Thursday, September 29, 2011

HIV Concurrency Theory is Dead; Can't You Smell it Yet?

In their desperation to explain why HIV prevalence is extremely high in African countries, hundreds of times higher than it is in many other countries, UNAIDS have flailed around and grabbed at any new theory that came their way. One of those theories was that overlapping sexual partnerships are responsible for levels of transmission that cannot be explained by any scientific data that is currently available. This is called the 'concurrency' hypothesis.

There remained the problem of showing that concurrency was exceptionally high in areas where HIV prevalence was high. This is still a problem and strong correlations between concurrency and HIV prevalence, even weak ones, have yet to be identified. But a more acute problem was the question of whether high rates of concurrency really would result in high rates of HIV transmission; is concurrency "especially effective in spreading HIV". The answer is 'no'.

Larry Sawers, Alan Isaac and Eileen Stillwaggon used a modified version of the mathematical model and data used by earlier researchers and added in an element that was missing from earlier work; 'coital dilution'. If someone has many partners, they have less sex per partner, on average. They found that, even with very high levels of concurrency, higher than those found in any population, once you add in slightly lower levels of coital frequency, the result is 'epidemic extinction'.

The orthodox view that Africans have inordinate amounts of sex, and inordinate amounts are required to explain massive HIV epidemics found in some African countries, is not supported by logical or empirical evidence. Only simulation models that use non-empirical evidence, or a very selective use of evidence, can 'explain' very high levels of heterosexual HIV transmission. And models that do use empirical evidence show that the orthodox view is wrong.

The authors conclude that "concurrency cannot be an important driver of HIV epidemics in subSaharan Africa. Alternative explanations for HIV epidemics in sub-Saharan Africa are needed." The concept of coital dilution even explains why "polygyny appears to protect populations from HIV", though UNAIDS often cite polygyny as a risk factor in the spread of HIV (note, this is not an argument for the promotion of polygyny, just one showing that it does not contribute significantly to HIV epidemics in Africa).

Indeed, other phenomena cited as factors that increase the spread of HIV are also put into perspective in this paper. Mobile populations, migrants, especially internal and temporary migrants have often been targeted by HIV campaigns. High rates of HIV in, for example, mining populations, were said to be a result of the sexual behavior of those infected. In the light of this research, miners are more likely to have been infected through shoddy health care practices provided by mine owners, who tend to score very badly in the field of corporate social responsibility.

The graphic depictions of epidemics driven by heterosexual sex alone becoming extinct are fascinating and I recommend the article. But there are other questions that were in need of answering before these researchers did this piece of work: why does the orthodox view of HIV, promulgated by UNAIDS and most of the other wealthy HIV institutions, fly in the face of evidence? And how can a view that is so inherently racist be accepted by so many?

But there's no point in wringing our hands in despair now that we know we have spent such a long time and so much money barking up the wrong tree. What are the 'alternative explanations' that these researchers suggest are needed? Eileen Stillwaggon herself has a whole set of suggestions, after all, why should there only be one way to reduce HIV transmission?

Plenty of other suggestions can be found on the Don't Get Stuck With HIV website, which looks at medical and cosmetic risks for HIV transmission. But at least we don't have to subscribe to the orthodox view of Africans as mere victims of their own stupidity, unsafe sexual behavior and lack of consideration for those around them, including their closest friends and relations.


Tuesday, September 27, 2011

Wangari Maathai's Awkward Questions About HIV Still Unanswered

Many have mourned the death of Wangari Maathai, a great Kenyan woman. But, while she was best known for her environmental advocacy, I would like to note her alleged unorthodox view of HIV. I don't agree with the views that have been attributed to her, but I can understand how confusion might arise about why Africans are so disproportionately affected by the virus. And I applaud anyone for refusing to accept an orthodoxy so logically obtuse and so gratuitously offensive to Africans, and even to women, who are infected in far higher numbers than men.

Maathai is said to have claimed that HIV was deliberately created by Western scientists in order to harm Africans, perhaps to reduce the population. However, Maathi denied that she believes anything like this and expressed a wish that the source of HIV would be discovered, so that such claims could be rejected.

However, the HIV industry expounds two theories of how HIV epidemics occur. The first theory is for non-Africans, at least, for Western countries; HIV is mainly transmitted through male to male anal sex and through intravenous drug use.

The second theory is for HIV epidemics in African countries, regardless of whether they are very serious or whether they are no more serious than those found in many US cities. According to the second theory, 80 to 90% of HIV transmission is through heterosexual sex and almost all other transmissions are accounted for by mother to child transmission.

The problem with having two theories is that there is only one virus. And while HIV really can be transmitted through heterosexual sex, it hardly ever is outside of some sub-Saharan African countries. What is it about heterosexual sex in some African countries that could account for rates of transmission not found elsewhere?

Well, as it happens, such rates of transmission have been found elsewhere. Massive rates of HIV transmission occurred in Romania in the 1980s and in various other countries at different stages in the pandemic, Russia, China, Kazakhstan, Libya, etc. But these appalling rates were only found to have occurred through non-sexual transmission. They resulted from use of contaminated blood products and medical instruments.

When Maathai was later asked about her views on AIDS, she gave a rather cryptic answer. She said "I have always thought that it is important to tell people the truth, but I guess there is some truth that must not be too exposed." Perhaps Maathai realizes that the HIV industry is aware that HIV is unlikely to be transmitted through heterosexual sex, but that it is very likely to be transmitted through unsafe healthcare?

UNAIDS insists that a very small percentage of HIV is transmitted through unsafe healthcare in African countries. But they also advise UN employees that:

"We in the UN system are unlikely to become infected [with HIV through contaminated blood] since the UN-system medical services take all the necessary precautions and use only new or sterilized equipment. Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere."

In other words, the UN is well aware that unsafe healthcare is a risk outside of 'UN approved' facilities. But they only tell UN employees, and not Africans. With that in mind, the racist 'highly-sexed African' theory is no longer required to explain why HIV prevalence reaches such incredible levels in some African countries. Perhaps the prejudice is just too media friendly to give up.

Maathai admits that she is not an expert on HIV, but she is not satisfied with the orthodox view (or views), perhaps because that requires one to see Africans as barely human in their sexual relationships, in their family lives, even in their broader social relationships.

As the HIV expert, Dr David Gisselquist has cogently argued (in personal correspondence): "If the virus were different in Africa, wouldn't we be afraid it [would] get on a plane and come to the US/EU? But we are not afraid - which is a dead giveaway that we know whatever is causing Africa's epidemics is something that stays in Africa."

What 'stays in Africa' is unsafe healthcare services, whose potential role in the worst HIV epidemics still needs to be investigated 30 years into the HIV pandemic. Some HIV transmission could be stopped in its tracks, perhaps a large amount of transmission. Maathai questioned the orthodoxy and was rubbished for doing so. But the HIV industry still needs to answer the question.


Monday, September 26, 2011

Why Would Anyone Want a HIV Test, Given the HIV Industry's Prejudice?

There may be some confusion about HIV testing in Kenya at the moment because some news sources are not too careful about saying whether the 40% figure for people never tested is only for adults or whether it's for the whole population. It's likely that the figure is for adults, but it's also likely to be exaggerated. Some people are bound to test more than once and Kenyan facilities may not be able to link multiple tests by one person.

But another confusion could arise about whether people will be 'requested' to be tested every time they visit a health facility or 'required' to do so. The article above cites someone who is advocating for testing to be requested. But an article in the Nairobi Star says everyone visiting their doctor will be required to be tested, which is quite a different matter.

According to an article in, the situation is actually far more serious than the above two articles would have us believe. It cites findings that only 20% or fewer HIV positive people know their status and that at least 50% have never been tested. AidsMap also reveals that HIV prevalence in Kenya has barely changed in the last 10 years, standing at about 7%, despite the level of resources going to treatment and, to a far lesser extent, prevention.

There's a more sober account of HIV testing in Kenya in The Lancet, published less than a year ago. According to this article, the plan was to have 80% of all Kenyans tested by the end of 2010. But the highest they have ever achieved is a few million people per year. And such huge scale programs are challenging, particularly in a country with crumbling health services.

The article makes it clear that there is a big difference between 'requiring' that people be tested and 'requesting' that they do so; the rights of people to choose whether to test are not guaranteed. Nor is the safety of those found to be HIV positive. Given current levels of stigma associated with HIV, it's still very dangerous to inform your partner about your status. Not only are you more likely to test first if you are a woman, you are also far more likely to be infected than your partner.

More HIV testing and then what? If there were support services for people found to be HIV positive, more testing might be a good way of ensuring that the right people get the services. But many people are tested and receivenothing. And as a result of the HIV industry's highly stigmatizing attitude towards HIV among Africans, people found to be positive are likely to be the victims of abuse, persecution and even death.

People who agree to be tested for any disease have legitimate expectations and those trying to persuade them to be tested need to address these expectations. You won't persuade people to be tested if they know that little of benefit and possibly a lot of abuse is awaiting them. So, given that HIV is not just transmitted sexually, we need to stop telling people that it is.

The message the HIV industry is giving may be dressed up in a lot of sweet words, but it sounds like this: 'this person is a HIV positive African, therefore there is an 80% probability that they were infected sexually, or else they were infected by their mother, so they are a slut or a philanderer or in some other way immoral, but we don't stigmatize them at all for that and neither should you'.

Whether HIV testing is compulsory, as one article says, or merely requested, the problem is that people will still risk victimization if they are found to be HIV positive. Stigma does not arise, as Peter Cherotich of the Kenyan Aids Control Program claims, because HIV testing has been voluntary up to now. It arises because HIV 'prevention' programs insist, falsely, that most HIV transmission in African countries is through heterosexual sex. Changing that message may not have an immediate impact on levels of stigma, which could take decades to efffect. But it's a start.


Saturday, September 24, 2011

Why Fabricate HIV Data When You've Got the Real Thing?

In the Kenyan Modes of Transmission Survey, which purports to estimate the relative contribution of each HIV transmission mode, the guesstimate for the contribution of men having sex with men is lumped in with a figure that is said to include prison populations.

This is a ridiculous way of estimating the contribution of these different modes of transmission in particular, though the entire document is unlikely to have any verifiable figures. But, as not all men who have sex with men are in prison, not all prisoners have sex with men and not all HIV transmission, especially in prisons, is transmitted sexually, it's difficult to understand why some well paid consultants even bothered to produce the document.

So when you come across an article entitled "Same Sex Hindering HIV Fight in Prisons", you might wonder where they get their figures from. We are promised a reduction in HIV transmission rates because the prisons are introducing 'counselling'. But will the counsellors inform prisoners and prison staff about non-sexual as well as sexual risks? HIV 'prevention' activities tend not to do so.

In a prison, you don't always have that much option about what kind of health care services you receive. It seems unlikely that you will meet with much sympathy if you complain that services don't include sterile procedures. Equally, you are unlikely to be able to choose who shaves your head, how sterile the instruments are or how careful the hairdresser is.

In fact, given the lack of attention to non-sexual HIV transmission through unsterile health care and cosmetic services, it is unlikely that many prisoners would even notice or be aware of the risks they are facing every time they go to the clinic or the barber's. It's as unlikely as non-prisoners knowing such things.

Also, tattooing is said to be very popular in some prisons, as are other forms of body art that involve breaking the skin. Instruments for tattooing and other skin piercing activities are not easy to come by, nor are materials for making paint. This means that they are likely to be reused, perhaps even sold to others.

Drug taking and various forms of traditional medicine, rituals and oath taking may also contribute to the many risks. The extent of male to male sex is not clear. But it is unlikely to represent anywhere near the highest risk of transmitting HIV and other blood-borne viruses in prisons.

Interestingly, Kenya's prison population is given as just over 50,000, which is not inordinately high for a country of more than 40 million people. And HIV rates are said to be less than 7% in prisons, which is about average for the country as a whole. Bear in mind, though, HIV prevalence in Kenya and other high prevalence countries is usually far higher among females, whereas most prisoners are male.

The rates, then, are higher than among Kenyan males, but the figure doesn't seem in any way extraordinary. In fact, it is low enough to make you wonder if male to male sex really does happen a lot in prisons. After all, it seems unlikely that the prisoners have access to safe sex counselling or to condoms.

But the Modes of Transmission Survey is a highly deceptive document. The figures try to make the case for blaming most HIV transmission on individual sexual behavior. Yet there is a body of evidence that a substantial percentage of HIV transmission is not through sexual behavior. Far more likely modes of transmission are unsafe medical and cosmetic services.

Therefore, HIV prevention efforts need to be directed more towards the real causes of its spread, not those imagined by the HIV industry. It's time to stop playing with mathematical models that use manufactured data and produce some real data on HIV transmission in Kenya.


Wednesday, September 21, 2011

Let Us Give Up Our Anti-Gay Prejudice, But Not Just Yet

If the blood transfusion services are not able to screen blood that may be contaminated with HIV and other blood-borne viruses, why just ban gay men from donating blood? What about people who face other sexual risks? And what about people who face non-sexual risks, for example, those who receive health care or cosmetic servicesthat may not be 100% safe?
Another question that this issue raises is about how well the blood transfusion service can assess risk if they will not allow a donor to donate blood even if they are practicing safe sex. Are these health professionals telling us that safe sex is not really safe, or that it’s not safe enough? Or are they just telling us that they can’t really guarantee the safety of the blood? Are the donors even safe?
But nothing was mentioned about the risks people could face if they went to a dental clinic, a hospital, a tattoo parlor or even a hairdressing salon. Half a million people descended on a few South African cities, the country with the highest number of HIV positive people in the world, and no mention was made of the most serious HIV risks that exist.
Of course, many people from Western countries travelling to African countries get advice from guide books, embassies, travel shops and travel agencies. But these don’t usually extend to cosmetic services. Should the UK also ban blood donations from foreigners, travellers, migrant workers and others suspected of falling into one of these groups? Or perhaps they would settle for a 12 month deferral period for them, too?
One commentator points out that HIV is not purely transmitted by men having sex with men. This is true, a small percentage of people infected in the UK are not gay and/or not male. And a large percentage are infected through intravenous drug use. But more importantly, HIV is not purely transmitted through sex; it is not just a sexually transmitted disease.
HIV risk is not confined to sexual risk. And while health and cosmetic services in Western countries are far less likely to use contaminated instruments now, compared to in the 1980s, the very fact that people still see HIV as an STD is worrying. It means that they will not recognize serious risks when faced with them, nor will they know how to avoid them.
Health providers have a duty to inform people fully about sexual and non-sexual risks and how to avoid them. A selective ban, partial or otherwise, on those felt to be ‘most at risk’ represents a failure to give people comprehensive advice about all types of risk and leads to a piecemeal and, as it happens, stigmatizing health policy.


Monday, September 19, 2011

Bjorn Lomborg and a Bunch of Economists to Eradicate HIV?

When environmentalist reactionaries like Bjorn Lomborg use words such as 'rethink', I become suspicious. For him, rethinking climate change was to sell consultancy to some of the biggest contributors to global warming. So when he uses the word in relation to the subject of HIV, please be aware that he is probably lying, but for good money, of course.

Firstly, Lomborg claims that "Alongside [various technical] advances, policymakers, human-rights advocates, and people living with HIV/AIDS have fought hard to reduce stigma and discrimination." This is not quite true. Some groups have fought to reduce stigma and discrimination. Others have fought hard to appear to fight them, while busily ensuring that both phenomena spread and grow faster than the virus itself.

Among those working hard to spread stigma and discrimination are UNAIDS, who never miss an opportunity to point to 'African' sexual behavior as the explanation for all the most serious HIV epidemics in the world. While ranting about how terrible stigma is, they deny the significance of any modes of transmission aside from heterosexual sex in African countries, though not in non-African countries.

Following in their footsteps are the media, who love an opportunity to write about sex, especially sex that they can paint as deviant or 'other'. Nudge, nudge, it's Africans, we all know about their sex lives, don't we. Religious and political leaders have never been far behind when it comes to sticking the knife in. Sadly, most African leaders have shown little enthusiasm for questioning the orthodoxy either.

Lomborg is also wrong about the "unprecedented amount of funds [being] invested in HIV treatment and prevention." Relatively small amounts of money have been invested in HIV prevention and most of that was frittered away on finger-wagging exercises about Africans' assumed sexual behavior. Treatment, on the other hand, is worth a lot of money. That's why a lot has been spent on it; but the bulk of that has gone into the pockets of Western multinationals, particularly pharmaceutical companies.

Lomborg's pronouncements on HIV are self-serving, much like his pronounements on the environment. And while he may be an expert on the environment, he is not an expert on HIV or any subject he happens to get paid for pontificating about. Yet his "Copenhagen Concensus Center" is going to get a lot of other like-minded academics and 'experts' to 'solve' some of the worst global problems that we currently face.

One of these global problems is HIV, which Lomborg is going to sort out by getting together five economists. Given how badly the global fight against HIV is going up to now, it probably wouldn't matter whether the experts were economists or basket weavers, but economists don't exactly have a great reputation for sorting out economic problems, let alone viral pandemics.

Lomborg's RethinkHIV could be better named because it's a lot more about regurgitating platitudes, recycling 'learned pronouncements' and, more to the point, trying to ensure that the billions that have poured into the pockets of wealthy institutions continues to increase. You'll notice that the only thing bold about the website is the typeface.

They have even partnered with a charitable body called the Rush Foundation, which funds 'disruptive ideas against HIV'. Even their buzzword sounds like something that died in the 1990s. But despite all the rhetoric about "stimulating urgent policy debate outside the existing frameworks and push[ing] thought leaders to think the unthinkable to address the pandemic", their only idea is to produce more drugs (just like Bill Gates and his foundation).

Here's a bit of a 'disruptive' idea for Lomborg and his friends: HIV transmission in African countries is not just about sexual behavior, so check out some of the other modes of transmission. If you really want to end HIV related stigma, try to think of Africans as humans, especially when it comes to sexual behavior. And don't listen to UNAIDS; they haven't a clue. Heterosexual sex does not fully explain the massive HIV epidemics found in some African countries; but non-sexual transmission might help to do so.

Rethinking HIV means challenging the orthodoxy, not compounding it with more of the same. So if there is any thinking to be done, some of the most vocal exponents of the orthodoxy need to be replaced by people who still know how to articulate disagreement with the mainstream, regardless of their discipline. Somehow, I don't think Lomborg or the cronies he selects will fall into this category, Nobel prizes notwithstanding.


Sunday, September 18, 2011

Institutional Racism Rules at UNAIDS

The belief that generalized HIV epidemics, such as those found in some sub-Saharan African countries, originate from and are driven by extremely high levels of 'unsafe' sexual behavior has always been undermined by a number of considerations. (Generalized epidemics are those where a significant proportion of the general population is infected, rather than members of high risk groups, for example, men who have sex with men and intravenous drug users).

Sexual behavior is not that different in countries with high and low HIV prevalence; levels of 'unsafe' sex would need to be higher that is possible for human beings to explain prevalence that is substantially greater than 1% of the sexually active population; and there has been no recorded massive increase in 'unsafe' sexual behavior in countries that experienced the worst epidemics, followed by a massive decrease in the same behavior a few years later.

These are embarrassments to the HIV industry, which has been pushing this theory, sometimes called the behavioral paradigm, for more than twenty years. But there is a far better set of factors that have been little studied, though enough to see that they shed far more light on rapid transmission of a virus that is difficult to transmit sexually.

Amongst these factors is blood transfusion. When it was realized that transfusion of blood and use of blood products was one of the most significant modes of HIV transmission in the 1980s, many countries made requisite changes in their health services. But countries with low (and falling) health spending often didn't make these changes, or only did so partially.

In 2006, William H. Schneider and Ernest Drucker published a fascinating history of the use of blood transfusions in Africa and their possible contribution to the HIV pandemic, particularly in its early years. They estimate that "approximately 20 million transfusions [were] done in sub-Saharan Africa during the 1980s" and that "30 to 40 million transfusions occurred in sub-Saharan Africa in the period 1950–1990."

It is still the case today that HIV prevalence is far higher in urban than rural areas. Indeed, in some parts of rural Tanzania and Kenya, HIV is virtually unknown. In South Africa, Lesotho, Malawi and other countries, HIV has been shown to cluster, especially close to main roads and even health facilities. It's worth remembering that 70-80% of people in many African countries live in rural areas.

Transfusions, also, are mainly carried out in urban areas. According to Schneider and Drucker, they probably always have been. There is also some evidence that transfusions and donations were more likely in the military, police, government employees and among mine workers, groups that have suffered from especially high rates of HIV.

Even the finding that transfusions were more likely among wealthy colonials brings to mind the fact that HIV is said to have peaked and begun to decline among white South Africans before it hit the black population.

It was also in the early years of the pandemic that the role of other medical procedures was recognized, such as injections and other skin piercing activities. While this also led to changes in practices in wealthy countries, conditions in health facilities in developing countries haven't changed so quickly. And shortages in personnel, training, equipment and supplies can result in numerous lapses in infection control.

UNAIDS insist that unsafe health care only contributes to a maximum of about 2.5% of HIV transmissions in African countries and the rest is accounted for by heterosexual sex and mother to child transmission. But UNAIDS also warn UN employees that they can't guarantee the safety of health facilities in developing countries. If this is so, Africans are also entitled to know that their health facilities are not safe.

"Extra precautions should be taken, however, when on travel away from UNapproved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere. It is always a good idea to avoid direct exposure to another person’s blood—to avoid not only HIV but also hepatitis and other bloodborne infections."

There are two separate instances of institutional racism here: firstly, the assumption about African sexuality and levels of 'unsafe' behavior being enough to explain HIV prevalence levels hardly ever seen among non-African populations; and secondly, warning UN employees about the risks of unsafe healthcare and how to avoid them while telling Africans that they don't need to worry about non-sexual risks.

Schneider and Drucker's findings should have triggered an investigation into historical and current conditions surrounding blood transfusion and donation. Other skin piercing practices in health and cosmetic facilities need to be investigated. Those most at risk need to be warned of all HIV risks, non-sexual as well as sexual. And people need to be told how they can protect themselves. Only then will HIV transmission fall enough for the virus to eventually be eradicated.

[For more information on blood-borne transmission of HIV and how to avoid it, see the Don't Get Stuck With HIV website and blog.]


Thursday, September 15, 2011

Homophobia in Uganda: the Tip of an Iceberg of Prejudice

According to one of the Wikileaks cables released recently, the wife of Uganda's president, Janet Museveni, was covertly behind the country's infamous Anti-Homosexuality bill. That's not very surprising, given her avowed views on other matters, avidly supported by Ugandan and foreign religious and political interests. (There's a commentary on the cable by a San Diego news site but the authors may have gone a bit beyond the evidence in their conclusions.)

The cable dates back to 2009 and the bill in question was not passed, but disinformation about sexuality, homosexuality and other matters is well entrenched in the minds of many, not just in Uganda or other African countries. Through the disinformation process the bill has often become associated with HIV/AIDS in the press and elsewhere, given the association between HIV transmission in Africa and sex in the popular imagination.

John Naganda, who opposed the bill and advised the president to do so too, said those behind it were obfuscating differences between homosexuality, rape, incest, and pedophilia. But it is worth putting the extreme prejudice against homosexuality and homosexuals in Uganda and Africa as a whole in perspective.

The homophobia here is just a subset of a wider anti-African prejudice that lies behind HIV discourse in general. The obfuscation extends to the sexual behavior of all Africans, especially those who are HIV positive, or even those thought to be at risk of infection. It is commonplace to state or imply that HIV transmission is high in some African countries 'because of their sexual behavior'.

As in any other continent and country, rape, incest and pedophilia are to be deplored. But they are deplored by Africans just as they are by non-Africans. The fact that they occur does not mean that all Africans, or even nationals of any particular African country, condone them. But, no more than there is a correlation between sexual behavior in general and HIV prevalence in African countries, nor will any correlation between rape, incest or pedophilia be found.

Because the HIV industry has (surprisingly) accepted that homosexuality is unlikely to be any more common in African countries than in non-African countries, it has become their constant refrain that 80% (or even 90%) of HIV is transmitted through heterosexual intercourse. The industry has never demonstrated how heterosexual intercourse could carry such a high risk of transmitting HIV in African countries compared to elsewhere, so they also have to invent levels and types of heterosexual behavior that might 'explain' some anomalies.

Uganda and other countries have long been happy to accept the 'bad person' theory of HIV transmission, the view that it is spread by 'evil things', whatever those things may be. As a result, fingers have been pointed at sex workers, long distance drivers, foreigners, migrant laborers, homosexuals and various other groups. Not only do the HIV industry and those informed about HIV (and 'African' sexuality) by them buy into the orthodoxy, but many Africans seem unwilling to oppose such an extreme manifestation of racism.

In Uganda and other high HIV prevalence African countries, men having sex with men account for a very small percentage of transmission. Intravenous drug users also are a small group and account for another small percentage; the two groups may even overlap considerably. But those most at risk are people who are, according to the orthodoxy, not really at very high risk at all, people in long term, heterosexual relationships.

According to the Ugandan Modes of Transmission Report, exactly 1% of HIV is transmitted by a combination of men who have sex with men, their female partners, intravenous drug users and the partners of intravenous drug users. Kenya's report, talking of obfuscation, lumps men who have sex with men along with prison populations (though not intravenous drug users) and comes up with 15%, so it's impossible to compare the two. But as in Uganda, most transmission is attributed to what amounts to low risk exposure.

The kind of stigma and prejudice that arises from the view that almost all HIV is transmitted through heterosexual sex in African countries seems to allow people, even encourage them, to hate, to discriminate, to persecute, to treat like animals, perhaps even to kill, rather than to investigate and understand why over 40% of people in some demographic groups are infected with a virus that should never have become a serious epidemic.


Saturday, September 10, 2011

HIV Publicity Recipe: Just Add Sex and Stir Vigorously

The view that HIV is almost always transmitted through heterosexual sex in high and medium prevalence countries in Africa is disturbing because it is assumed to be a true and accurate starting point for most research. If research began without the assumption and then adopted it once it was shown to be useful and/or not inimical to shedding light on HIV transmission, that wouldn't be so bad. But surely, making unwarranted assumptions is something to be avoided by serious researchers?

Some researchers in Uganda analysed various HIV subtypes found in a group of women engaged in 'high-risk' sexual behavior to find patterns that might show how the women were infected. But the assumption was that the virus was transmitted sexually, hence the use of women considered to face high levels of sexual risk ("sex workers and bar workers").

However, many of those who face high levels of sexual risk can also face high levels of non-sexual risk. Many sex workers regularly attend sexually transmitted disease clinics for the treatment and prevention of STIs, to receive injectable hormonal contraceptives and undergo various kinds of testing that can be invasive. In countries where health services are not always well staffed, well equipped or well run, the possibility that instruments can be contaminated is always present.

In fact, the researchers found that 75% of participants had either subtype A or D, which doesn't suggest a huge amount of variation. If most people were being infected sexually by a virus that had been going around for several decades, one might expect a lot more variation. Perhaps this suggests that most people are being infected by a small number of different sources, which might more likely be a clinic or group of clinics?

Or perhaps not. But the research only showed that there was some clustering of subtypes around particular geographical areas. Showing that several people may have closely related viruses does not necessarily mean they all belong to the same sexual network. It could also mean they all attend the same STI clinic or the same hospital. But the most disturbing thing about the research, then, is that no attempt was made to identify any non-sexual risks that participants may have faced.

The researchers are effectively emasculating any possible value their research might have. All they have shown is that some people have HIV virus subtypes that may have come from the same source. This sheds no light on what that source was. The fact that all the participants engage in 'high risk' sexual behavior may be relevant, but we have no idea of how relevant.

Since early on in the HIV epidemic in African countries, the same groups have been rounded up for research that has similarly failed to examine the non sexual risks they may face. Fingers have been pointed at sex workers, long distance drivers, fishermen, people living in border towns, etc. But most, if not all of them, also face non sexual risks. HIV does tend to cluster round main roads and in densely populated areas. But it also tends to cluster around health facilities.

Another group of researchers have questioned the work carried out in Uganda for these reasons. They suggest that the work is not finished until all the risks the participants face have been assessed, not just the sexual risks. Others who may have been involved in transmitting or being infected with HIV need to be contacted and their virus subtype also needs to be identified. This will allow a proper infection network to be drawn up, not just a sexual network.

But what are the chances of people who seem obsessed with the sexual behavior of Africans carrying out research into the possibility that HIV is not always sexually transmitted? If you are faced with a massive epidemic that you assume was spread sexually, you will then make similarly unfounded and ridiculous assumptions about the sexual behavior of those infected. And if you are like these researchers in Uganda, you may forget to reflect on the sheer racism of attributing such absurd levels of sexual behavior to fellow human beings.


Thursday, September 8, 2011

Gender Sensitivity: Investigating Non-Sexual HIV Risks

Yet another article about the fact that far more women than men are infected with HIV in Kenya (as is the case in all African countries); this time, women account for 65% of all new infections. According to another document, "women aged 15-24 are four times more likely to be infected than men". Cue a collective wailing about 'gender mainstreaming' and other nebulous buzzwords.

But even taking the first figure, twice as many women are infected as men. So who is infecting them? Given probabilities such as one in 500 for transmission from men to women and one in 1000 from women to men, this would take an awful lot of 'unsafe' sex. And it would need to be spread over many years, whereas many females are being infected in their teens and twenties, when most of them would not have been sexually active for long.

Assuming that this is almost all a result of heterosexual sex, as the HIV industry does, would also suggest that women are far more sexually active than men, which is not the case according to research into sexual behavior. Not only do most men not frequently engage in 'unsafe' sex, but women do so even less frequently.

And for someone to be infected, whatever the probability of transmission, they must infected by someone who is HIV positive. But if most men are not HIV positive, we go back to the first question; who is doing all the infecting? In one part of Kenya, fewer than two men are infected for every 10 women.

Popular as it is to indulge in speculation about 'African' sexuality, how often 'they' have sex, what kinds of sex they have, how badly the women are treated and how bad the men are, much of what is written about such things is based on prejudice, not on the findings of valid research.

The fact is, no one has yet demonstrated how a virus that is difficult to transmit sexually has come to infect up to a quarter of the population in a few countries and half of all females in another few countries. Even less has anyone shown how a relatively small number of men managed to infect a large number of women, including women who have only had one, HIV negative partner.

So the Kenyan and other governments can write as many official documents as they like bemoaning HIV transmission figures, and calling as many of these documents as they like 'new', but none of them are new. Everything is done the same way as it has been done for years, despite this having no noticeable effect on the epidemic.

HIV is not just about sex. Authors of these documents may accept that but there is little substance behind their acceptance. HIV needs to be prevented, yet only an estimated 20% of HIV money goes to prevention, while nearly 60% goes into treatment and care. Much of that prevention funding goes to rather vague activities that relate to individual sexual behavior, activities that have been shown to be virtually useless.

Less than 3% of all funding goes towards ensuring that people have access to safe injections and other healthcare procedures. This is where all African strategic plans come apart (they are all very similar); they simply ignore non-sexually transmitted HIV. UNAIDS may deny it vehemently, but non-sexual HIV transmission contributes a lot more than the 2-2.5% that they claim for Kenya's epidemic. Even the WHO publicly accepts this.

Doing things differently means reducing the emphasis on sex when there is plenty of evidence for non-sexually transmitted HIV, among women whose only partner is HIV negative, infants whose mothers are HIV negative, virgins and people who have only had 'safe' sex. Recognizing the importance of gender means investigating the non-sexual risks that women face.

The most important type of gender sensitivity right now is to investigate the risks that women face and that men face less often, if at all. This should also reveal the risks that African women and men face, ones that non-Africans face less often. Sex may play a part in serious HIV epidemics, but not as big a part as in the collective fantasy that is the current HIV orthodoxy.


Wednesday, September 7, 2011

Mugabe Needs to be More Careful in his Choice of HIV Advisers

Zimbabwe's President Mugabe has been poorly advised when it comes to understanding HIV transmission: he claims that some of his own officials are contributing to the spread of HIV through promiscuity. Is he not aware that HIV is a difficult virus to transmit through heterosexual sex? It is far easier to transmit through unsafe healthcare practices or cosmetic services.

Instead of addressing important issues, ones that are ignored by the HIV industry, Mugabe is wasting time with admittedly well-funded initiatives that will have little effect, such as promoting 'abstinence', teaching about female condoms in beauty salons and rolling out male circumcision programs. He would be better off to concentrate on safety in beauty salons and in health facilities where circumcisions and other procedures are carried out.

While the world's media, politicians, academics and others obsess about African sexual behavior and the obscene levels it would have to reach (and therefore must have reached) to explain massive HIV epidemics such as that found in Zimbabwe and other countries, HIV transmission that doesn't relate to sexual behavior is allowed to continue, unabated and uninvestigated.

Others claim that sexual behavior is all about money and that you just need to give handouts so that the women don't involve themselves in transactional sex. Would the World Bank and others be able to get away with their insinuations and bald statements if they were talking about people other than Africans?

But there is no evidence that HIV epidemics in Africa are 'driven' by sex, of any kind. HIV may be transmitted sexually, but it has been demonstrated quite clearly that levels of sexual behavior, safe or unsafe, are of little relevance to HIV rates. Countries with high levels of types of sexual behavior considered unsafe can have low HIV prevalence. Whereas, countries with high HIV prevalence can have low levels of these same types of behavior.

If Mugabe is worried about promiscuity, male domination and lack of gender equality, unplanned pregnancies, sexual violence and abuse, or any other issues, he should get on with addressing them. But those issues were around long before HIV was identified; they won't just disappear along with HIV, if HIV ever disappears. Yes, "the role of men is unquestionable", but his Excellency needs to bear in mind that far more women than men are infected with HIV.

And while he is on the subject of prevention of mother to child transmission of HIV (PMTCT), Mr Mugabe should bear in mind that the best way to protect children is to protect their mothers, preferably before they become pregnant. If a mother's life is compromised, so is her child's. The president should investigate conditions in Zimbabwean hospitals and health facilities so that the safety of mothers, children and everyone else can be guaranteed.

Surveys of conditions in health facilities in African countries with serious HIV epidemics show that, right now, people's health can not be guaranteed. Blood is not always adequately screened before being transfused, non-reusable equipment may be reused, often because it's in short supply, precautions to avoid infection with various diseases are not always taken, dangers are not even recognized, at times. There are too few trained, motivated and properly paid health professionals.

Mr Mugabe appears to be badly briefed about the HIV epidemic in Zimbabwe, and in Africa in general. But then, the entire HIV industry has studiously avoided researching non-sexual HIV, investigating possible outbreaks of HIV in health and other facilities and in replacing their highly prejudiced and inaccurate view of sexual transmission of HIV with something that matches the evidence.


Sunday, September 4, 2011

HIV: If All your Questions are About Sex, All your Answers will be About Sex

A paper published in the Journal of Adolescent Health in February alludes to the need to rethink sexual risk for HIV among young people in South Africa and the US in its title. But the significance of the results of the study seems to be completely lost to the researchers involved.

The research finds that "Young people in the US report riskier sexual behaviors than young people in SA, despite the much higher prevalence of HIV infection in SA." From this they conclude that "Factors above and beyond sexual behavior likely play a key role in the ongoing transmission of HIV in South African youth, and thus should be urgently uncovered to develop maximally effective prevention strategies."

That's great to know, but the research doesn't shed much light on what other factors could give rise to HIV prevalence hundreds of times higher than that found in most Western countries. They vaguely suggest that "Unique biological forces must be playing a role as well." The research doesn't probe such forces, presumably that's way outside its scope. But nor does it make any attempt to go beyond sexual risks.

In fact, the authors nail their colors to the mast in the first paragraph: "Considering that most of the infections in sub-Saharan Africa are the result of heterosexual transmission, popular opinion has continued to foster the belief that the HIV epidemic in Africa is fueled by promiscuous sexual behavior, or unique sexual mixing patterns. I would suggest that the researchers question the antecedent of that sentence. Where is the evidence that most infections anywhere are the result of heterosexual transmission?

However, much of this 'popular opinion' emanates from some very prominent HIV academics. And it's hardly surprising that the populace associates high HIV prevalence, particularly in African countries, with promiscuity and 'unique sexual mixing patterns'. The entire HIV industry, led by UNAIDS, is built on the assumption that almost all HIV transmission in African countries (though not elsewhere) is a result of heterosexual sex.

In other words, sexual behavior that is not particularly risky is still very likely to result in HIV transmission, but only in African countries. If people are at high risk of infection as a result of low risk behavior, that is tantamount to saying we don't really understand why some people are being infected in huge numbers, all of them Africans, while other people are infected in very small numbers. The researchers don't appear to have a clue.

They say "This high prevalence of infection in the general South African population means that young people do not have to engage in high-risk behaviors (i.e., multiple partners, lots of unprotected sex) to be at risk for HIV infection. Certainly sexual behavior is an essential element of HIV risk; nevertheless, high-risk behavior may not be a prerequisite for HIV transmission."

Yes, people are at higher risk of being infected in a country where prevalence is out of control. But what gave rise to such high prevalence of HIV when the virus is difficult to transmit sexually? If the researchers want to explain current transmission patterns, they need to have some basic grasp of the patterns that gave rise to the epidemic in the first place. They appear to lack this basic grasp.

The authors graciously list some limitations, but one they don't list is the fact that non-sexual risks were not examined: for all the people who were infected with HIV and all those who could have been exposed to the virus without being infected, the researchers don't know anything about their non-sexual risks. They don't appear to have considered non-sexual risks worth the effort.

They didn't even ask about anal sex, same sex partners or intravenous drug use. In the US, anal sex is the number one risk factor, with intravenous drug use being number two. When it comes to extremely high rates of HIV transmission, there needs to be an investigation of all risks, especially the most serious. This piece of research appears to have examined some of the least serious risks and decided that they must be serious despite all appearances, particularly in South Africa.

We don't just need to rethink sexual risk, as the authors claim: we need to rethink all risk. We urgently need to establish why one in ten South Africans are infected with this virus, which is so much easier to spread through contaminated blood that through sex, while only one in 1000 Americans are infected. Research that fails to address non-sexual risks for HIV transmission is a pointless waste of time and money and it allows millions to continue to be infected needlessly with HIV.


Thursday, September 1, 2011

Racism Aside, Why are so Many Africans HIV Positive?

I commented on an intriguing article last February and I'm not going to write another commentary now. But for some reason, UNAIDS have only just managed to include it in their very carefully selected weekly collection of very carefully annotated articles, HIV this Week (one doesn't want to say anything that flies in the face of idiocy, does one?).

The article is entitled "It's not just who you are but where you live: an exploration of community influences on individual HIV status in rural Malawi" and it concludes that it's not just proximity to a major road that is highly associated with increased odds of HIV prevalence but also proximity to a public health clinic.

What would have been a eureka moment for people with basic reading and analytic skills, though, has put UNAIDS on the defensive. The UNAIDS author, evidently more highly trained in publicity and face saving than epidemiology, calls the findings 'thought provoking'. They note that rural residence 'seems' protective, which is what virtually every other similar study has shown.

But UNAIDS can't figure it out, because they are honor bound to bring sex into it. Why should living in a rural area protect you from a sexually transmitted disease? Oh, it's because extramrital sex may occur in urban areas. Phew, there was me thinking that people may face non sexual risks in additon to sexual risks when it comes to HIV, which is difficult to transmit sexually but easy to transmit through the sort of poor quality healthcare facilities found in all high prevalence countries.

UNAIDS finds higher HIV risk with proximity to health centers "puzzling". Because they are absolutely positive that HIV can not be transmitted any other way in African countries but through sex. This certainty is not acquired through any kind of investigation, of course. It is just the entire UNAIDS 'theory' of HIV transmission in African countries. (HIV is mainly transmitted through male to male anal sex and intravenous drug use in non-African countries.)

But the astute commentator contents her or his self by reflecting that "health posts are often located in small commercial centres that are themselves associated with increased sexual risk taking" and that "people with HIV infection may move to be closer to health centres for improved access to care". The commentator may be right. But isn't it about time to check? It doesn't take a long, carefully planned study like the one in question to find out what conditions are like in Malawian hospitals, or in other African countries.

In fact, someone at UNAIDS already knows what hospitals are like because they have published a leaflet for UN employees, warning them that "Extra precautions should be taken, however, when on travel away from UN approved medical facilities, as the UN cannot ensure the safety of blood supplies or injection equipment obtained elsewhere." Perhaps UNAIDS just haven't read the leaflet yet.

The commentator is interested that "income inequality, as opposed to absolute poverty, is associated with increased HIV in women" and asks "Why would this be so?" Predictably, their suggested answer is related to sex, via mention of trust, social ties, risk and what not, but mainly to sex and African women and we all know where that leads, don't we, etc.

Have UNAIDS saved their skin again? Perhaps so, but only at the cost of continuing to propagate the stereotype of the sex and money obsessed African, who really doesn't give a damn about much else. The truth is, HIV is not only transmitted through sex. UNAIDS just don't wish to investigate non-sexual HIV transmission. Therefore, the institution needs to be abolished and replaced with an institution that can produce a comprehensive and non-racist HIV strategy.