Wednesday, June 29, 2011

If It's Not PR, it Will Probably Never Get Published

But if it is PR, it will be bounced about like a genuine human interest story. You may have read about Coca Cola being the only institution that gets to the remotest villages in Tanzania? And that's why the unscrupulous multinational will now receive large sums of money to distribute their toxic products?

In fact, there are many products that reach even the remotest villages, too many to list. If there's money to be made, naturally, someone is there to provide the transport. But in Tanzania, we are led to believe, no one has that sort initiative, except Coke.

So, in a 'public-private' partnership, Coke will distribute antiretroviral drugs to HIV positive people. For those won don't know, the 'public' bit means that money destined for aid work goes to private industry, often without any question of competition, appropriateness, effectiveness, etc.

It's interesting to bear in mind that the remotest villages usually have the lowest rates of HIV. But those same remote villages are most in need of cheaper drugs for things like respiratory problems, diarrheal diseases, intestinal parasites, drugs that are so cheap, even Coke can't make a profit from distributing them.

Will Coke distribute anything else that HIV positive people need? Or is it just drugs? Surely the care of HIV positive people requires more than just drugs? How about trained personnel, medical facilities and equipment, day to day medical supplies? But no, Coke is not interested in helping to develop Tanzania's health infrastructure. That would be too much like philanthropy.

And talking of philanthropy, those paragons of the stuff, Gates and Co. are involved in Coke's generous measures to increase their profits and possibly bolt on a (very) small part of the country's ailing health infrastructure. In fact, Melinda Gates is one of the people who has often trumpeted the plight of poor Coke, who are so generous that they need aid money to help increase their profits to extortionate proportions.

Incidentally, Gates mentions the Mererani Tanzanite mine and how hard it is to reach it from Kilamanjaro International Airport because of the state of the roads. I don't think the roads would still be in such poor condition if the mines had to depend on them. And Gates didn't mention the fact that the mine has an unenviable record itself, with a minimum wage of 120 dollars, despite its massive profits.

Make no mistake about it, there are many enterprising Tanzanian transporters and distributors who would willing take on the job of distributing drugs, not just HIV drugs, and at a fraction of the cost that Coke will be extracting from the cause.

The article does mention a little about Coke's foul record when it comes to corporate social responsibility but focuses on the multinational's supply chain. Yet, there are others in Tanzania whose reach is just as broad as Coke's. The article would be better to expose the 'story' for what it is, blatant PR. Though you can't expect the Gates Foundation to notice these things; strengthening multinationals is one of their main aims.


Saturday, June 25, 2011

By Following UNAIDS' Advice, Angola's HIV Epidemic Should Rocket

Following a recent posting about the risk of HIV and other blood borne diseases being spread in beauty salons and barber shops in the country of Georgia, here's another one about the same issue in Angola.

Even in Angolas capital, Luanda, many establishments lack sterilizing equipment. Beauty and hairdressing processes sometimes carry the risk of breaking the skin, especially where an area of skin is already damaged. If an infected area is involved, the risk of transmitting HIV is particularly high. Pus is a lot more risky than blood.

The articles don't mention additional risks from things like body piercing and tattooing, though these involve, by definition, breaking the skin. The Angola Aids Institute has pointed out that it is the establishment owners' responsibility to provide equipment and other materials. But it is the employees who need the training.

Anyhow, it's good to have the issue aired. Here in East Africa, a lot of hairdressing, cosmetic treatment, manicure and pedicure takes place on the street and in people's homes, often carried out by ill-equipped and untrained people. And people appear to be entirely unaware of the risks. They point to the small bottle of surgical spirit and cotton wool which they use, to a greater or lesser extent.

If those providing the treatment are unaware of the risks, their customers are even less aware. Worse still, official warnings from UNAIDS and the like about HIV are almost entirely about sexual risks, with non-sexual risks either diminshed, ignored or denied.

Angola borders some of the highest prevalence countries in the world but HIV prevalence there is not even as high as it is in East African countries. This is, even by UNAIDS, accepted as relating to the long civil war there. War is said to keep many parts of a country isolated.

What UNAIDS don't say is that war can also reduce the use of beauty and hairdressing establishments, even the provision of such services. And the august and over-financed institution is even less likely to point out that during long civil wars, over 25 years in Angola's case, health services tend to break down. These factors might significantly reduce the risk of non-sexual HIV transmission.

'Unsafe' sexual behavior was likely to have been far more common during the civil war than since. At least, it's unlikely to have been less common. It is only now that the civil war has ended that people, especially children, are receiving information about sex and HIV. Yet, ironically, it is now that the war has ended that HIV prevalence is rocketing.

Unfortunately, the usual suspects, political, religious, scientific, etc, are rushing to Angola to wag their collective fingers about safe sex. These groups are unlikely to have any impact on HIV transmission. So it's reassuring to hear news from Angola about non-sexual transmission. Let's hope they include unsafe medical practices in their warnings.

Almost all HIV transmission in Angola could have been prevented. There were people warning about non-sexual transmission in the early 2000s, even in the 1990s. But the HIV agenda has long been hijacked by those obsessed by sex, especially sex in Africa. If Angolans don't see the error of global HIV policy and go their own way, they will end up like all the other countries 'guided' by UNAIDS and their ilk.


Thursday, June 23, 2011

HIV Transmission Takes Many Forms, So Let's Not Concentrate on Just One

In the US and many other Western countries the number one way of becoming infected with HIV is through anal sex, usually men having sex with men (MSM). The number two way is intravenous drug use. Other modes of transmission are in need of elucidation but we are told they include penile-vaginal heterosexual sex.

Many people, when asked to guess, think that penile-vaginal heterosexual transmission is very common. They are not aware that it is an inefficient mode of transmission, especially compared to anal sex (between men or between men and women) and intravenous drug use.

In some African countries, HIV transmission is said to be predominantly through penile-vaginal heterosexual sex. Intravenous drug use may well be low in a lot of high prevalence African countries. Exactly why male/male or male/female anal sex should be relatively rare or should rarely transmit HIV in African countries has never been made clear by the HIV industry.

But because of the insistance on harping on about penile-vaginal (usually just by implication) heterosexual sex, very little attention is given to any other modes of transmission. And non-sexual modes of transmission, such as unsafe healthcare, unsafe cosmetic practices or anything else, are barely mentioned and are claimed to be almost non-existent if mentioned at all.

So it's not surprising that there is a lot of misunderstanding about anal sex (as well as HIV and sexual transmission in general). People in African countries in particular are usually unaware that anal sex carries a risk of transmitting HIV, or even sexually transmitted infections, let alone the fact that it carries a far higher risk than other forms of sexual intercourse.

The risk may be as much as 18 times higher. That makes it very risky indeed. But, for some reason, the HIV industry has pinned their hopes on targeting penile-vaginal heterosexual sex, almost exclusively. And it's not working. Whether the industry lies or simply doesn't bother to tell the true story, many people are taking risks, getting infected, suffering and dying, completely unnecessarily.

What is so difficult, or even wrong, with telling people the full story? HIV is transmitted in many different ways. Some of those modes of transmission are efficient, such as anal sex, intravenous drug use, unsafe medical and cosmetic practices; and some are not efficient, such as penile-vaginal heterosexual sex. Even sex work is not particularly risky in Western countries, only in African countries, it seems.

To tell people only the bit you want them to hear, for example, about penile-vaginal heterosexual sex alone, is to fail to educate them. They do not get an understanding about how HIV is transmitted. Therefore they remain in the dark about how to protect themselves. The behavioral paradigm, the view that HIV is almost always transmitted through penile-vaginal sex in African countries is a fallacy. And it's killing people.


Wednesday, June 22, 2011

Sometimes Targets of Prejudice Embrace that Very Prejudice Themselves

It's odd sometimes how the targets of a prejudice embrace that very prejudice themselves. UNAIDS' prejudice about HIV almost always being transmitted sexually in African countries is a case in point. Academic articles and press coverage alike, explicitly or tacitly, assume the truth of the prejudice. And people here say 'we' or 'Kenyans' or 'Africans' like sex, have a lot of sex or prefer 'unsafe' sex.

In an article about adult male circumcision in Uganda, carried out with the aim of reducing HIV transmission (from females to males), Robert Kalumba warns that many people, male and female, seem convinced that the operation protects everyone from both infection and transmission. This is not the case, although the warning is nothing new.

But he also claims that "Ugandans love sex a lot" and it's hard to know what that means, aside from being an echo of the oft expressed prejudice. HIV prevalence is low in some parts of Uganda, high in others, low in some demographic groups and high in others. Do all Ugandans love sex? More than non-Ugandans? What about in places where HIV prevalence is low? What about non-Ugandans among whom HIV prevalence is far higher than it is in Uganda, such as Swaziland?

Kalumba also embraces the reflex about HIV being related to 'ignorance', just as others say that HIV is 'driven' by poverty. Neither of these reflexes are borne out by the evidence. HIV rates in high (and medium) prevalence countries are, in general, higher among those who have a higher level of education and are wealthier. And the effect is usually stronger among women than men.

Of course, lack of education and poverty are undesirable. The continued appalling educational, health and economic circumstances in developing countries is repugnant; but not because of their relation or lack of relation to HIV prevalence. Rather, HIV is repugnant because it is a virulent disease, one that spreads most readily among people who already face many other problems, such as low levels of access to adequate health facilities.

What Kalumba should be asking about mass male circumcision campaigns is why so much money and attention is going towards an operation which will only benefit some people, all men, when so many others are in even greater need, more often women than men. In fact, any effect in the field may prove small or even negative.

The United Nations General Assembly Special Sitting (UNGASS) report for Uganda in 2009 also makes one wonder to what extent HIV is sexually transmitted. A quick look at their graphs for HIV on the one hand and other recognized sexually transmitted diseases on the other shows that infection patterns are completely different.

Many would suspect that HIV is only partly sexually transmitted. And if they do, they will recognize that circumcision and other measures that assume the truth of the above mentioned prejudice will never be enough on their own.

While he is at it, Kalumba and others could take a look at various data from the Ugandan Demographic and Health Survey, which show that the highest figures for 'unsafe' sexual behavior are those for men, whereas the highest figures for HIV are for women. If he looks at the Aids Indicator Survey, he will notice many other anomalies, such as the number of people who are infected with HIV when they have never had sex, rarely had sex, only had sex with their partner or rarely had 'unsafe' sex.

The fact that some of the richest and most powerful HIV related institutions agree that HIV is almost always sexually transmitted in Africans does not make it so. And people like Kalumba need to be able to spot a prejudice for what it is. Because if Africans don't reject the prejudice, policy for HIV 'prevention' in Africa will continue to fail. You can't eliminate non-sexual transmission of HIV by targeting people's sexual behavior, especially among those who are not even sexually active.


Tuesday, June 21, 2011

HIV Can Be Spread in Beauty Salons, Despite UNAIDS Denial

An article about beauty salons in Georgia (the country, not the US state) makes it clear that HIV, hepatitis B and C and other serious viruses can be spread when good hygiene measures are not observed. Many salons, we are told, do not meet adequate standards. Customers are more interested in getting a good price than in avoiding health risks.

Perhaps people are not even aware of the risks, though. The article didn't manage to find any cases where serious infection had been confirmed to have come from a beauty salon. But if few people know about the risks, they are not likely to connect their infection with a visit to a beauty salon, which may have taken place years, or even decades before.

Even health professionals are unlikely to make the connection. When a HIV positive patient visits a health facility in most countries (I don't know if it's the same with Georgia), they are far more likely to be asked about their sexual history, with other risks given less attention, if any.

Adequate sterilization of instruments that may break the skin requires expensive equipment and good training and management. These may be absent in some salons. And all sorts of treatment can carry risks, not just manicure and pedicure but also male and female hairdressing, shaving and body piercing.

With a population of 10 times that of Georgia and a GDP per capita of less than one tenth, Tanzania must be in a far more dangerous position. There are many salons here, but price is even more important than it would be in a relatively rich and far more developed country.

In fact, the majority of poorer people in Tanzania do not go to salons for a lot of cosmetic work. The needs of many are attended to by friends and family with little or no training and even less access to sterilization equipment. Others go to the ubiquitous street cosmeticians, who will do your hands and feet out in the open as you wait for your bus or your friends or whatever.

UNAIDS doesn't even consider non-sexual transmission to be an issue when it comes to HIV in high prevalence countries. They insist that only around 2-2.5% of transmission occurs in health facilities. No mention at all is made of cosmetic or other non-sexual risks in the Modes of Transmission Surveys that I have seen for African countries.

It would be odd indeed if a country like Georgia were to be a risky place for such non-sexual transmission and a country like Tanzania (or Kenya, Uganda, South Africa, Swaziland and other high prevalence countries) were to be risk free. If people face sexual risks, they probably also face non-sexual risks. And that means they need to be made aware of these risks.

Non-sexual risks are recognised in some countries. A recent paper on the subject of hepatitis B in Pakistan notes "Lack of awareness, socioecomic conditions, sexual activities and sharing of razor blades, syringes and tattooing needles" as risk factors. And there, 21% of the population are infected with hepatitis B. Therefore, non-sexual risks in high prevalence countries need to be given as much attention as sexual risks.

[I should have mentioned that the Pakistan study is about Internally Displaced Persons (IDP), a group that is not representative of the population as a whole. National hepatitis B prevalence is estimated at about 67.5%, far higher than in the study population. In African refugee and IDP camps, HIV prevalence is usually significantly lower than in the population as a whole. Risks are clearly lower, although these camps are said to involve many hazards.]

Any exposure to blood, pus and other bodily fluids could carry the risk of serious disease transmission, especially where viruses like HIV and hepatitis are endemic. Teaching people only about sexual risks when serious non-sexual risks are being faced by everyone in a population, sexually active and non-sexually active people alike, is allowing some of the most easily prevented instances to continue, uninvestigated and unhindered.

UNAIDS have a standard excuse when non-sexual transmission is mentioned. They feel that it could deflect attention from sexual transmission. But if people face both sexual and non-sexual risks, UNAIDS are failing in their duty to give people accurate information that could protect them and their children. We will not protect people from HIV by lying to them about the risks they face.


Monday, June 20, 2011

Tenofovir Gel Still Hyped, Despite Serious Questions About Trial

The rather disappointing 39% reduction in HIV infection among women who received tenofovir microbicide gel during the clinical trials has since been written about as if it is going to turn the epidemic around. It might, but the reduction would need to be a lot higher than 39%. A lot of questions will also need to be answered about the way the CAPRISA 004 trial was run and reported on.

But immediate efforts have been made to 'fast-track' approval so that the gel can be produced commercially. A site has already been identified for the factory, which makes it sound as if the many further trials that are needed to establish if the gel is going to have any impact at all on the HIV pandemic are irrelevant.

Any drug that is overused carries the risk of widespread resistance. This is something pharmaceutical companies are acutely aware of, given the substantial increase in their profits when people need to change to a newer and inevitably more expensive drug as a result of resistance. But if millions, perhaps tens of millions, eventually use this gel, levels of resistance could go far beyond what could be controlled (whatever level that might be).

And an important question, apparently, is that the reasons behind the HIV transmissions during the trial, and therefore the effectiveness of the Tenofovir drug, are not yet clear. One researcher has suggested that anti-inflammatories may be useful in reducing HIV transmission.

Another question that has been raised about effectiveness is that it is possible the gel only protected women if the viral load in their partner's semen was high. The trial results made public were a bit vague about exactly what risks were faced by the women who became infected, and if all of them were really infected sexually. Perhaps the less flattering results of the trial will be made public now?


Tuesday, June 14, 2011

Reducing Maternal HIV: the Only Acceptable Way of Reducing Pediatric HIV

The received view of HIV in high prevalence countries, especially African countries, is that roughly 80% is transmitted through heterosexual sex and most of the remaining 20% is transmitted from mother to child. So it's not surprising that the HIV hierarchy should target mother to child transmission, or at least talk about doing so. Even if the 80% estimate is way out, a very large number of children are infected during pregnancy, delivery or shortly after birth.

While no one could object to aiming to eliminate mother to child transmission, some might wonder if any effort will be made to prevent HIV in pregnant women. That might seem stupidly obvious but I don't see attempts being made to establish why so many pregnant women become infected with HIV, especially late in their pregnancy, or even shortly after birth.

Of course, transmission of sexually transmitted infections (STI) occur as a result of unprotected sex, as does pregnancy. But many of the women infected with HIV are not also, or not as much infected with more common and easier to transmit STIs. Perhaps more strikingly, many women who are infected with HIV don't have HIV positive partners. And in a lot of cases, there is no routine follow up and testing of partners in African countries, so we can't always even be sure.

Although there is always the assumption that women who are infected shortly before, during or after their pregnancy are infected by their partner as a result of unprotected sex, there is a good chance that many women are not being infected by their partner, nor even through unprotected sex. UNAIDS' insistance that 80% of transmission in African countries is through heterosexual sex is, after all, not based on evidence. It is, on the whole, an unsupported assumption.

Something even better than preventing mother to child transmission, then, is preventing HIV in mothers. And where sexual partners are not even HIV positive, there is good reason to establish just how women are infected, and then use the resulting data to adjust the 80% figure. HIV transmission through some unknown route is very unlikely to be prevented. And that makes prevention of mother to child transmission a lot more difficult to effect.

In countries such as Libya and Romania, where massive rates of HIV transmission were recognized (and acknowledged) to have occurred through unsafe medical practices, many of the children infected went on to infect their mothers through breastfeeding, as opposed to the other way around. But such modes of transmission need to be recognized (and adknowledged) before they will be investigated, let alone prevented.

Recognizing non-sexual transmission would have another benefit: it would reduce stigma. If HIV positive Africans are told that it is almost certain that they were infected sexually, they will be stigmatized. Especially if it turns out that their partner is not infected. Allowing the possibility that HIV can be transmitted in other ways, which it most certainly can, could save a lot of marriages and lives, even the lives of children at risk of becoming infected.

There is some recognition that the state of public health facilities has direct consequences for the health of the people using those facilities. A lack of drugs, equipment and trained personnel has a negative impact on goals such as reducing child and maternal mortality, HIV transmission, malaria and other diseases.

Apparently, drugs and equipment can be stolen or may never reach health facilities. Sometimes patients have to bring the latex gloves and other equipment that will be used for their care. Perhaps sometimes equipment in short supply is reused, even without proper sterilization. But accepting that it can happen is not enough. It also needs to be established if this is contributing to transmission of diseases, such as HIV, and if so, how big this contribution is.

It's all very well to talk/write about destigmatization. But many of those doing the talking/writing are also doing the stigmatizing. There is plenty of evidence that HIV is not always transmitted sexually in Africa and there is evidence that possible cases of non-sexual transmission need to be investigated. Admitting this would go a long way towards reducing transmission, and also reducing stigmatization.

You will no more reduce stigmatization by saying 'stigma is bad' than you will influence sexual behavior by saying 'unprotected sex is risky'. We have learned that through many years of failing to have much impact on HIV transmission. The issue of stigma is very much in the hands of the people who warn us about how damaging it is, the UN, UNAIDS, WHO, CDC, the World Bank, etc.

The best way to reduce HIV transmission is to be clear about how the virus is being transmitted and not to depend on out of date and inappropriate figures. The best way to reduce mother to child transmission is to reduce the number of mothers being infected. And the best way to reduce stigma is to be honest about HIV transmission: we know that it is not always transmitted sexually and we don't even know how much is transmitted sexually.


Monday, June 13, 2011

Are UNAIDS Getting Off On Their Own Sexual Fantasies?

If paying for sex commoditizes it, does paying people not to have sex also commoditize it? Would anyone bribe their daughter with money to wait till they are married before they have sex? Or would they bribe them with money not to have sex for money? Somehow, I can't imagine parents thinking this way.

I don't know if paying girls not to have sex commoditizes it but I know it's one of the stories that does the rounds because it seems to appeal to journalists. And I know that UNAIDS sees it as worth a try in South Africa. I just can't see them trying it out in Washington DC (which might have the highest HIV rates in the Western world).

The article informs us that young South African girls are "one of the highest risk groups, because poverty drives them to have sex in exchange for gifts." What, all young girls? Or is it just all 'poor' young girls? "Researchers now want to see whether using cash payments as a reward for getting good grades and having annual HIV tests could curb the girls' risky sexual behaviour." So if the grades are not good and/or they don't have annual tests for some reason, no money for them?

Maybe things have changed radically in SA but only a few years ago "Startling new evidence from a three-year survey [showed] that HIV is now growing fastest among those who are wealthier and educated." This phenomenon is quite familiar in Kenya and even more so in Tanzania. In fact, the phenomenon is most marked among female Tanzanians: HIV rates are higher among well educated, well off Tanzanian women.

The Nature article is not too clear but I think it is saying that money is being given to boys and girls. Apparently boys are being involved because "Men are driving the epidemic — through their sexual behaviours, drug-taking, risk-taking and the fact that they often hold the balance of power in decision-making in intimate relationships."

Maybe the epidemic is being driven by men, but people could be forgiven for not being entirely convinced of that. HIV prevalence among females at age 15-19 is 6.7% and among males it is only 2.5%. We are informed, frequently, that young women sleep with older men. But how much older? And do all young women sleep with older men? Because in the 20-24 age group, female prevalence is 21.1% and male only 5.1.

Some estimates suggest that some (but by no means all) females sleep with men who are between five and ten years older than them. So if 15-19 year old females were sleeping with 20-24 year old men, it looks like a lot of the males are actually being infected by females, not the other way around. 6.7% of 15-19 year old females are infected, compared to 5.1% of 20-24 year old males. Sorry for being repetitive but these figures don't suggest that HIV transmission is being 'driven by men'.

Even if some young women have sex with much older men, there is no evidence that they all do. And while female prevalence peaks at 32.7% in the 25-29 year age group, it peaks at only 25.8% among 30-34 year old males, never reaching female prevalence rates in any age group. The figures could even suggest that the number of promiscuous females, if you go for the promiscuity theory of HIV transmission, radically outnumbers that of promiscuous males.

This doesn't really give credence to the idea that the epidemic is being driven by men. In fact, it might make you question the assumption that the epidemic is entirely driven by sex. You have huge numbers of females being infected at a very young age and far smaller numbers of men who could be infecting them. The whole principle behind making money from sex is that there are relatively few women being paid by a relatively large number of men.

If the number of women selling sex outnumbers the men buying it, the bottom falls out of the market. But, interestingly, if fewer women are willing to sell sex, the value will go up. If lots of these young females, said to be selling sex because they are so impoverished, suddenly disappear off the market, those left selling sex will be able to command a far higher price. The scheme may have some benefit, but probably not the one intended by UNAIDS!

But the two main claims in the article about paying young women not to have sex are that HIV is driven by large numbers of poor young women having sex for money and that HIV transmission is driven by (smaller numbers of) promiscuous men. Neither of these claims seems very plausible. What is plausible is that small numbers of poor young women have sex for money and that small numbers of promiscuous men pay for sex.

And this still doesn't explain extraordinarily high HIV prevalence figures found in South Africa, therefore it can not justify paying young girls (or boys) to not have sex. HIV prevention interventions need to be based on reality, rather than on the fantasies of a bunch of bureaucrats desperate to have something to show for the billions that have been poured into their institution.

Enabling girls to stay in school has been shown to reduce 'unsafe' sex, unplanned pregnancies and possibly sexually transmitted infections and HIV. But if HIV prevalence is usually higher among better educated girls, perhaps this needs to be investigated before spending money and precious time with interventions that may not work and that may make things worse. There is no substitute for establishing exactly how HIV is being transmitted in high prevalence contexts. Because we clearly don't know that yet.


Thursday, June 9, 2011

HIV Treatment Has Come a Long Way, Prevention Has a Long Way to Go

South Africa, apparently, has a plan to "eliminate HIV in the next 30 years". The plan is based on a mathematical model, which assumes very high HIV prevalence and a population that will be tested once a year. Those found positive will be given antiretroviral drugs immediately, to take for the rest of their lives. The model says that this will eliminate the epidemic.

It would be interesting to know what figures they used in their model. South Africa has indeed tested many millions of people in the last twelve months, perhaps 12 million or more. But it has been estimated that people might need to be tested more frequently than once a year, perhaps twice or even four times a year. Will once a year be feasible, even if it turns out to be enough?

Sure, plenty of research has shown that a lot of people responding to antiretroviral treatment have a very low viral load and are unlikely to transmit the virus to their sexual partners. But that doesn't mean that 'test and treat', as it's called, will eradicate transmission altogether.

Recent research which gave rise to a lot of the hype about test and treat involved discordant couples. These are couples where only one person, the 'index case', is infected. It is believed that the index case will, sooner or later, infect their partner if they continue to have unprotected sex. The rate of transmission in discordant relationships is, indeed, very high. Putting the infected partners on drugs, assuming that they are found to be HIV positive early enough, could significantly reduce the risk to the HIV negative partner.

But that doesn't answer the question of how the index partner was infected. They would probably not have been protected by a test and treat policy, unless that policy was able to ensure that a huge percentage of new infections were discovered and treated very early on. But, while you can see the motivation for putting the HIV positive partner on drugs to protect the negative partner in discordant couples, in a couple where neither is positive there is no such motivation.

The South African plan doesn't deal with the issue of whether all HIV positive people will agree to or adhere to treatment. It doesn't even ask if putting people on treatment immediately is the best thing for those people's health. Leaving treatment till too late is clearly bad for people's health. But treating them too early, as well as being expensive and more likely to result in non-adherence and consequent resistance, may not be ethical.

It certainly won't be ethical if people are compelled to take the drugs, regardless of whether they need them or not. But there's also the question of whether people should take drugs for the benefit of others, or for the benefit of public health. [There's an interesting discussion of patient autonomy by Dr Joseph Sonnabend on his POZ blog.]

Treating more people, if and when they need treatment, is a good thing. Testing more people and testing them regularly is also good, especially if the results of such widespread testing are used to figure out why so many people become infected in South Africa. But test and treat alone is very unlikely to eliminate any epidemic in any country in 30 years, or even in 100 years.

No matter what any model (or 'expert') tells you, treating as many HIV positive people as possible is not the same as developing strategies to ensure that people don't become infected in the first place. Public health is a lot more complicated than any mathetical model can show. That's why so few diseases have ever been eradicated.

Diseases that have been virtually eradicated in some countries were not eradicated merely because of some powerful technology, either. They were eradicated because the conditions under which the disease is transmitted were also addressed. Water, sanitation and hygiene in the case of many diseases, air quality and habitation in the case of others, food and nutrition, living conditions, working conditions, etc. Test and treat remains relatively blind to the conditions under which HIV is transmitted (as has the HIV industry).

Alarmingly, research has shown that test and treat alone will not even come close to eradicating HIV in the US, where transmission is many times lower than in South Africa and the amount per head spent on healthcare is the highest in the world. And this is not because the universal testing part of the strategy is not in operation but because only 1 in 5 people on treatment have the undetectable viral load requried to ensure that they don't infect their partner through unprotected sex.

Test and treat is neither a miracle nor something that is impossible to effect. But it will not eradicate HIV epidemics, ever, anywhere. And public health experts should know that there is no such precedent for eradicating a disease that is transmitted in a number of ways (some of which are adequately acknowledged and some of which are not). It is wholly irresponsible to make the implicit promises that one hears constantly about test and treat.

There is a lot we don't yet know about HIV transmission and, apparently, a lot we are not very anxious to discuss. So let's not get distracted from HIV prevention by what is just one in a long line of hyped technical fixes. Test and treat, treatment as prevention, whatever you want to call it, will only ever be part of an effective strategy to eradicate HIV.


Wednesday, June 8, 2011

One Unsupported Assumption Can Infect a Whole Body of Research

The author of a book on AIDS with one of the most stigmatizing titles possible, Elizabeth Pisani, is interviewed by IRIN about why HIV prevention efforts have failed to curb the spread of the pandemic. One of the answers she gives is that we started too late, which I guess suggests that she thinks we have started now.

She's right about missing an important opportunity by not implementing needle exchange programs in some countries where the bulk of HIV transmission continues to occur among injecting drug users. Russia and a lot of Central and Eastern Europe are still dithering about such programs and the US continues to deprecate them, though they have worked well in countries where they have been implemented.

She's a bit wide of the mark in claiming that not targeting sex workers to reduce sexually transmitted infections represents a missed opportunity, certainly in the case of developing countries, anyhow. Trials on the impact of such interventions showed that they had little effect in reducing HIV transmission and some of them may have even increased the risks of non-sexual transmission for participants.

Pisani is right about abstinence not working very well but she failed to influence attitudes towards that 'strategy' when she was working at UNAIDS. But now that she's a rebel, working at the London School of Hygiene and Tropical Medicine, that bastion of public health reaction, going along with the HIV industry line that almost all HIV transmission in African countries results from heterosexual sex is unlikely to change things much.

Again, Pisani is right that the 'all men are evil, all women are innocent' reflex is not helpful and never has been. But she fails to mention the extent to which women are affected by HIV in comparison to men. Overall in Africa, in excess of 60% of HIV positive people are women and among young people, the figure is in excess of 70%. HIV prevention activity has failed to address that and the industry seems oblivious to it.

Pisani still holds her stigmatizing view of HIV transmission as being a matter of promiscuity, which it is not, and never has been. Data about sexual behavior, such as it is, shows that those who are infected with HIV often faced lower sexual risk than many who were not infected and some who took precautions were even more likely to be infected than some who did not. The idea that HIV is mainly about sex is unsupported by evidence, but still the mainstream view.

Treatment as prevention, we are told, is not the answer to ending HIV transmission. But anyone who thinks the strategy will address the needs of any more than a small subset of people has been brainwashed, anyway. But this is not an argument against expanding the number of people receiving treatment. So far, so good.

The author of the Wisdom of Whores, surprisingly, admits that she doesn't know what is the best approach to HIV prevention in sub-Saharan Africa. And she seems to have some intuition that incidence, the yearly rate of new infections, might rise. Unfortunately, we are not told what is behind this intuition so it's hard to say if it's one of her good ones or one of her not so good ones.

Ultimately, Pisani doesn't touch on the great elephant in the UNAIDS room: why a virus that is difficult to transmit heterosexually is said to be almost always transmitted heterosexually, but only in Africa, where sexual behavior is little different from that in many other places. She has never justified the highly stigmatizing title of her book, nor the attitude towards Africans which has had, and continues to have, so much influence on HIV policy.

Indeed, Pisani is one of the people behind the kind of dubious research and mathematical modelling that so much current HIV thinking is based on. The claim that HIV is mainly transmitted sexually in African countries, and hardly ever transmitted through non-sexual modes, is supported by the flimisiest evidence, at best. Until this massive flaw in mainstream HIV thinking is revised, prevention efforts will continue to have little impact on epidemics.


Sunday, June 5, 2011

The Myth about HIV and Sex: 30 Years in the Making

Today marks the 30th anniversary of the discovery of HIV. When the virus was discovered, it was still being transmitted rapidly in high prevalence countries, mostly in Africa. But over the ten years or so following its discovery, transmission declined, even in high prevalence countries. In Kenya, incidence peaked in the early to mid 1990s, almost a decade before the government even admitted that there was a HIV epidemic there.

Similar patterns are found in other countries. HIV incidence peaked before most people had even heard of the virus, many years before in most countries in Africa. So why did the virus decline? Because people who had spontaneously begun to have outrageous amounts of sex in the late 1970s and early 1980s, just as spontaneously ceased to have such outrageous amounts of sex in the late 1980s and early 1990s, and that trend continued up to the present?

That's what the HIV industry would have you believe, anyhow. For them, something like that story is true, although they don't ask why people would suddenly and profoundly change their sexual habits twice in the space of less than 20 years. And they don't allude to the fact that incidence, the yearly rate of new infections, peaked and declined long before mass HIV 'prevention' campaigns even started.

Thirty years ago, it was still permissble to talk about there being several ways for HIV to be transmitted, especially in a rich country context. After all, it was hardly ever transmitted through heterosexual sex in rich countries and it is even less so now. In rich countries, HIV was always transmitted mainly through men having sex with men and intravenous drug use. But talk of non-sexual transmission has declined significantly over the last 30 years.

In African countries, HIV was first noticed to reach massive levels in sex worker populations. In Kenya, prevalence is said to have reached over 80%, in Tanzania, over 70%. And this is in populations where hardly any men were infected. The fact that these ridiculous and completely unacceptable levels were found in sex workers who had been put through sexually transmitted infection (STI) programs has since been conveniently ignored. As I said, talk about such things has declined.

Fingers have been pointed, but in rich countries those fingers were pointed at men who have sex with men and intravenous drug users. Sex workers were also implicated but it's hard to see why because HIV rates were always low, except among sex workers who were also intravenous drug users.

But in African countries, fingers were pointed at men who have sex with men, commercial sex workers, truckers, soldiers, police, prisoners, internal migrants, migrant workers, internally displaced persons, fishing populations, those who engage in 'cultural practices' (such as wife inheritance, ritual cleansing, etc), teachers, 'sugar daddies', clients of commercial sex workers, partners of men who have sex with men, uncircumcised men, circumcised women, polygamists, bigamists, alcohol users, khat chewers, (non-injecting) drug users, sex tourists, Ugandans, young women and girls, older men who marry younger women, and the list goes on.

Most of these groups are still considered to be 'most at risk' populations or 'MARP'. And yet, modes of transmission surveys show that in African countries, the biggest groups of HIV positive people engage in low risk sex. Those surveys completely ignore the fact that many HIV positive people don't engage in sex at all, or hardly at all, those who take precautions are often more likely to be infected than those who do not and various other details which don't fit into the picture of the sexually animalistic African that UNAIDS has built up over the years.

UNAIDS often bandies about authoritative sounding figures, such as that 80% (sometimes even 90%) of HIV in some African countries is heterosexually transmitted. But it's interesting to see what these modes of transmission surveys are based on. There is an oft cited article that seems to have a disproportionate influence on HIV policy documents by Eleanor Gouws and others but this is based on a simplistic piece of mathematical modelling with some highly questionable figures.

If you don't believe that the mathematical model is simplistic and that the figures are questionable, you can download it and play around with it. You might be struck by the transmission probability per risky exposure act, for example. The risk for sex workers is dubious, but the risk for clients, at half the risk for sex workers, is even more so. And the risk for clients' partners is the same as that for sex workers, as is that of various other groups.

The risk for casual heterosexual sex, partners of those who engage in casual heterosexual sex and low-risk heterosexual sex is questionable enough as well. And only 10% of the population are deemed to have no risk from their sexual behavior. That's in African populations, of course! As I've said, heterosexual sex poses little or no risk to people outside of a few African countries, even in certain parts of some high prevalence African countries (such as Zanzibar and Kenya's North Eastern Province, where prevalence is lower than in a lot of US cities).

But the most laughable parts of the model relate to risks from unsafe medical injections and blood transfusions. Gouws estimated these risks to be very low, contributing less than 1% of all infections. UNAIDS ups that figure to a little over 2% when you add unsafe injections and unsafe blood transfusions together. However, this ignores any other kind of medical risk, such as from contaminated gloves, instruments and machinery of various kinds in sub-standard hospitals, wielded by poorly trained, underequipped personnel. (You can try plugging in some of the figures from here, or just make some up. UNAIDS did.)

Anyhow, the transmission probability per risky exposure act for these two items is absurd. You can try the model with a more reasonable value, even if it's just the figure for injecting drug use, and you get a far more credible estimate for the contribution of unsafe healthcare including, but not limited to, unsterile injections. And if you change the number of injections per year to something more reasonable you will also see the contribution of these non-sexual transmission modes rocketing up.

Looking at figures provided by the Kenyan Demographic and Health Survey (or the Tanzanian one, or that for many other African countries) you would be forgiven for thinking that females tend to become infected first and later infect their male partners. Far more females are infected than males, they are infected at earlier ages and rates exceed rates for males until many years of sexual activity have passed. In some population groups the number of females infected can exceed the number of males infected by 4 or 5 to one.

Does this mean that HIV is not almost always heterosexually transmitted? Certainly not. Nor does it mean that non-sexual transmission, such as through unsafe healthcare, is high, let alone higher than heterosexual transmission. It means that we don't have the faintest idea how high non-sexual HIV transmission is, relative to heterosexual transmission. And if you are puzzled at the fact that HIV prevalence is highest among young heterosexual women in a few African countries, and virtually nowhere else in the world, then you are awake (and almost certainly not working for UNAIDS or any of the HIV industry).

And yet, not only are men who have sex with men and intravenous drug users hardly ever targeted in high prevalence countries, but sex workers are not even targeted consistently in most. 'Prevention' spending represents less than 25% of HIV spending in countries like Kenya. How much less is unclear because about 80% of that is spent on unspecified prevention activities. In other words, no one has a clue what it's being spent on and they probably don't care  Even youth are not a particularly lucky group, receiving only about 5% of prevention spending. And that shows. Over 70% of infected youth in African countries are females.

And who infects them? Well, if 80% (or 90%) of transmission is heterosexual, men, of course. But which men? UNAIDS and the HIV industry can't say. Give them another thirty years of highly distorting funding and they may modify their answer. Some patterns may be consistent with HIV being sexually transmitted, but this does not mean that it always is. And some patterns are consistent with HIV being transmitted in STI clinics and other medical facilities.

But read around the data on non-sexual HIV transmission, especially unsterile injections, and you'll find that there is "Very little information on injections safety" and that it is "hard to get baselines". In fact, there is "no data about the quality of service provision". This is also a good time to look at the latest Service Provision Assessment for Kenya, which won't tell you as much about quality as it does about quantity.

The Modes of Transmission conclusion about service provision is brief, but telling: "in the future, Kenya will have to spend more time and effort analysing and assessing the quality of services provided – providing a bad service (particularly in the sensitive areas of sexual behaviour) may be worse than not providing a service at all."

What could this mean? Could it mean that the many people who do not have access to any health facilities might thereby be avoiding infection with HIV, hepatitis and various other diseases? Could it mean that people who get large numbers of injections in STI clinics every year, for STIs, hormonal contraception, etc, might face a high risk of HIV and other infection there?

HIV prevalence figures in both Kenya and Tanzania tend to be lower in areas where people have little or no access to healthcare. Unprotected sex tends to be more common in those areas. It doesn't take a genius to work out that HIV is not all about sex, but also that it could have an awful lot to do with unsafe healthcare. If even UNAIDS could inadvertently come to that conclusion, anyone can. But now it's time for UNAIDS to do what they have avoided doing for so many years: empirical research into the relative contribution of non-sexual HIV transmission in high HIV prevalence countries.


Saturday, June 4, 2011

Gates Wants to do for International Development what he did for Software

Continuing the theme of copying drug pushers' trick of giving away free drugs to get people hooked, the Gates Foundation has been at it again. They actually boast about 'giving' farmers free 'drought tolerant' maize seeds. Well, firstly, drought tolerant maize doesn't work and secondly, giving someone genetically modified organisms (GMO) is like giving someone HIV. They will risk giving it to others before they realize they are infected and they will not be able to get rid of it.

That may sound a bit harsh, especially to those who think that people like Gates is doing a great job in Africa, looking after agriculture, health, education and just about everything else. But GMOs are not, despite claims to the contrary, sustainable. If the farmer falls for the Foundation's lies, they may be stupid enough to start buying this contaminated maize seed. But they will find that yields are no higher than before and the costs are higher, the costs of the seed, the fertilizer and the pesticides. And the costs increase rapidly so that in a few years, profits will be far lower than the farmer is used to.

An article that purports to be written by a small scale Kenyan farmer, but is in fact by a Gates (Alliance for a Green Revolution in Africa or AGRA) employee who has a bit of land, talks about small farmers being the future. But GMOs are not appropriate for the sort of small farmer than make up 70-80% of African farmers, those with a few acres of land, at the most. These small farmers will disappear because Gates model involves farms that are large enough to be mechanized, at least to some extent.

Apparently Gates is aware that the majority of farmers will go out of business and end up unemployed in cities, but so far he hasn't found a way of exploiting them. Not that he has mentioned, anyhow. I'm sure he'll let us know when he thinks of one.

This Gates employee also bemoans the fact that he couldn't find the right type of seed for local conditions. This is ironic because most GMOs are one size fits all, a complete removal or all crop diversity, the opposite to what African farmers need. And world seed markets are almost all sewn up by a handful of multinationals who also happen to be the biggest proponents of GMO. Nor is it a coincidence that these multinationals work closely with the Gates Foundation.

The Foundation claims that it has invested millions in seed research but that it places very little emphasis on GMOs. What they place emphasis on is any kind of proprietary product, as opposed to the system many farmers use of selecting a good stock of seeds from each year's crop. The Foundation's work may or may not involve genetic modification but the effect on the farmer is the same, it impoverishes them. And the Foundation has invested a lot in GMOs, they just seem to be a bit ashamed of it.

The so-called 'golden' rice is an example. It doesn't work, it's expensive, but it's just the kind of dirty trick that the Gates Foundation enjoys, probably something they picked up from the Microsoft Corporation. The Foundation has a similar model for health. That's pills and vaccines for everything when basic healthcare, clean water and improved sanitation, good nutrition and better living conditions would do far more for people than all the technical fixes in creation.

Gates has spent a lot of money showing that he knows nothing about development, health, agriculture or, indeed, democracy. His intention appears to be to render these fields into his own model of how they should be, that is, dominated by technology that is wielded by a few rich multinationals. Frequently Gates, the Foundation or one of their mouthpieces rants on about education or lack of education and the plan seems to be to 'educate' people, by telling them all about how great the world will be if people would just think like him, it or them.

There is a sense in which Gates wants to do for international development what he did for software. And the important thing is whether you think that's great or whether you think that's a disaster. I think it's a disaster.


Thursday, June 2, 2011

Syngenta Dumps Upriver, Sells Fertilizer Downriver

If you are one of the biggest seed and agrochemical multinationals in the world, you might have enough confidence in your products to launch them on the market without trying to get people 'hooked' on them, right? But if you know that the only way to get your merchandise 'accepted' is to create some kind of dependency before people even know what's going on, you might stoop to any trick.

Well, in the case of Syngenta and their genetically modified organisms (GMO), it is clearly not in the interest of poor farmers to buy seeds that are more expensive, give a similar or lower return and involve significant increases in more expensive agricultural inputs, in addition to degrading the environment and resulting in the loss of sales to countries that don't buy GMOs.

Syngenta is one of the biggest seed companies in the world. Along with Monsanto, DuPont and Limagrain, they control over 50% of the seed market. It is also one of the biggest agrochemical companies in the world. Along with DuPont, Monsanto, Dow, Bayer and BASF, they control 75% of the market.

So it's easy to see why Syngenta don't expect people to buy their seeds without some 'sweetners'. In Kenya the Syngenta Foundation, itself a non-profit, but wholly funded by the organisation that benefits directly from its dirty work, has found it expedient to sell seeds that come with built in insurance.

Officially, commercial GMO agriculture does not even exist in Kenya. But the Syngenta Foundation has, apparently, tricked 12,000 farmers into buying their seeds and they hope to recruit another 50,000 additional suckers. They have even given the scheme a nice Kiswahili name, Kilimo Salama (Safe Farming).

A good drug pusher would be proud of the scheme. When the farmer buys the seeds, they also get insurance, so if there is too much rain, too little rain, to many pests or conditions are otherwise inclement, the farmer is eligible for compensation. Conditions are monitored remotely in GMO contaminated areas so no money will be wasted on assessing individual circumstances.

Once a farmer buys GMO seeds, they need to buy the seed manufacturer's inputs, such as pesticides. As the pesticides cease to work, as they have done everywhere else, the farmer needs to purchase them in larger and larger quantities. These pesticides are already more expensive than other products, but other products don't work at all with GMOs. And once the manufacturer's pesticides are completely useless, they can sell you an 'improved' version, which is even more expensive, and you can start the vicious cycle all over again.

GM cotton, which is now common in India, was introduced by such trickery, before it was even legal to grow it. Having been introduced by the back door, the claim was that most of the country's crop was contaminated, so there was little point in opposing it. It was a done deal, supposedly. India has spent the years that have followed regretting that they went down the GMO path in the first place. But it is unlikely they will ever be able to reverse the process now.

GM contaminated maize has also been surreptiously brought into Kenya. Someone knew, of course, but it wasn't done legally. The maize was legitimately imported from South Africa, as far as the vendor was concerned. The shipment was not certified GMO free, but nor was such certification sought. Some of that maize may have remained in the port, it's hard to find out, but GM contaminated maize is apparently now common in Kenya. Is GMO now a done deal in Kenya, before most of the public have even been armed with impartial information about what they are getting themselves into?

This doesn't seem to be the behavior of a multinational that has confidence in its products or that has the interests of Kenyans at heart. The country may have gone through the motions of creating the legislative framework, but no one would claim that Kenya is in any position to monitor GMO contamination, let alone commercial production of GMOs. But that's the way multinationals like Syngenta operate. It's also unlikely that Kenya is the only African country to have suffered this fate.

It shouldn't take long before people in Kenya start to notice some of the disadvantages of taking the Syngenta shilling. Those who farm close to where GMOs are grown will soon be growing GMO contaminated crops. Contamination is inevitable, through wind, water, soil movement, crop proximity, seed swapping, etc. And even those who grow GMOs and then revert to conventional seeds will also end up with contaminated crops. And the seed owner, because the farmer is not the seed owner, will be entitled to make claims against the farmers for patent infringement. Notice, they are not selling insurance against patent infringement or contamination!


Wednesday, June 1, 2011

Biofuels: Stealing Land to Steal Food and Water from Africa

Western countries wring their hands and rush for their mobile phones to pledge money to whatever catastrophe happens to be fashionable enough to attract the attentions of some brainless celebrity. But they are not so interested when it's a matter of stopping their country from causing the next catastrophe.

Eight million Kenyans (out of a total of about 40 million) are currently short of food. They are not short of food because there isn't enough of it. They just can't afford the food that is produced in their own country. Europeans can afford to buy agricultural products that are grown in Kenya, even though they produce so much in Europe they have to dump a lot of it, sometimes in Kenya.

A number of factors have driven up the cost of basic foods in recent years. Food has been treated as a commodity that can be played with by speculators. Costs of agricultural inputs have become more and more under the control of a few multinationals. And rich countries have been buying up land in developing countries for a song so that biofuel crops destined for these rich countries can be grown there.

Despite what the landgrabbers say, they are not paying fair compensation for the land, the land is not marginal (if it was it would be of no use to them), the land is not unoccupied, nor virtually so, and large numbers of people are not being employed in producing biofuels. Nor is there any environmental payoff. In fact, environmental destruction on a massive scale is often required before these vast tracts of land can be used to produce biofuels, causing even more environmental damage.

According to an article in the English Guardian, British firms have been grabbing more land than any other country. This contrasts with their recent boasts about how they have increased aid spending and even improved the quality of foreign aid. Aid spending is a piffling amount compared to what can be extracted through biofuel and other forms of exploitation.

In addition to competing for land and water, and thus increasing the price of food, the type of farming involved is totally disempowering to local communities. Where once many families subsisted, now none do. Where once whole communities were employed, now a mere handful are. Instead of relatively harmless practices that allowed a healthy ecosystem to remain, biofuel production will destroy everything in its path, irreversibly.

It would be useful to contrast these disadvantages with some advantages, but there are none for the poor farmer. Whatever advantages there are accrue to the landgrabber alone. They are coming up with fancy brochures to impress investors but this is just the usual rose tinted excrescence that goes with foreign exploitation of all African resources, gold, uranium and other minerals, sugar, coffee, cocoa, anything that can be produced cheaply without those profiting having to leave much behind in the form of tax, royalties, skills, assets or even investment.

The last thing African countries need is to lose their rights to their land and water, given that these are among the means of production for food, to feed themselves and to export. Coupled with the current threat of genetically modified organisms (GMO) being imposed on the continent, rates of poverty, dispossession, endemic disease and starvation are only going to increase.

Not content with making our fat asses fatter, we're proposing burning the potential for growing food in our cars, at the expense of people who are dying for lack of food and water. So we needn't see ourselves as being so generous whenever another disaster hits the news, considering we're happy to allow even greater disasters to occur just so we can fulfil our consumerist dreams. There is enough food, but not if we use it all up on power games and car fuel.