they were not in this instance, or perhaps the authors didn't think it important enough to comment on. Half of all HIV positive women in African countries have HIV negative partners. How did they become infected?

But one of the most striking aspects of HIV testing in pregnant women is how many of them seroconvert very late during pregnancy or even in the months after giving birth. This suggests that many of them were also infected after they would have known they were pregnant or even just after they had given birth.

I'm not an expert in these matters but many women have told me they do not tend to have that much sexual activity during late pregnancy or in the months just after giving birth. And they certainly don't see this as a good time to engage in unprotected sex with people who are not their main partner. Why not cast the net a little wider and look at the most likely modes of transmission, non-sexual modes, rather than the least likely mode, heterosexual transmission?

I'm looking for what researchers don't talk about, what they don't find, usually because they are not looking. Why are researchers not contacting and testing partners as a matter of routine? Why are they not following up HIV seroconversions which are very unlikely to have resulted from sexual transmission? They need to put their anti-African and anti-woman prejudices aside and start investigating. African hospitals are clearly dangerous places.


Friday, March 11, 2011

You Can't Reduce Stigma By Replacing One Lie With Another

I have just spent the last couple of weeks in Ireland and the UK visiting relatives and friends. I'm always struck by how distorted a picture of HIV people there have. Most people in Western countries have an education beyond anything that most Africans will ever receive. But what the public get to hear about massive industrial interests is as skewed there as it is here in Africa.

There are different distortions involved, though. Low prevalence, Western countries are usually said to have 'concentrated' epidemics; most of those infected belong to subgroups in the population, such as men who have sex with men (MSM) and injection drug users (IDU). Because the majority of people in these groups happen to be men, far more men than women are infected.

High prevalence epidemics in African (and a few other) countries are called 'generalized', because the majority of people infected do not belong to any specific 'risk groups'. In fact, in generalized epidemics, the majority of people are heterosexual and more women, often far more women, are infected.

There are two other ways of categorizing HIV epidemics. There are also those referred to as low, though still generalized, and those referred to as hyperendemic. But in reality these are just a matter of degree. The most significant difference between epidemics is between those where the main risk factor is said to be penile-vaginal sex and those where there are clearly other risk factors.

That makes it sound as if there are really two different viruses. People are often rightly puzzled about how a virus that is difficult to transmit via penile-vaginal sex is almost always transmitted in that way in certain, high (and even some medium and low) prevalence countries. UNAIDS deals with that puzzlement by building up a picture of a highly aggressive and totally unrealistic level of sexual behavior that is said only to exist in Africa.

And many are happy to accept that Africans have extraordinary amounts of sex with eye-watering numbers of partners, and probably even that they do all sorts of things that non-Africans wouldn't do.

Such a racist and sexist view of HIV transmission is endorsed by academic, religious and political institutions and a whole industry has built up around it. Media participation in the distortion has also been vital and media organizations have been falling over themselves to bellow out the latest 'discovery' in the field.

There are those who ask questions about certain aspects of the orthodox account of HIV transmission. If they are laypeople, they are usually ignored or, at best, patted on the head and told the 'facts of life' about HIV. If they are professionals they are branded as denialists and publicly humiliated.

I happened to meet a journalist last week who has questioned the orthodox view, at least as it relates to one small Western country. He has worked with injection drug users, men who have sex with men and commercial sex workers. He has long been aware that the risk of being infected with HIV is small unless you belong to one of these groups. He is even aware that the risk to commercial sex workers is low unless they are also IDUs.

He hasn't been publicly disgraced, but he has been told to be more careful what he says. The reason he has been told to be careful may be valid enough: it upsets the gay community. But gay communities in every country need to be aware that unprotected anal sex and injecting drug use are the two most common means of transmitting HIV in most Western countries.

And heterosexuals in every country need to be able to evaluate their risk. They can not do this if it is stated or implied that the risk they face is as high as that of anyone else; it isn't. If HIV was mainly transmitted by heterosexual sex there would be no pandemic. In fact, the virus might never have gone beyond a few isolated cases in a small area in Africa.

If the HIV pandemic can not be explained by penile-vaginal sex, how can it be explained? Well, we know that HIV can be transmitted far more efficiently by contaminated blood and other bodily fluids than by sex. Most forms of health care transmission may have been eliminated in Western countries, but some may still be common in poorer countries.

There are really only two kinds of HIV epidemic; those where most people infected are users of health (and possibly cosmetic) facilities and those where most people infected are MSM and IDUs. People are not infected because they are in some way less innocent or less worthy individuals. Such a view is sinister and pervasive, but without foundation of any kind.

HIV is difficult to transmit via penile-vaginal sex, but it is easy to transmit via contaminated bodily fluids, including blood. That blood and anal mucus are involved in anal sex, and often in HIV transmission, is not to say that HIV a 'gay disease'. It is not tantamount to saying that gay people are bad or that gay sex is bad. After all, heterosexuals have anal sex too and the risk is just as high for them.

But if HIV transmission is to be reduced and eventually eradicated, people need to be clear about exactly what risks they face. And when those risks are health care related risks they don't need lectures about safe sex, condoms, number of partners, etc. If gay people are worried about prejudice, this is completely understandable.

But making out that HIV is commonly transmitted through penile-vaginal sex when that is not the case leads to prejudice too. As a consequence of this distortion, many people are infected non-sexually because most are unaware that such risks exist. These millions of people who are avoidably infected are also stigmatized because non-sexual transmission is said to be so unlikely. Let's not replace one distortion with another.


Tuesday, March 1, 2011

Institutional Sexism and Racism Driving African HIV Epidemics

If you were to consider just two aspects of HIV transmission, firstly, that it is not easily transmitted through heterosexual sex and secondly, that it is easily transmitted by certain non-sexual routes, you might come up with a proto-hypothesis that high prevalence epidemics found in some African countries are not primarily driven by heterosexual sex.

I say 'might' because the HIV industry concludes from the fact that HIV is not easily transmitted through heterosexual sex, that Africans must have extraordinary amounts of sex. Evidence suggests that Africans don't have extraordinary amounts of sex, so the industry further concludes that almost all the sex Africans have is 'unsafe'.

Research has also makes it clear that only some people have a lot of sex, although quite a few Africans (and non-Africans) are reluctant to take precautions and engage in what is considered to be safe sex much of the time. But the majority of Africans, like the majority of non-Africans, just have ordinary amounts of sex, safe or otherwise.

More worryingly, 'safe' sex practices, such as later sexual debut, fewer partners, greater condom use, etc, are often correlated with similar and even higher rates of HIV transmission. Yet still, the HIV industry doesn't conclude that they should put aside their obsession with the sex lives of others and re-examine non-sexual modes of transmission.

Over the years, the industry has come up with one 'explanation' after another as to why very high heterosexual HIV transmission rates are only found in some countries and some parts of some countries, and they are all in Africa. Multiple partnerships was eventually shown not to explain high transmission rates so the concept of concurrency was added in.

But like sex and unsafe sex, evidence showed that only some people engage in concurrent partnerships, sexual partnerships that overlap. Most people don't engage in such partnerships. Also, concurrent partnerships are not exclusive to Africans. They occur everywhere, but without the massive rates of HIV transmission found in some African countries.

It didn't take HIV researchers long to compound the racism of their account of African sexuality with the racist assumption that Africans generally lie about their sexual behavior. Well, some do, as do some non-Africans. But anything that fails to fit the HIV industry picture of African sexuality is discounted as lies.

And the institutional racism itself is compounded by a form of institutional sexism. Women, under the orthodox model, appear to lie a lot more than men. We are told that, not only are they far more promiscuous than men, but they admit to far less promiscuity. The industry 'knows' that they are lying because HIV rates are far higher among women than an assumed greater susceptability could account for.

Few may be surprised to hear that academics, political and religious leaders, professionals of all kinds, journalists and many others are deeply racist and sexist. But I think it would come as a surprise to many to hear  that the heterosexual HIV pandemic in African countries is driven by these prejudices.

If Africans don't have the extraordinary sex lives that only exist in the minds of those who should be able to see prejudice for what it is and women in developing countries are not highly promiscuous, callous, uncaring and careless about their lives and the lives of others, we have to look elsewhere for an answer to the oft repeated question: why is HIV transmission so different in a handful of African countries?

It is not for lack of evidence that the entire HIV industry still assumes that HIV is predominantly driven by heterosexual sex in African countries (though, unintuitively, not in non-African countries); the assumption is underpinned by these prejudices. There is nothing else supporting the assumption. There is ample evidence showing that the assumption is contradicted by everything we know, or should know.

Clearly it needs repeating: HIV is also transmitted non-sexuall, through unsafe healthcare, unsafe cosmetic practices and perhaps through other routes. Until these modes of transmission have been adequately quantified, it will not be known whether they play a greater or lesser part in HIV transmission than heterosexual sex. But we will have little impact on HIV transmission until we are clear where the majority of infections are coming from.

UNAIDS and the HIV industry don't like people to mention non-sexually transmitted HIV. That's fine, we can stop talking about once it has been investigated properly. But unless there is some mystery mode of transmission that has remained undiscovered up to now, we can't continue to pretend that it is all heterosexually transmitted in Africa when we know that's not true. There may be billions of dollars invested in sexually transmitted HIV, along with the reputations of a lot of institutions and people. Perhaps the ones who embrace the truth will gain first mover advantage.