Sunday, February 5, 2012

Turning Off the Tap: Don't Forget, There Are Two of Them

There's an article published by Peter Piot in 1987 that has had a lot of influence on the way many others have written about HIV ever since. I'd like to say it has had influence on the way people have thought, but this article seems to have been a serious obstacle to thought. Concentrating on what it has to say about women, here's how it goes: "Among 446 sera from prostitutes in Nairobi, the prevalence of antibody to human immunodeficiency virus (HIV) rose from 4% in 1981 to 61% in 1985." Also "Among pregnant women, 2.0% were seropositive in 1985 versus none of 111 in 1981."

This article and the numerous articles like it support the 'behavioral paradigm', the view that almost all HIV transmission in African countries (but not in non-African countries) is heterosexually transmitted. Why did this become the dominant paradigm and remain so to this day, despite clear evidence that it was wrong, in addition to being deeply prejudiced and stigmatizing? Well, it was concluded from the fact that "Seropositive [ie, HIV positive] prostitutes and women with sexually transmitted diseases (STDs) tended to have more sex partners and had a higher prevalence of gonorrhoea, and in women with STDs, significantly more seropositive women practiced prostitution."

Before concluding that the last statement proves, or even supports the behavioral paradigm, consider this: if someone is found to be HIV positive, it is necessary to look carefully at both sexual and non-sexual risks before concluding that they were infected sexually. while it is indeed fairly clear that people have most probably been engaging in unsafe sex if they have one or more STD, and many commercial sex workers do engage in unsafe sex, this does not mean they never face non-sexual risks. The very same sentence that identifies the sexual risks also identifies the non-sexual risks: they were probably treated for and/or vaccinated against STDs at some time in their lives, perhaps many times in their lives.

Long before HIV was recognized, sex workers were routinely rounded up for sexual health programs. In fact, the very blood samples collected in 1981 pre-date the discovery of HIV. The blood was taken at a time when injecting equipment was often reused without sterilization to an extent that has rarely been investigated. Every one of the women participating in the program faced a whole host of non-sexual HIV risks. In all probability, sex workers all over the world continue to face serious risks of being infected with HIV and other bloodborne diseases, though the risk may no longer be so high, even in African countries.

The authors can not show that the women involved were infected sexually. They wouldn't have been able to demonstrate it then and it would still be difficult to do so now. Nor can they rule out the possibility that many, if not all, were infected through the STD programs during which the blood samples were collected. But they have good reason to suspect that they are quite wrong in their conclusion about this massive rate of heterosexual transmission. And there are many other articles like this one with these exact same flaws. There is only one way that HIV prevalence can go from 4% to 61% in the space of a few years and that is through unsafe healthcare, especially that received in STD clinics.

There's a lot more that could be said about this article but let's shoot forward to the present, where the standard of analysis set by Piot and colleagues is still being rigorously maintained. As I mentioned in my last post, PEPFAR held a consultation on what they called 'mixed' HIV epidemics, those where HIV prevalence is high among those thought to be most at risk of being infected and also high among the general population, those thought (if thought is involved) to be at low or even zero risk of being infected. Remarks about Kenya's epidemic presented during this consultation show just how persistent an obstacle to thought Piot's article is.

Despite three decades of hollering about risky sex (and keeping quiet about risky healthcare), the committee accepts that 44% of HIV in Kenya is actually transmitted through heterosexual sex among couples in long term partnerships, married or otherwise; low risk sex is, according to their figures, the most risky sex of all. After low risk sex comes slightly higher risk sex, accounting for over 20% of all transmission, that between casual partners, where there is no indication that either partner is a commercial sex worker or visits commercial sex workers.

The entire contribution assumed to come from sex workers and their clients is only 14%. Note, it is no more certain that those falling into this group were infected sexually than those found to be infected in Piot's research. Sex workers and their clients, since they may often have STDs, face significant non-sexual HIV risks. But like the general population of African countries, it is mainly African sex workers who face very high HIV risks. In other countries, sex workers are unlikely to be infected with HIV unless they are also intravenous drug users. Sexual practices in some parts of some African countries may, as claimed by the HIV industry, be risky, but so are healthcare practices.

Another 15% of Kenya's HIV epidemic is said to come from men who have sex with men and prisoners. This is very ambiguous. While there may or may not be a lot of male to male sex in prisons, and anal sex is very risks, whether homosexual or heterosexual, there are also elevated non-sexual risks in prisons. Men tattoo themselves and each other, using makeshift equipment and dyes, they may take blood oaths, engage in various traditional practices, including medicine, that involves bloodletting, even take various drugs. What proportion of HIV in prisons is non-sexually transmitted?

Having inflated the figures for sexual transmission of HIV in the 'high risk' groups and claimed that low risk sex is also high risk sex, these experts conclude that all that's left for health facility related HIV transmission is 2.52%. of course, if you start off believing that 80 or 90% of HIV is transmitted through heterosexual sex, then healthcare transmission will only account for a small amount; but that's just arguing in a circle. The approximately 95% of HIV transmission that is said to be sexual needs to be re-examined. Have those producing these figures shown that all, or even most of that 95% was sexually transmitted? or, to put it another way, can they rule out non-sexual transmission in all those groups?

They are not even asking the questions. As I say above, there is an obstacle to thought here, in the form of the behavioral paradigm. Those who hold the paradigm seem unable to go beyond it. The very questions Piot should have been asking in 1987 remain unasked by most academics publishing in the field of HIV today. Papers like this one by Piot have amply fuelled prejudices ranging from those aimed at Africans and women to those aimed at men who have sex with men, drug users, prisoners, migrants, long distance drivers, religious denominations, tribal groups, nationals of various countries and others too numerous to mention.

How do we know that most people said to have been infected with HIV through heterosexual sex were really infected through sex? We don't. How can we rule out non-sexual transmission in 95% of Kenya's HIV positive people? We can't. What is the relative contribution of non-sexually transmitted HIV, such as through unsafe healthcare? We have no idea. The HIV industry likes to use the metaphor of 'closing the tap', preventing new infections; they need to see that there are two taps and both need to be closed, regardless of which one contributes most to the pandemic.

[For more about non-sexual HIV risks, such as through unsafe healthcare practices, see the Don't Get Stuck With HIV site.]


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