Thursday, April 28, 2011

Literacy as a Source of Ignorance

A review of a film entitled 'Shame in the time of cholera' mentions, as so many articles do, the role of illiteracy in such epidemics and how high levels of illiteracy make it difficult to disseminate information on how to avoid cholera.

High levels of illiteracy are a disgrace in the 21st century and make efforts to improve health conditions very difficult. But it is worth comparing illiteracy in poor areas with the sort of priorities rich and powerful people make about the health of those in poor areas.

Telling people to wash their hands, keep their houses clean, be careful about sanitation and personal hygiene, etc, is like a sick joke when there is little or no access to clean water or basic sanitation facilities (I'm not criticizing the film maker or the reviewer here).

And there may well be all sorts of stories about cholera coming from the wind, witchcraft, miasmas, etc, but there is also the story about cholera epidemics being prevented by drugs and technology and other great human feats.

But are people supposed to take these drugs and use these technologies in the absence of improvements in water, hygiene and sanitation? If so, the exercise will fail. Cholera and other water borne conditions were eradicated in Western countries, not by drugs, but by clean water, modern water infrastructures and sanitation facilities.

Some people and insititutions seem to think that they can pick out a few diseases, such as cholera and polio, and produce vaccines for them. They think that distributing these drugs far and wide will reduce morbidity and mortality, but they are wrong.

People treated for a handful of diseases will simply suffer from, and some will die from, other water borne diseases unless the whole issue of water and sanitation is addressed (and, of course, nutrition, health in general, education, social services, etc).

A name (of a person and an institution) that springs to mind is Gates. Bill has put a small amount of money into water and sanitation projects, but the main thrust of his spending is on vaccines. He even boasts about this.

His wife has talked abut how much we can learn from Coca Cola, because they have a distribution system for their destructive product. I know Coca Cola like to wave their products about in famine and drought areas, but people don't need bottled water, which wastes far more water than it produces. They need a sustainable supply of clean water, unlike what those living in Kerala and other parts of India experienced when they happened to be close to a Coke factory.

Myths are not exclusive to poor, undereducated people suffering from bad health. The sort of myths emanating from Gates (the people and the foundation) are far more harmful, because the media, that great purveyor of myths, blasts them around the world, and so many powerful people seem anxious to repeat myths from the powerful Gateses.

Drugs, scientific breakthroughs, technology and things that the likes of Gates are interested in are not a priority; clean water and sanitation, along with basic health and education are priorities. This is not new, but the message doesn't seem to have reached the literate.


Wednesday, April 27, 2011

Unsafe Injections Are Common, Especially in Poor Countries

The weekly Safe Injection Global Network newsletter has arrived in my inbox. As always, I'm stunned by how many new incidents are uncovered every week that demonstrate how dangerous lapses of safety can be in hospitals, even in countries with very well funded health services.

A survey of 87 facilities in the US found that hemodialysis patients were twice as likely to be infected with hepatitis C virus (HCV) as non-hemodialysis patients.

222 endoscopy patients in New Orleans are being contacted because they may have been exposed to HIV, hepatitis or other diseases through unsterile equipment. This is the second such incident this year. The last time, 360 patients were contacted. The period covered this time is over 7 months. The risk may be small, but it was a long lapse, and the hospital is rightly taking no chances.

In Alberta, 226 patients are being screened HIV and HCV because a care worker was found to be positive for both viruses. Again, the risk to patients is low, but these things can't be left to chance. Apparently, the investigation revealed no breaches of infection control practices.

A report suggests that thousands of patients who have attended a certain Veterans' Affairs dentist need to be screened. This is not the first article about the same dentist, but the dentist in question was working for 18 years in the clinic and failed to change gloves and to sterilize equipment between patients.

The problem might even date back to the mid 1970s. Two patients have already been identified as having hepatitis B virus (HBV), but only a few hundred have been screened so far. This whole episode is in need of clarification. Former patients must now be wondering if other practitioners could have done the same, and how long it will take before they are informed.

The use of multi-dose flasks of vitamin C in an Australian health facility has been demonstrated to have resulted in at least three people being infected with HCV. Inadequate infection control was 'apparent'.

The point I am making is that health facility acquired infections occur, there are lapses in procedures, mistakes made and what not. But in Western countries, where such occurrences often don't represent a very high risk to patient safety anyway, an investigation is carried out. Sometimes people are disciplined, controls are tightened up, effort is made to ensure that adverse events don't happen again.

In developing countries, where health facilities are in short supply, underfunded, understaffed, underequipped, lacking in written procedures and trained personnel who can (and do) follow them, the risk that people could be infected with a serious disease is very high when adverse events occur.

The fact that there are very few articles about such events in developing countries, and even fewer about investigations and patients being contacted to be screened, is very suspicious indeed. Only an idiot would conclude that such events never occur. So the question arises as to whether anyone is even checking for them, if they are recognized, if they are reported and if anything can be done, or if anything is done, when these breaches occur.

Another recent article finds that patient safety incidents are underreported and, as a result, policy is biased. In other words, the extent of patient safety issues is not even well established in Western countries, let alone in developing countries.

Finally, an article looks at 'deliberate, extreme' underreporting of hospital acquired infections in Mongolia and the strategies that health personnel use to avoid accurate reporting.

Unsafe injections occur everywhere, but in some countries, effort is made to establish to what extent and to identify remedial action that can be taken. But in many countries, no such effort is made. On the contrary, the whole issue is ignored, denied or swept under the carpet.

In some countries, unsafe injections are very common and are known to cause tens of millions of serious infections, such as HIV, HBV and HCV. But in these countries, no remedial action is taken and, worse than that, UNAIDS and other institutions simply deny that unsafe injections is a problem.

How, in the light of so much evidence that unsafe injections are very common, especially in poor countries, UNAIDS can claim that as little as 2-2.5% of HIV is transmitted by this route, I can not understand. But this bias results in biased policy, policy that concentrates on sexual transmission. And biased policy results in biased spending, with hardly anything going towards non-sexual HIV transmission.

Unsafe injections and other forms of non-sexual HIV transmission clearly make a considerable contribution to HIV transmission in high prevalence countries. It is the job of UNAIDS to work out the exact extent of this contribution and ensure that funding for adequate prevention measures is provided to countries. Otherwise, high HIV transmission rates will continue to destroy the lives of millions of people every year.


Tuesday, April 26, 2011

Blinded by Influence: the 'Rightness' of Big Funding

Matthew Black has raised some issues in response to my last post, which I would like to answer in detail. It appears that his opinion is based to some extent on a very brief article which denies, but doesn't adequately refute, some of the most pressing arguments against the behavioral paradigm, the view that HIV is almost always transmitted sexually in African countries.

Firstly, in saying that I don't believe all HIV is transmitted sexually, I am not claiming that it is never transmitted sexually. Nor am I saying that it is mostly transmitted non-sexually, by unsafe health care or any other non-sexual modes.

What I am saying is that we do not know the extent of non-sexual transmission and that it is vital to address this lack of knowledge in order to judge how much time, effort and resources are spent on each mode of transmission.

Aside from lack of thorough research into non-sexual transmission, particularly through unsafe injections, but by no means limited to that, no adequate explanation has ever been given as to why heterosexual transmision of HIV is realatively uncommon outside of a few high prevalence countries, mostly in sub-Saharan Africa.

People all over the world have sex, some of them have a lot of sex and it is often 'unsafe'. But rates of sexual transmission appear to be hundreds of times higher in a few African countries, if UNAIDS and the AIDS orthodoxy are to be believed.

Another anomaly is what is known about non-sexual HIV transmission: not only is it far more efficient than heterosexual transmission (regardless of which sets of figures you actually use) but it is also the commonest form of transmission in most Western countries and other countries where prevalence is not excessively high.

Indeed, aside from men who have sex with men, the only high prevalence group in Western countries is intravenous drug users. Even sex workers who are not intravenous drug users are very unlikely to be infected with HIV.

The Service Provision Assessment data I refer to in my previous posting is the latest available from Measure DHS and this kind of survey only takes place about every five years, the same as most demographic and health data relating to HIV (an assessment was carried out last year but the data is not yet publicly available).

But health services are not receiving anything like the sort of resources that are being thrown at antiretroviral drugs. If anything, as populations increase, services are less and less able to cope with demand.

But we don't need to ask if health facilities in high HIV prevalence countries are risky places for those who wish to avoid HIV, hepatitis and other blood borne viruses. The UN itself bears witnes to the fact that they are not trustworthy. The UN warns its own personnel to avoid health facilities that are not approved by the UN itself because of the known risks.

But when it comes to advising African countries about HIV risks, the UN changes its story and says that HIV is unlikely to be transmitted non-sexually, particularly through unsafe injections. Why there is this discrepancy in their advice, we are not told.

But despite the WHO claims in the brief Continuing Medical Education Journal document mentioned above, the WHO has also published material which accepts that 70% of injections globally are unsafe and an unknown percentage, perhaps as high as 15 or 20%, may be contaminated with HIV. Huge percentages of hepatitis B and C are transmitted by unsafe injections. And the WHO is part of the UN.

Mr Black may be interested to know what happens in Western countries when there has been a suspected case of unsterile equipment being used on patients in health facilities. Hundreds, thousands, even tens of thousands of people are contacted and advised to be tested for HIV and other viruses. I cite just one example here, but new ones are reported every month. But I have cited others in the past.

On many occasions in rich countries, nosocomial transmissions have been identified and treated, where possible. Such investigations do not take place in countries that have very poor health facilities, and that's what I and Gisselquist, Brody, Potterat and a number of other people are questioning.

People in Western countries do not tolerate such outbreaks occurring. When they do occur an investigation follows. As a result of the investigation, procedures are improved accordingly. Why are the authors of this CMEJ article prepared to tolerate conditions in African countries, where health facilities are so lacking in every way, that would be unthinkable in Western countries?

And more importantly, how can UNAIDS and others deny that non-sexual HIV transmission is worth investigating in countries where they have not even bothered to investigate it?

The issue, Mr Black, is not just about whether sexual transmission is or isn't responsible for most HIV infections in a handful of high prevalence countries: the issue is that the contribution of non-sexual transmission, especially through unsafe healthcare, has never been properly evaluated in those countries. And just as UNAIDS seem afraid to use African health facilities themselves, they also seem afraid to investigate them.


Sunday, April 24, 2011

Public Money Pays the Piper, So Why Do Big Pharma Call the Tune?

Every now and again I read UNAIDS' publications. Not just for the pretty pictures and diagrams, but because I hope that some day they will play a different tune. Mainly, I want to hear that they have modified their claim that 90% of HIV is transmitted through heterosexual sex. That was the figure that appeared in a draft of their 'Getting to Zero' 2011-2015 Strategic plan. In the published version, the figure is 80%.

But that's not really a modification. They just got it wrong. The official line has for a long time been that 80% of transmission is from heterosexual sex and almost 20% is through mother to child transmission (MTCT). Men having sex with men and intravenous drug users, it appears, make a negligible contribution to high prevalence epidemics. In fact, most HIV transmission is said to result from what is essentially low risk sexual behavior. Which is strange, for a virus that is difficult to transmit through penile-vaginal sex.

UNAIDS' claim to use a 'Know your Epidemic, Know your Response' methodology is flatly contradicted by their claims about heterosexual and other modes of transmission. They don't know their epidemics and nor, we can safely conclude, do they know their response. That's why they have failed to have much impact on transmission rates.

Oddly enough, the plan doesn't mention abstinence, ABC or any of the other rubbish that has filled so much of the official literature. In fact, prevention by useless strategies appears to have been replaced with prevention by wishful thinking. Instead of admitting that hardly anything has been spent effectively on prevention since UNAIDS was established, they are implying that treating people is preventing HIV transmission.

In truth, antiretroviral treatment can reduce transmission, but on its own it is unlikely to reduce it very much. Indeed, many of the figures that 'support' various claims made by UNAIDS about heterosexual transmission are years out of date and are assumed or modeled figures, they are not drawn from empirical research. Therefore, UNAIDS also undermines its many claims that their strategic plan is 'evidence-based' or 'evidence informed'.

One area of HIV transmission that presumably fits into the 2% category is non-sexual transmission, through unsafe healthcare, unsafe cosmetic practices, etc. The WHO, in the last year or so, has admitted that an estimated 40% of injections in African countries are unsafe and the organization accepts that at least 5% of HIV infections could come from such unsafe injections. This estimate is for a region, not for any particular country. The figure for some countries is likely to be a lot higher.

Despite claiming that HIV transmission from unsafe injections is very low, UNAIDS warns its employees and those of the UN as a whole to avoid medical facilities that are not UN approved, as I mentioned yesterday (and on other occasions). If there is a risk for UN employees, there is a risk for non-UN employees. So why the discrepancy between the WHO's figures and those of UNAIDS, and why the warning for UN employees but not for ordinary people?

The whole Strategic Plan is similarly biased towards a behavioral view of HIV, whereby it is depicted as overwhelmingly a matter of individual sexual behavior. This is a dated view, it hasn't worked in the past and it is not going to work in the future. It is difficult to see how this Strategic Plan differs materially from anything UNAIDS has published in the past. Most of the references seem to be to UNAIDS publications or similar.

Finally (although there is little positive that one could say about the Plan), it states that "investment in HIV is critical for the strengthening of health systems and achievement of the MDGs." On the contrary, investment in health systems is critical for the treatment and prevention of HIV. Claiming that money spent on HIV is money spent on health systems is neither honest nor based on empirical evidence.

One only need take a cursory look at Kenya's Service Provision Assessment (or the SPA for any other high prevalence country) to see how unprepared they are to play any part in preventing HIV transmission, especially nosocomially transmitted HIV. And they are equally unprepared to treat or care for HIV positive people adequately.

UNAIDS need to pay a little less attention to what politicians, religious leaders and industrialists think they should do and pay a bit more attention to HIV, a blood-borne virus that is sometimes transmitted sexually, especially through anal sex. They have sold enough drugs for the friends in the pharmaceutical industry and it's time to address the one disease they were established to eradicate.


Saturday, April 23, 2011

Comfortable With High Rates of Mother to Child HIV Transmission?

According to the UN, "Extra precautions should be taken...when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere." This excellent advice is given to UN employees. But it is not given to people who don't have the benefit of access to 'UN approved' medical facilities.

Is everyone comfortable with this? UNAIDS say that only around 2.5% of HIV transmission results from unsafe medical practices in high prevalence countries. But they think it necessary to warn UN personnel working in high prevalence countries to avoid the health facilities that people in developing countries have to put up with, if they actually have access to health facilities at all.

Sometimes you read about how awful it is that large numbers of infants are still born HIV positive or go on to be infected by their mother (mother to child transmission or MTCT). And it is horrific, but it is preventable. The problem with worrying mainly about the infants is that they are infected by someone else who is already infected, possibly their mother. And their mother's infection was probably also preventable.

So why does UNAIDS not worry about the person who infects the infant? And why is the person who infects the infant possibly their mother? I can't answer the first question but I know UNAIDS don't worry about it because they deny that unsafe health care plays a significant part in HIV transmission, and therefore refuse to investigate possible instances of it and they refuse to give proper estimates for its extent.

And the reason I say the person who infects the infant is only possibly their mother is that many infants have been identified whose mother is HIV negative (for instance in Mozambique and Swaziland). UNAIDS has tied itself in knots trying to argue that many babies are breastfed by a HIV positive person who is not the child's mother, etc. And while that might be a possiblity sometimes, it is unlikely to explain away all such instances.

Many women are known to become infected with HIV when they are already pregnant. Many are infected in the second or third trimester, even in the few months after they give birth. Now, I can't prove that women abstain from sex during and just after pregnancy. But nor do I think UNAIDS can demonstrate that most women don't abstain or, at least, reduce their coital frequency.

Nor can I prove that women don't have large numbers of unprotected sexual experiences with people who are not their partner during and just after pregnancy. But nor can UNAIDS demonstrate that they do. Indeed, the belief that African women, from a handful of African countries, sometimes from limited regions in those countries, engage in reckless sexually behavior ragardless of their own personal risk or circumstances, sounds to me like pure prejudice.

Sarah Boseley of the UK Guardian reports on a study questioning the suitability of antiretroviral treatment for young sufferers, a study which finds that very high rates of resistance result when people born with HIV are still young. And continued incidence of resistance is just a matter of time.

There is good and bad news for Sarah Boseley and for others who think that HIV rates in people born with HIV or who convert in their first few months or years is totally unacceptable: it is very likely that most mother to child transmission is preventable. And most of it is not just preventable in the way such transmissions are preventable in Western medical contexts, through careful support, treatment and medication.

It is very likely that a large percentage, perhaps the majority of transmissions, are a result of unsafe health care practices, injections, transfusions, intravenous drips and various other invasive procedures. After all, who believes that health facilities in high HIV prevalence countries are able to guarantee safety from transmission of HIV and other blood borne conditions? UNAIDS certainly doesn't.

The bad news is that little is likely to be done to reduce this kind of transmission because UNAIDS and other institutions who decide how HIV is transmitted (no, establishing how it is transmitted is not an empirical matter, don't be silly) have failed to investigate non-sexual transmission of this kind. In fact, they have refused to investigate, despite plenty of evidence that there is a case to be answered.

Is everyone comfortable with this? What makes the behavior of UNAIDS and those who follow their directives so despicable is that UNAIDS and other parties are well aware that a lot, perhaps a majority of HIV transmission, is a result of unsafe medical practices. It is not just a matter of sexual behavior. Africans do not have weired sex lives and they do care about their children, sexual partners, families and compatriots. Africans do not want their children to be born with HIV. But UNAIDS don't seem to mind.


Friday, April 22, 2011

Ever Increasing Numbers on Drugs is Not Reducing HIV Transmission

There's been a lot written about increasing the use of antiretroviral drugs, not just to treat people who are HIV positive, but also to reduce HIV transmission as well. One such strategy is called 'treatment as prevention', where those on antiretroviral treatment, under the right conditions, are said to be unlikely to transmit HIV to their sexual partners.

Another is called pre-exposure prophylaxis (PrEP), where HIV negative people take antiretrovirals because that has been shown to slightly reduce the risk for men who have sex with men, though not for women who have sex with men.

Reading the claims about 'treatment as prevention', you might think that it would make PrEP redundant. Advocates of treatment as prevention say that if a large proportion of the population in a high prevalence country were to be tested regularly, perhaps every year, and immediately put on ART if found to be HIV positive, transmission rates would drop rapidly.

But a group of researchers recently looked at sexual risk taking among patients on antiretroviral therapy in Nairobi's Kibera slum. And they note that many HIV treatment programs in such contexts do not include efforts to reduce HIV prevention beyond treating those already infected.

As a result, rates of sexual behavior considered to be risky remain high. It appears that, in their eagerness to get as many people on drugs as possible, the issue of preventing new infections has received little attention. And claims that this is not a problem, or even that it is not the case, sound rather hollow.

The researchers say "ART is often not enough to prevent HIV transmission, especially where there are high rates of inconsistent condom use and multiple sexual partners". Both these phenomena were found in Kibera.

Kibera may receive a lot more attention than most of the many slums in Nairobi. But the people living there only make up a fraction, perhaps a small fraction, of the total number of slum-dwellers in the city. Out of about 4 million inhabitants, as many as 60 or 70% may be living in slums.

It is noted that the tendency to treat people for HIV without also taking steps to reduce transmission is especially a problem in developing countries, which have weak health and social services. HIV prevalence in Kibera is estimated at about 12%, compared to 7.8% nationally.

People living in slums face multiple vulnerabilities, not just vulnerability to HIV transmission. Apparently "people living in urban informal settlements...have earlier sexual debuts, have more sexual partners, are more likely to use alcohol, and are less likely to adopt preventive measures against contracting HIV compared with urban residents in formal settings".

This research found that 28% of patients use condoms inconsistently (or not at all). Condom use was higher among those who were employed and among those who had been on treatment for longer. But women were three times more likely than men to report inconsistent condom use.

Married men were four times more likely to have had more than one sexual partner than married women, although only 9.5% in total said they had two or more sexual partners in the previous six months. Unmarried men were slightly less likely to have had more than one partner than unmarried women.

The context in which this research took place was described as "a relatively well-functioning ART programme with an inherent support structure focusing on patient education and information". But 'risky' behavior was still considered high, especially among those who had recently started ART, who are more likely to infect their sexual partners.

The authors conclude that "the roll out of ART cannot serve as a single preventive intervention, but must be linked with other preventive strategies for increased community effectiveness."

They also warn that "weak infrastructure and challenged health service delivery in informal settlements must be considered by policy makers and the donor community when developing future interventions to avoid the risk of negative effects, such as increased HIV transmission."

Putting more HIV positive people on ARV drugs has, for many years, led to very little money being spent on HIV prevention. While HIV positive people need treatment, and sooner rather than later, hundreds of thousands, perhaps millions of people have become newly infected with the disease.

Now those peddling drugs want to put HIV negative people on the same drugs, insisting that this will reduce transmission further. Drugs may reduce transmission, but neither of these strategies, treatment as prevention or PrEP, are identifying how so many people continue to be infected in somecountries and in certain parts of other countries.

Many African people live in conditions where the risk of being infected with HIV, either sexually or non-sexually, is very high. Neither of the above strategies even attempt to lower people's exposure to risk. Both of these exorbitantly expensive strategies, on the contrary, allow hundreds of thousands of people every year to be newly infected with a deadly disease.

[For more about pre-exposure prophylaxis (PrEP), see my other blog.]


Wednesday, April 20, 2011

Do Some Researchers Get Commission for Each New HIV Infection?

An article by Drs Robert van Howe and Michelle Storms entitled 'How the circumcision solution in Africa will increase HIV infections' brings together many of the arguments I have been putting forward about HIV and circumcision, but far more elegantly. And there are some arguments I haven't discussed as well.

The authors question the assumption that all HIV infections in the three often cited randomised controlled trials of male circumcision (in South Africa, Kenya and Uganda) resulted from heterosexual transmission. They argue that less than half resulted from sexual transmission and that therefore the majority of infections would not have been prevented by circumcision.

They argue that concentrating on mass circumcision will deflect attention and resources from effective HIV prevention work and may result in an increase in HIV risk. They recommend the promotion of correct and consistent condom use, which, unlike circumcision, is highly effective. If circumcised men think they don't have to use condoms, HIV transmission could increase considerably.

This argument also makes pre-exposure prophylaxis (PrEP), the use of antiretroviral drugs by HIV negative people, said to reduce transmission by 44% when used by men who have sex with men, look like a very weak prevention strategy. PrEP also could lead to an increase in HIV transmission if it resulted in lower condom use.

The authors conclude that "a fifteen-fold increase in the circumcision rate would have the same impact as a 3.8% absolute increase in the use in condoms." So why not just concentrate on promoting the use of condoms and other complementary prevention strategies that actually work?

The authors also mention the barely mentionable iatrogenic HIV transmission which is clearly far more common in developing countries than UNAIDS and the HIV industry would like to admit. They comment: "Before Africans address sexually transmitted HIV, a concerted effort to eliminate the iatrogenic spread of the virus is needed."

They also note: "Condoms would be expected to be ineffective in regions where the majority of infections are from non-sexual transmission." Some authors, such as Drs David Gisselquist and Devon Brewer and Mr John Potterat have been writing on this subject for many years. But iatrogenic transmission is rarely mentioned in the official HIV literature and academic articles that discuss such concepts never seem to see the light of day.

Circumcision enthusiasts have concentrated their attention on populations where circumcision rates happen to be low and HIV prevalence high. But there are populations where circumcision rates are low and HIV prevalence is low. And there are populations where circumcision rates are high and HIV prevalence is high. It is hard to imagine why they have received so much attention, and presumably funding, when their overall stance is so unscientific.

But the vagaries of UNAIDS and the HIV industry have always been beyond comprehension to me. Meanwhile, massive rates of HIV transmission continue to occur in some of the most closely observed populations in the world. And yet those doing the observing don't seem to have figured out how HIV is being transmitted. Doesn't that ring alarm bells for anyone?

[For more about pre-exposure prophylaxis (PrEP), see my other blog.]


Tuesday, April 19, 2011

Underlying Factors in HIV Transmission Are Not Causes

When I was researching for a grant proposal to address gender based violence (GBV) and female genital mutilation (FGM) in the Mara region of Tanzania, I was unsurprised to find that HIV rates there are relatively low. High levels of violence, even GBV and FGM, do not necessarily lead to high levels of HIV. On the contrary, high rates of FGM are often correlated with low HIV prevalence.

This does not, as far as I am concerned, make GBV or FGM any less repulsive. But low prevalence of HIV in an area can sometimes make it difficult to attract funding. Low levels of nutrition, food security, education and other basic human rights are often ignored until it can be shown that HIV rates are high, or that rates are connected with other developmental problems.

Any claim that something is the 'main' driver of HIV is suspect, including an article on today entitled 'Women's inequality Main Driver of HIV'. Like GBV and FGM, all inequalities need to be addressed, because they are symptoms of underdevelopment, not because they are more or less related to HIV transmission.

Of course the "relentless cycle of vulnerability affecting girls and young women" needs to be addressed. But the attitude of UNAIDS and other institutions contributes to that relentless cycle. Telling whole populations that HIV is almost always transmitted through heterosexual sex gives rise to the sort of disempowering social and cultural norms and attitudes that such institutions claim to find so abhorrent.

The article correctly refers to staggering infection rates among women between 15 and 24 years but it does not refer to the fact that many of these women have only one partner who is HIV negative. Fewer men than women are infected in many countries and in some regions, rates among women are several times higher than those among men. It doesn't take people long to work out that something about what they are being told is not true.

Apparently 80 per cent "of young people, aged between 15 and 24 years, living with HIV are female". But most men are not infected until they are a lot older, well into their 20s, perhaps even their 30s. Why wouldn't some people think that HIV is introduced to populations by women? People know more about their own sexual behavior than they are sometimes given credit for, and if they or their partner become infected, they have a right to question the HIV orthodoxy.

All the HIV industry has succeeded in doing is in disempowering women further and undermining their efforts to change their situation. The industry has also further alienated men from wanting to bring about any kind of change. They have been branded as the main culprits in HIV transmission, in addition to all the other things they are accused of. They may not be innocent, but that's no reason to condemn them for something they are not all guilty of. And condemning them, rightly or wrongly, will not help bring about change, either.

Apparently men will be targeted in HIV campaigns that have so far mainly targeted women. But if this means further accusations of promiscuity, strange sexual practices and widespread antisocial behavior, it will prove as fruitless as most prevention work that has taken place so far. It will not be a new strategy, just another way of beating people over the head with the old strategy.

Another 'leading cause' of HIV often mentioned is illiteracy. Again, continuing high levels of illiteracy and profound inequalities in education are disgraceful after so many decades of development work. But HIV transmission has usually been found to be higher among the better educated (and richer) people in high prevalence countries. That wouldn't justify the claim that education 'causes' HIV, but nor should it justify the claim that illiteracy is a cause.

If UNAIDS are interested in what causes HIV, they should re-examine data about sexual practices and sexual transmission. They will find that some of the data is anomalous if it is assumed that almost all HIV is sexually transmitted but the anomalies disappear once they allow that some HIV is transmitted non-sexually.

Reliance on mathematical models is unwise when it comes to estimating the contribution of various modes of transmission because this can lead to circularity. But HIV prevention will be a whole lot easier when it begins to target genuine causes, rather than mere underlying factors.


Monday, April 18, 2011

It is Sweet and Beautiful to Die for One's Scientists

A little while back, I blogged about research that identified HIV prevalence 'hotspots', where high figures were clustered together. This research, carried out in Lesotho, looked at hotspots for males and females and found that they were spatially distant, which may seem anomalous for what is said to be a mainly sexually transmitted disease.

Similar work carried out in South Africa was a bit disappointing. Because, even though it is well known that fewer men are infected than women, often far fewer, this research by Handan Wand and Gita Ramjee only looked at hotspots of high HIV prevalence and incidence for women [Apologies for providing the wrong link yesterday.] Excluding men from such research is odd if it is assumed that women are mainly being infected by men.

But it clearly is assumed that all, not just almost all, transmission is through sex. "At all visits, all participants received counselling on risk reduction and as many male condoms as desired. Counsellors emphasized that condoms are the only known method to prevent HIV and sexually transmitted infections (STIs), and that condoms should be used for every act of sex."

There is something small but crucial wrong with this statement: condoms are the only known method to prevent sexually transmitted HIV. But using condoms during sex will not protect against non-sexually transmitted HIV, which could result from unsafe health care or unsafe cosmetic practices.

Indeed, failing to inform people about non-sexual risks means that they are unable to protect themselves from them and this could be a reason why HIV prevalence is so high in some sub-Saharan African countries. Pretending that HIV is always (or even almost always) sexually transmitted flies in the face of all evidence and is probably responsible for a substantial proportion of all transmission.

As for this research, it found some significant correlations between being HIV positive and certain types of behavior considered to increase the risk of being infected with HIV. 'Significant' in the strict statistical sense of the word, but not particularly large correlations. A non-statistician might think the data needs to be re-examined in the light of such apparently minor differences but not our intrepid authors.

For example: "The proportion of women who reported being legally married was significantly higher among those outside the hotspots than within them (16% vs. 12%, p = 0.001). Significantly more women in the geographical hotspots reported being Christian (94% vs. 90%, p < 0.001) and speaking Zulu at home (91% vs. 86%, p < 0.001) compared with those in non-cluster areas."

The article goes on: "The spatial clustering of HIV cases was found to be related to certain demographic and risk behaviours. Number of male sexual partners was not collected in this study; however, being single, combined with high frequency of sexual acts, gives strong evidence for those women having multiple partners, as well as possibly engaging in transactional sex."

'Strong' evidence? How does this 'high frequency of sexual acts' compare to countries with low HIV prevalence? The same question regarding 'multiple partners'? And would the authors come to the same conclusion of 'possibly engaging in transactional sex' if the risk factors in a low prevalence country were similar? I don't think so.

The authors may be leaving the door open to further research about the safety of health care facilities, but then again, they may not: "These results may be due to fundamental differences between the communities with regard to health care centres, population density and other socio-economic factors. These data provide new evidence to support the need to investigate potential sources of infection and to study transmission patterns in the community in order to apply relevant interventions for prevention of this devastating disease."

Let's hope that 'relevant' interventions means interventions that prevent non-sexual as well as sexual transmission, but it doesn't look as if these particular researchers will see things that way.

It is concluded that "Information on the spatial distribution of populations and services is essential to understand access to health services." But if some HIV is being transmitted nosocomially, as a result of inadequate health facilities, this also needs to be established. Otherwise increasing access to health services could result in higher rates of HIV transmission.

The authors don't just need to "determine and target the specific communities that are most in need of education, prevention and treatment activities", they also need to determine exactly what sort of education and what sort of prevention activities are required. Otherwise, at best, things could remain as bad as they are and atworst, they could get a lot worse. Neither of these would be good for South Africa.


Friday, April 15, 2011

Circumcision Enthusiasts: Screw the Evidence, We're Going Ahead

HIV prevalence has been high in Kisumu since early on in Kenya's epidemic. Rates went higher there than anywhere else in the country and they are still about twice as high as the next highest area, and three times as high as the national figure. This meant that a lot of HIV research work has been done in Kisumu. But no explanation has ever been given of why rates should be so disproportionately high there.

Naturally, fingers were pointed at the fact that people in Kisumu must have a lot of unsafe sex. But what is it about Kisumu (or Luo) sex that makes it so different from sex in other parts of the country? Some people have more than one partner, a few have lots. Most don't use condoms very much and many have their first sexual experience when they are still teenagers.

But those things could all be said about most of the other tribes and cities and provinces of Kenya, and about some people in every country. Birth rates, a sure sign of unprotected sex, are highest in Northern, ethnic Somali inhabited areas. There isn't really anything extraordinary about Kisumu or Luo sex that anyone has been able to discover.

Also early on in the epidemic, it was pointed out that Luo men are not usually circumcised. It was suggested that this might make them more susceptible to HIV. Research has shown that HIV transmission can appear to be connected to circumcision status. However, though in some places circumcised men are less likely to be infected, in others uncircumcised men are less likely to be infected.

But this finding didn't make the people for whom mass male circumcision is their personal cursade very happy. The more research they did, the more ambiguous the effect of mass male circumcision appeared to be. But they are still at it. In fact, research suggests yet another thing that was recognised early on in the HIV pandemic: that HIV is probably not always transmitted sexually.

The risk factors are particularly interesting, not just because risky sex is likely to be driving a good deal of HIV transmission, but because some non-sexual risk factors are also likely to be involved. Both medical injections and traditional practices (saro, bloodletting) were implicated. Those who received injections in the last 6 months were three times more likely to be infected that those who had not and those who ever practiced bloodletting were twice as likely to be infected.

Another surprise was that men who reported washing their genitals immediately after sex were also less likely to be HIV positive. This gives some confirmation to the view that circumcision may not be necessary if men take measures to ensure penile hygiene. Little research has been done into this phenomenon but it is not clear why the authors of this research paper are still advocates of circumcision without knowing how and why HIV transmission appears to be correlated with circumcision status, sometimes positively correlated, sometimes negatively.

Catholics were more than twice as likely to be HIV positive as members of other religions and this was not related to condom use. In fact, condom use is not even a reliable indicator of risk.

The authors try to explain away the data about receiving injections by arguing "because this is a cross-sectional analysis, it is also possible that HIV positive men were more likely to report recent injections to treat HIV/AIDS related illnesses". But these are young men. Even the HIV positive among them are unlikely to be receiving injections related to their HIV status.

While 72% of eligible HIV negative people took part in the survey, only 22% of HIV positive people did so. This could skew the results considerably, though it's not possible to know in which direction they would be skewed. But despite this, and despite the indications that HIV is not always transmitted sexually (or 90%, as is usually claimed), the authors are still devoted advocates of mass male circumcision.


Tuesday, April 12, 2011

If Tanzania Had More Health Personnel, Would HIV Be More or Less Common?

Apparently "One-third of U.S. hospital admissions can expect a medical error, an infection or other adverse outcome". But sometimes up to 90% of these outcomes can remain undetected. This is in the country with the highest health spending per head in the world. What percentage of patients in Tanzania, say, could expect a medical error?

For a start, who is counting? There is generally no way of keeping track of such errors, even serious ones. There are too few health personnel, too few of them are trained and most hospitals don't have the capacity to keep such records or prevent such incidents.

On the plus side, if you could express it that way, most Tanzanians will never see a doctor and won't spend too much time, if any, in a health facility. The percentage of patients suffering adverse outcomes may be higher than in the US but the number of people involved is a hell of a lot lower.

An article about the pastor in Loliondo, Arusha Region, who claims to have a concoction that cures just about anything, points out that the people flocking to drink the potion are not just following the herd; they are desperate.

This is a significant observation. For people in rural parts of Tanzania, and that's over 80% of the population, all health services are elusive, requiring a lot of patience, faith and perserverence, perhaps even some money.

This magic potion is even said to cure HIV/AIDS. It costs less than a dollar, 500 Tanzanian shillings. Of course, people have to pay the costs of waiting for days, not working, paying for accommodation, food, transport, bribes and anything else that someone can screw money out of them for.

But this may not be so different from some antiretroviral (ARV) programs, where the drugs, if you can get hold of them, are free. And ARVs don't guarantee survival either. Under the right conditions ARVs are very powerful, but many Tanzanians don't live in such fortunate circumstances.

This article cites estimates that Tanzania needs 126,000 health workers but only has 35,202, a 76% deficit. The ratio of doctor to patient in some places is as bad as 1 to 62,000 but in Kigoma, that ratio is one to 308,000. Coincidentally (perhaps), Kigoma is also the region with the lowest HIV prevalence in the country.

Per capita health expenditure is $22 in Tanzania, 2.7% of the global average. Much of that, an estimated 75%, comes out of the pockets of people where the majority wouldn't earn much more than a couple of dollars a day. Most illnesses, clearly, go untreated.

When I think of health conditions in East African countries and then look at HIV prevalence, I wonder why HIV prevalence is not a lot higher. And I wonder why HIV prevalence is so much higher in other African countries where far more people have access to health care.

But looking at the figures for adverse outcomes in the US, I'm not so surprised. Good health facilities are dangerous enough, I hate to think of the uncounted hazards people face in bad health facilities. In countries with high HIV prevalence, health facilities could be among the worst places to go.


Monday, April 11, 2011

'Counterfeiting' is a Problem That Can Only Be Solved By Big Pharma

If a business produces something and sells it for a price that covers costs and also gives a decent profit, that's a good model. Others may make the same thing, so a business needs to make the best and work hard to make sure they are not undercut. But most people will pay for something good rather than something that isn't up to scratch, if they can afford it.

However, if a business produces something and sells it for a price that is a complete distortion of the above business model, it is worthwhile for someone else to produce the same thing and charge a lot less. They don't even have to cut costs, they can just accept a lower profit. And those who have no chance of affording the expensive product may well be able to afford the cheaper one.

This is an oversimplification, but it is roughly what the pharmaceutical industry does, charges an outrageous price for something because they can. In addition, the industry depends on a form of protectionism called 'intellectual property rights'. Arguably, this has its uses, even that it is vital, but it is still a form of protectionism.

Often, the research that pharmaceutical companies claim to spend so much on is done by publicly funded, or partially publically funded, institutions. But there is little or no return to the public. And the amount spent on PR and marketing far exceeds what is actually spent on research.

So when someone else makes the same product but demands less for it, the industry reacts by resorting to all sorts of tricks to make sure the competition is destroyed. Competition, when you don't have a high level of trade protection, is not appreciated by the pharmaceutical industry.

The word 'counterfeit', therefore, can mean all sorts of things. It can mean a generic version of a branded drug, a fake version of a branded drug, a substandard version of a branded drug and probably other things. But a generic version of a branded drug is not a counterfeit and claiming that it is one threatens to deny  lifesaving treatments to many people in developing countries.

If drug companies don't want generic versions of their drugs to be produced, they should produce affordable versions themselves. There is clearly a huge market for them and a very good profit to be made. Dropping the price to affordable levels would also make the production of substandard and fake drugs a lot less tempting, perhaps not even worth the effort.

But instead of encouraging the production of generic drugs, the EU and, of course, the entire pharmaceutical industry, want to make sure affordable versions of drugs are not produced. They are currently trying to rope India into signing a 'trade agreement' whereby it will no longer be possible for the country to produce cheap drugs. Yet another form of protectionism.

India is one of the main sources of affordable drugs for developing countries. Some drugs will cost many times, perhaps even tens or hundreds of times more, just because they are protected by the sort of regulation that big industry claims to detest.

There is no doubt that some drugs are fake, made of materials that have no effect or are harmless, and this is unacceptable. But as long as ridiculous profits are made from drug pricing models, people will always find ways of selling their versions, no matter how useless or dangerous. It's not as if copyrighted drugs are always effective, or that they are never dangerous, either.

The pharmaceutical industry, already protected and subsidised in so many ways, wants more public money to be used to 'regulate' drug supplies in developing countries. Multinationals refuse regulation for themselves, but they seem to love the idea of regulating any competition.

Big Pharma have effectively created counterfeiting and many other related problems themselves, it's how they keep their profits so inordnately high. So they should sort it out themselves. If people object to the danger to the health and lives of so many people, they should aim their objections at the industry, the problem, not the mere symptoms of the problem.

The Science and Development Network have a selection of articles on the subject of 'counterfeit' drugs and some of the many issues involved. But the article doesn't really point out that Big Pharma don't lose out from counterfeiting because most of those who buy cheap drugs will never be able to afford the expensive versions.


Saturday, April 9, 2011

Can We Guarantee that Public Health is Truly in People's Interest?

There's been an outbreak of measles in Somalia and apparently it may be connected with rumours that the vaccine could cause HIV in children and interfere with their reproductive abilities.

What is your reaction to such a statement? Would you dismiss it as nonsense and say that public health programs aim to prevent and treat diseases, not spread them? Would you say that no one would try to influence the fertility of a whole population, for any reason, and even put their lives at danger while claiming that it is in the interest of public health?

That would be a naive reaction. Some of the wealthiest institutions in the world care a great deal about the fertility of whole populations, especially when those populations are poor. Let me name some: the US Government, the Bill and Melinda Gates Foundation, FHI, PSI, the World Bank, and there are many others.

We don't know what lengths these parties would go to for the sake of their agenda. The Tuskegee Syphilis 'experiment' may seem like something that happened a long time ago, but Ugandans taking part in more recent HIV research were followed to see how long it took for some of them to become infected and how long it took for some of them to infect others. Many of them are now dead, others are still suffering from the disease and transmitting it to others.

What does the WHO or UNAIDS care about who gets HIV, how many people they may go on to infect or how many people die, and whether painfully or not? UNAIDS still insists that HIV is almost always transmitted through heterosexual sex but an estimated 30% of HIV positive infants in Mozambique (who can be matched with tested mothers) have mothers who are HIV negative.

UNAIDS's response in such situations is to suggest that the infants were raped. It's pretty obvious what their attitude towards Africans is, when they know that infant rape is no more likely in African countries and that incidence of rape, even infant rape, could never be high enough to explain such massive rates of infant HIV.

Quarraisha Abdool Karim, one of the people behind the CAPRISA vaginal microbicide gel fiasco, is planning another way of influencing reproductive choices, in the interest of public health, of course. This time, the idea is to hand out sums of money 'to reduce HIV infection in High School Learners'.

This is interesting for public health experts working with TB. This disease if often caused by occupational hazards, such as mining. It might be too extreme to pay people not to breathe when they are working. But you could compensate them for not working on some of the more dangerous tasks. That would at least drive up the value of labour.

Karim's plan, by the way, is not without it's exclusion criteria. Those who are 'cognitively challenged' will be excluded. I wonder if those who could be considered morally challenged would also be excluded, but there's no mention in the brief details on WHO's site.

Several countries have reported involuntary sterilization carried out on people who were said to be HIV positive. But a program in the US, 'Project Prevention', plans to offer people money to be sterilized if they are drug 'addicts' or 'alcoholics'. If 'addict' or 'alcoholic' just refers to users of these drugs, this would be bad enough, though I wonder who is judging. But what if those judging are evangelical Christians?

And the project is hoping to move to South Africa where it will aim at HIV positive women. Why it won't aim at men, I don't know. There are far more male than female drug and alcohol users. But women are always an easier target. Project Prevention's final solution can eventually move on to men.

One of the people behind this 'initiative', Barbara Harris, says "How can anyone object to anything that can prevent innocent children suffering needlessly?" She could try asking UNAIDS personnel in Mozambique the same question. Apparently Project Prevention are already operating in Kenya, where people are offered $40 (about a month's wages, a fraction of what those in the US receive) to take long term contraception.

Doctors needn't worry, they are given $7 to perform the insertion. Let's hope they wear a new pair of gloves with each patient and avoid reusing single-use instruments. They haven't had a great record of taking such precautions in the past. Even simple procedures like this carry serious risks in countries with a miniscule capacity for health provision, one of those risks being HIV.

This charade reminds me a bit of the mass circumcision campaigns currently raging in Kenya. In a country where only a few dollars are spent per head on health, some institutions are willing to pay many times that to slightly reduce (if at all) the probability of infection with one disease out of hundreds.

Measles is a terrible disease and it is especially worrying that the outbreak in Somalia (and other countries) could have been avoided if it were not for some rumour, probably completely unfounded. But public health authorities do not have much credibility when it comes to being able to assure people that there is no hidden agenda. There usually is a hidden agenda and it looks as if global public health is busy sawing off the branch they are sitting on.

The article concludes: "it is sad that in this day and age our children must die because of ignorance and lies". But the rumours in Somalia are based on lack of information. Far worse are the lies and half truths based on thorough knowledge coupled with an unspoken (and unspeakable) agenda. Lies do not exclusively arise from ignorance; the most harmful lies are those from people who know the truth.


Thursday, April 7, 2011

Promoting Female Condoms in Salons is Great But Don't Forget Non-Sexual Transmission!

Some people like to depict vaginal microbicides as being in the control of women, unlike male condoms and other methods of reducing HIV transmission. Pre-exposure prophylaxis (PrEP, the use of antiretroviral drugs by HIV negative people to reduce probability of infection) can also be depicted this way.

However, it is interesting to hear what many people say about contraceptive pills. Most women in East Africa opt for injectible versions of hormonal contraceptives because they say their husband or partner will not allow them to take the pills if they know they are contraceptives.

But if concerned people are interested in female controlled HIV prophylaxis and contraceptives, perhaps they should take a look at female condoms, a simple enough technology that has been available for over 20 years. They are not 100% female controlled, but they are another arrow in the quiver.

Whatever the HIV industry's feelings about female condoms, they are rarely discussed. And while male condoms are often discussed, the issue of women not necessarily having much control over the use of male condoms constantly arises.

Perhaps it's time to take another look at female condoms. There is convincing evidence that they would make an excellent complement to current HIV prevention programs. Maybe those expressing an aversion just don't know enough about them. I have asked a number of people and the ones who express an aversion, all of them, have never used female condoms. (Similarly, those who said male condoms sometimes burst have either said it never happened to them or it happened once or twice).

Apparently there is a program in Zimbabwe which aims to promote the female condom through hairdressing salons. This is a great venue for promoting knowledge of HIV transmission because so many women go to them and because hairdressers themselves need to know a lot more about HIV transmission than they currently do.

For example, most people who have been lectured, sorry, advised about HIV transmission have been told about sexual transmission, mother to child transmission and possibly something about intravenous drug use. Less likely, they'll have heard about transmission through blood transfusions.

It is unlikely they will have heard much about other forms of medical transmission, such as through the reuse of poorly sterilized equipment, such as injecting equipment, IV lines, dental equipment, etc, although such knowledge could reduce this kind of infection.

It is also unlikely they will have heard about the possibility of HIV transmission through unsafe cosmetic practices, such as tattoos, ear piercing, shaving (where cuts and abraisions can occur), hair straightening (where the relaxants can cause burning) and other practices.

Apparently PSI (Population Services International) is running the program, which makes it unlikely they will mention much beyond sexual transmission of HIV, but there is hope. And it's good to hear that they are promoting female condoms, it's time someone did.


Wednesday, April 6, 2011

If Mass Male Circumcision Fails, Will We Be Told?

In order to implement HIV prevention, treatment and care programs, countries need adequate health facilities, with sufficient numbers of trained staff and supplies of equipment and drugs. Most high prevalence HIV countries don't have these.

A quick look a health statistics for most African countries show that they can't even cope with the most basic health issues, such as clean water and sanitation supply, nutrition or prevention and treatment of common diseases, such as water borne conditions and acute respiratory problems.

It is said that Africa has 24% of the global disease burden but only 3% of the world's health workers. It's common for countries and regions to have only one doctor for every 50 or 100,000 people. There are too few health facilities, they are all short of supplies and service provision can not meet demand, or services are of very low quality, or both.

None of this is particularly new. A glance at health service provision assessments from Measure DHS shows that the countries who have the worst problems often have the worst health services.

So it's not surprising that Kenya's ambitions to circumcise 1.1 million men in the space of a few years is proving quite challenging. An assessment of the first year or two of this program, which claims to have already circumcised 230,000 men, should worry those who have gone through the operation, as well as those who are planning to do so.

There is no mention of the numbers of men who have been infected with HIV or any other sexually transmitted disease since undergoing the operation. This is worrying because the whole aim of the exercise is to reduce HIV transmission. Those who have opted to be circumcised will need to be followed up for some time, but HIV transmission rates in the intervention are are massive.

If the program is going well, releasing the figures could help with enrollment. But if it is not going as well as expected, perhaps some problems should be aired and ironed out now to limit the amount of damage that could be done.

The assessment of health facilities involved in the parts of Nyanza selected for the intervention is not wholly encouraging. One of the 'minimum criteria' for service provision was "Sterilization and infection control compliance." Only two thirds of the facilities have autoclave equipment. No mention is made of whether the equipment is used, or used properly. And going by other similar assessments, most facilities don't have written procedures for sterilization and infection control.

Out of the 81 facilities assessed, none of them possessed all seven of the criteria necessary to provide safe services. Most didn't have enough doctors or clinical officers to perform circumcisions, although they were the only staff authorized to do so prior to the mass circumcision program.

85% of hospitals had enough nurses, so they were trained to perform the operation. How these facilities managed to cope with routine, non-HIV emergencies is not made clear. Indeed, it is to be wondered if all this information about health facilities will have any impact on the health development agenda, or if non-HIV health issues will continue to be ignored.

So far, much of the resources and personnel required have been supplied by donors. Whether the program can be continued using existing capacity, whether the program is sustainable, is debatable. And whether it can be continued safely is something I wouldn't like to bet on. I'm sure those who are being offered the services would have the same worry, if they had access to unbiased information.

The efforts to make mass male circumcision rollout seem successful suggest that a lot more could be done to develop health services in resource poor countries. But the lack of effort to deal with non-HIV health development issues suggests that little will be done. Ultimately, the program could result in similar or even higher rates of HIV transmission. It just remains to be seen how long it will take before useful data becomes publicly available.


Monday, April 4, 2011

If Maternal and Child Health is Bad, Family Planning = Large Families

Would having a vasectomy make some men more likely to have unprotected sex? If they see contraception as just a protection against HIV (and perhaps other sexually transmitted infections), the vasectomy shouldn't, logically, result in a reduction in condom use. But I suspect it would be a good excuse for not using condoms.

If they see condom use and/or vasectomies as a means of reducing unplanned pregnancies, having a vactomy could well result in men having unprotected sex. They could see condoms having a dual purpose, but many HIV prevention and other types of health programs have made little effort to emphasize this dual purpose.

If male circumcision was also involved, how would that affect condom use? Of course, mass male circumcision campaigns do drone on about having to use condoms for circumcision to be effective. But I don't see many men getting circumcized if they don't think they can reduce their condom use, perhaps even dispense with them altogether.

If programs that aim at reducing heterosexual HIV transmission are combined with programs that aim at reducing a country's population, this could result in a very mixed message indeed. Who is going to undergo both circumcision and a vasectomy and still use condoms?

If circumcision in conjunction with condom use is intended to reduce sexual HIV transmission, this sort of program might best be kept separate from a program that aims purely at population control.

Besides, people who are not in a position to, or don't see themselves as being in a position to make family planning related choices that we in the Western world take for granted, may require a more subtle approach than 'offering' them vasectomies.

There must be a lot more to family planning than merely reducing the probability of conception in as many ways as possible. This smacks of the eugenicist subtext that seems to be hidden in much of the public health programs one hears about in developing countries.

Apparently Rwanda is combining its population growth program with its circumcision program, which is intended to reduce HIV transmission. Yet, the respective merits of each strategy, circumcision, condom use and vasectomies, are themselves matters for debate.

There is little doubt that correct and consistent use of condoms plays a large part in reducing unplanned pregnancy. But will people continue to use them if they think there is an alternative, or if they take care of unplanned pregnancy?

But it is far less clear that mass male circumcision has a significant impact on heterosexual HIV transmission outside of (relatively) carefully controlled trials. And even those trials only claim that circumcision reduces female to male transmission, which is a lot less common than male to female transmission, which it may even increase.

And a vasectomy may well reduce conception, perhaps even eliminate it completely. But the ethics of encouraging large numbers of people to have vasectomies, perhaps young men, should be considered carefully. And maybe those advocating the combination of all three should also look at the potential incompatibilities involved.

Programs designed to, or even programs that happen to reduce conception need to be accompanied by programs that aim to improve health services and even health education, nutrition, water and sanitation, working condititions, living conditions and everything else that make up the determinants of health.

Rwanda still has high infant, under five and maternal mortality. Life expectancy is low and most premature deaths are due to treatable and preventable conditions. Even HIV positive people tend to die of treatable and preventable conditions. Under such circumstances, the only viable form of family planning is to have big families.

Health programs that ignore the broader determinants of health will have little positive impact and may do a lot of damage. And the combined contraception/HIV reduction/vasectomy approach suggested for Rwanda sounds entirely unethical, as well as ineffective.