HIV: What's Different About Africa if it's Not Down to Sex?

In an article about HIV in Botswana, Ntibinyane Ntib remarks on something I have always found hard to understand about the virus in high prevalence African countries; the issue of families and of several members of the same family being infected with HIV. Of course, in Botswana, several members of many families must be infected, given prevalence figures of 25% nationally and far higher rates in certain groups and geographical areas. But how were they infected? Sexual behavior between different African and non-African countries, and indeed within African countries, doesn't vary that much. And differences have never clearly been correlated with HIV prevalence. Or rather, some people in all countries, Africa and elsewhere, have a lot of sex, most don't have a lot and some have none at all.

If you swallow the orthodoxy about African sexuality and various other bigoted views, it wouldn't be so surprising that HIV 'runs in families'. About 10 years ago I saw a brief play in Western Kenya purporting to be about the spread of HIV through illicit sex, as well as to a small extent through licit sex. The father slept around and became infected, he went on to infect his wife and the housegirl, his wife was pregnant, the implication being that the baby would be infected, and to cap it all, their teenage son was also sleeping with the housegirl. It's no wonder Kenya was getting a lot of HIV money while the pickings were rich, they certainly pushed all the right buttons.

But outside of African countries, and it's only some African countries where HIV prevalence is very high, HIV does not 'run in families'. It primarily infects men who have sex with men and intravenous drug users. So what is different about Africa? Well, a lot of surveys show that HIV is not always transmitted sexually. Babies are infected whose mothers are uninfected, many virgins have been infected and many people who only have one uninfected sexual partner are infected. What we don't know is the extent of non-sexual transmission. But we do know that heterosexual transmission cannot be entirely responsible for extraordinarily high prevalence rates found in countries like Botswana.

In a blog post on the Don't Get Stuck With HIV site, David Gisselquist goes into more details. About 10 years ago, an initiative called the International Network of Religious Leaders living with or Affected by HIV/AIDS (INERELA+) came up with an alternative to the ubiquitous but wholly ineffective ABC strategy (Abstain, Be faithful and use Condoms). INERELA+'s strategy is called SAVE, which stands for: Safe sexual and skin-piercing behavior; Access to treatment; Voluntary counseling and testing; and Empowerment. Gisselquist goes on to outline a two ways of using SAVE to reduce HIV transmission by as much as 45%. This would involve existing programs for preventing mother to child transmission and couple counselling, both of which would need to be stepped up.

The author of the article on Botswana makes the point that the country is relatively rich, as if HIV should never have spread so rapidly there. Well, HIV is highest in several relatively rich  African countries, Botswana is not the only one. HIV is also high in countries that have (or had) high rates of formal employment compared to a lot of other countries on the continent. These high prevalence countries also tend to have good infrastructure, accessible health services and even relatively high educational standards. Even within medium and high prevalence countries, it is often the richer and better educated people who are most likely to be infected with HIV.

Proponents of the sex theory (if it could be called a theory) of HIV argue that wealthier and better educated people are more mobile and have more sexual partners, or bigger 'sexual networks', etc. They also studiously ignore the non-sexual risks that wealthier people may have, such as access to health services. But access to health services is not enough to reduce HIV transmission, those health services must be safe. Diamond miners in Botswana, it has often been remarked, suffer high HIV rates. But they don't just have more money that they can spend on 'illicit sex', they also have access to health services. Are these health services safe?

The Botswana article also describes sick people in ways that suggest it was not always known what a person was suffering from or what they died from. What the author describes, in fact, could be something other than HIV, such as TB, some other disease or several diseases. Were all these people just assumed to be suffering from and dying from HIV? Large scale extractive industries have an appalling corporate social responsibility record, especially in Africa. Could many people in Botswana have been infected with TB though their work in mines or through contact with TB infected people? TB doesn't just infect people with HIV, it also increases susceptibility to HIV infection and increases the chances of transmitting HIV. And while it's hard to see why HIV should 'run in families', it's not at all hard to see why TB should.

There are several things that are different in Africa when it comes to inordinately high HIV prevalence rates, and sex is probably not one of them, or not one of the most important. Unsafe healthcare, high disease burden, risky living conditions and working conditions look like fruitful areas for inquiry. The author is right to worry about cuts in funding for antiretroviral treatment and I hope this is addressed. However, Botswana needs to give HIV prevention a lot more attention and sex a lot less attention. There's a something wrong in a country where one quarter of the adult population is infected with a virus that is hard to transmit sexually; it may be that the virus is being transmitted non-sexually.

[For more about non-sexual HIV transmission and male circumcision, see the Don't Get Stuck With HIV site.]

HIV Prevention: Blinded by Profit or Paid Not to See?

We have been hearing a lot recently about various HIV treatment and prevention strategies that will significantly increase the quantities of HIV drugs produced and sold. For example, the US DHHS recommends starting antiretroviral therapy (ART) for HIV positive people at a relatively early stage of disease progression. One might think that such decisions are made on the basis of scientific evidence and concensus among medical practitioners. But Joseph Sonnabend shows that this is not necessarily so.

Dr Sonnabend finds that 'expert opinion' in this instance refers to that of DHHS panel members, most of whom have a financial interest in selling more drugs. There are many experts who would not agree that starting ART early has a net benefit, but they don't sit on the panel. There is scientific evidence for the benefits of starting later, but none for those of starting earlier. Basing such decisions on the expert opinion of a few people is bad enough; expert opinion should never trump scientific evidence. But when most of the experts can also benefit financially from the recommendation as well, there is a clear conflict of interest.

ART must be taken for life and has side-effects, only some of which are currently recognized. It is also expensive and life changing. And there is the issue of the virus developing resistance to the cheaper drugs that people usually take at first. Resistant strains of HIV can be transmitted, so there could be a snowball effect here. We already know what can happen when drugs are overprescribed and adherence is poor from the case of antibiotics and perhaps malaria medication. So this is not a minor issue about precription recommendations. In contexts where HIV is common, it could profoundly affect the course of the epidemic.

It's fashionable enough these days to claim that 'treatment is prevention', but as Dr Sonnabend points out, it is those who have reached a later stage of disease progression who are most likely to transmit HIV. Therefore, the preventive value of ART will only be high for partners of people who start treatment at a later stage. Treatment at an earlier stage will be less relevant, perhaps irrelevant, and the benefits have not been shown to outweigh the risks. While it may be empowering to provide people with the drugs they demand, it is only so if they are also informed about the known effects of those drugs, in addition to the hypothesized ones.

WHO has also made a recommendation that similarly serves the interests of Big Pharma. As the English Guardian reports, "Aids drugs should be given immediately to anyone with HIV who has an uninfected partner, to stop transmission and slow the epidemic". As mentioned above, this is unlikely to slow the epidemic much and could have many drawbacks which have, as yet, not been investigated. Resistance rates are steady enough to guarantee that people taking relatively cheap (but still grossly overpriced) first line drugs will gradually need outrageously overpriced second line, and even third line drugs. And resistance will eventually develop in second and third line drugs too, as they have found in Uganda. Quite a virtuous cycle for Big Pharma!

Far from just being used to treat HIV positive people and to prevent transmission to HIV negative people, ART programs appear to have the effect of drawing attention away from possible HIV risks. How has a virus that is difficult to transmit heterosexually infected, for example, 43% of adult women in Mozambique and nearly 38% of adult men? There are clearly non-sexual risk factors involved, but what are they? If diseases such as malaria, TB, intestinal parasites and the like are involved, for example, they urgently need to be treated and prevented, which can be done cheaply and relatively safely. But if the virus is being transmitted through unsafe healthcare practices, showering people with drugs is a misdirected effort and may not even reduce transmission.

The relative contributions of all risks need to be identified, whether they relate to sexual or non-sexual transmission. But putting more and more people on drugs while ignoring possible risks is not the way to eradicate the virus. Two things that are blind to the causes of HIV transmission and to appropriate prevention strategies are drugs and high profits. Of course, Big Pharma make drugs and big industries, especially the HIV industry, make profits. But the problem is when profit is seen as the only goal and treatment is seen as a mere step to be taken in the pursuit of profit. As for prevention, the industry seems to be looking for ways of making money out of it rather than for how best to achieve it.

[For more about non-sexual HIV transmission and male circumcision, see the Don't Get Stuck With HIV site.]

2007 Rakai Trial Found Genital Hygiene More Effective Than Circumcision

Some time ago, I wondered out loud if penile hygiene could be more effective than mass male circumcision when it comes to reducing HIV transmission. It's certainly cheaper, more appropriate and should carry fewer risks. Even men who are circumcised still need to practice genital hygiene and use condoms. A research project to find out if penile hygiene would be acceptable, convenient, practicable and if adherence would be high, received funding a few years ago. As far as I know the findings have not yet been reported.

But it turns out that the Rakai circumcision trial, which made its findings public in 2007, also found that penile hygiene is a lot more effective than mass male circumcision. The findings for the relative effectiveness of penile hygiene were reported. But those who continue to urge for circumcision, many of whom would have been involved in the Rakai study (or one of the other studies), have chosen to ignore the more effective, safer and cheaper option. Yet men who remained uncircumcised and waited at least 10 minutes after coitus faced a far lower risk of being infected with HIV than men who were circumcised.

Men are advised to use a dry cloth rather than water. Coupled with the advice to wait a while this could be seen as complicated. But circumcision doesn't obviate the need to take this advice. Therefore circumcision is not just very expensive and has potential risks in countries where health services can be very unsafe, it also gives less protection than something that could already be second nature to most men. The biggest mystery, though, is why there is so much pressure to spend what would probably amount to several billion dollars to circumcise tens of millions of men when those advocating for the campaigns had access to this information at least five years ago.

Dr David Gisselquist has written extensively on this subject on the Don't Get Stuck With HIV website. He has also created a table showing that, according to the Rakai trial data, the biggest reduction in HIV transmission is among those who remained uncircumcised but waited at least 10 minutes after coitus to clean their penis. Hundreds of thousands of circumcisions, perhaps millions, have already been carried out, ostensibly to reduce HIV transmission; tens of millions are planned in adults, children and infants. It is vital that those being persuaded to have the operation have access to all available information in order for them to give informed consent. So far, they only appear to have been given information calculated to bias their decision towards circumcision.

HIV Conjunctivitis: a Serious Problem for Drivers

This is not about eye inflammation but rather the use of conjuncts in the field of HIV. The virus has been linked with various things that are indisputably undesirable, such as national security threats (mainly against the US, it seems), drug use (often conflated with intravenous drug use or IDU), sex work (often conflated with sex trafficking), sex (often conflated with 'unsafe' sex), female genital mutilation (or FGM, as opposed to male genital mutilation), poverty, lack of education, migration, war and conflict, gender based violence, gender inequalities, unemployment and alcohol abuse (which is conflated with alcohol use), etc. Many of these phenomena are claimed (or assumed) to be 'drivers' of HIV epidemics.

So a paper about alcohol-related HIV risk in Namibia begins "A growing body of epidemiological and social science research links alcohol consumption with the sexual behaviors that put people at risk for HIV and other sexually transmitted infections." Ireland, Finland, the UK and various other countries have serious problems with alcohol abuse, but low HIV prevalence. Indeed, Kenya, Tanzania and Uganda have serious problems with alcohol abuse, yet HIV prevalence is less than half that found in Namibia.

Each of the items associated with HIV listed above may well be linked with the virus, but not always in the ways you might be led to believe. HIV infected people from developing countries have not flocked to the US; IDU is the second biggest risk for HIV in many Western countries, but other types of drug use may not be such serious risk factors; sex work in Western countries is often only a high risk for HIV if IDU is also involved; FGM may be a risk factor, but HIV prevalence in tribes where it is common often have lower prevalence than in those where it is not practiced; poverty and lack of education are often associated with lower prevalence, as are war and conflict; gender inequalities are found in many countries with low HIV prevalence; unemployment is often associated with low prevalence in African countries, etc.

An article about gender based violence in a region in Tanzania makes the common jump from rates of violence to HIV rates. But there is no clear correlation in Tanzania showing that areas with high levels of gender based violence are also areas where HIV prevalence is high. Of course, the intervention should go ahead if it is likely to be successful in reducing levels of violence and changing people's attitudes towards any form of violence. It's just unlikely to have much impact on HIV transmission. In fact, whatever is driving HIV transmission in the region, it may fail to receive the attention it deserves because of the belief that it is driven by violence, perhaps fuelled by alcohol and drug abuse, gender inequalities, poverty and various other, unarguably, undesirable circumstances.

Alcohol abuse is a terrible social problem and can have even worse consequences for those who don't drink at all, or drink little. But the paper argues that alcohol abuse is linked to certain sexual behaviors; it doesn't make a convincing case that all or most HIV transmission is sexual, nor that alcoholics and their sexual partners are a lot more likely to be HIV positive because of their sexual behavior. In fact, levels of alcohol abuse in the study area may not even seem that shocking to people who have worked in 'informal settlements' or slums. And levels of 'unsafe' sexual behavior are hardly earth shattering either.

Notably, the people surveyed have a much higher income than most people in Kenya, Tanzania, Uganda or several other countries where HIV prevalence is not so high. Educational levels are also higher and there is almost no gender inequality in education in the study population. If anything, the paper fails to get to the bottom of what, exactly, could be driving the epidemic. Prevalence in Namibia ranges from less than 5% to 25% or more, and the study area is by no means the highest prevalence area.

What is particularly unconvincing though, is the idea that the sexual behaviors said to be linked to alcohol use actually increase the risks for HIV transmission, simply because the claim also mentions 'other sexually transmitted infections'. Syphilis, being another sexually transmitted infection, is nowhere near as common as HIV in most areas of Namibia; but also, the 2008 HIV sentinel survey shows that syphilis prevalence figures do not correlate with HIV figures, neither by area nor by age group.

The 'conjunctivitis' may partly stem from the (now rapidly declining) availability of funding for HIV, which can drive fundraisers to make connections that don't exist, or don't really have the significance attributed to them. But the consequences can be serious for both HIV and the chosen conjunct. Most development areas have received a fraction of the funding made available for HIV; but HIV programming has often failed to put a finger on, and adequately address, what is really driving HIV in high prevalence countries. Sexual behavior, alcohol abuse and the like cannot explain high rates of transmission, so their possible role in HIV transmission, and the extent of any putative factors, need to be exaggerated to mythical proportions.

At times, programs addressing non-HIV issues can lose their chances of increased funding because their connection with HIV transmission is not considered to be close enough. Examples are nutrition, food security, intestinal parasites, sexually transmitted infections aside from HIV, and various other diseases that have been shown to be serious co-factors in HIV transmission. The fact that these co-factor conditions are so widespread mitigates against their funding because the effects of an intervention would dwarf any possible effect on HIV, which infects far fewer people than the most common diseases in high HIV prevalence countries. Eradicating co-factor diseases is generally dismissed as a mere externality.

Alcohol, drugs, sex and many other factors can be involved to a greater or lesser extent in HIV transmission in various parts of the world. And there is no doubt that these issues are deserving of funding. But the donor-friendly moral aspects of these factors should not blind us to ones that may be in far greater need of attention. After all, HIV has been shown, over and over again, to cluster in ways that can not always be associated purely with sexual behavior. It is a virus that is spread by bodily fluids, including blood. On top of the many co-factor diseases that facilitate HIV transmission, there are not that many ways in which people exchange bodily fluids with others that could explain epidemics such as the ones in Namibia and other sub-Saharan African countries.

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]

Tanzanian Universities and HIV Risk

"Urgent and concerted effort is needed to rescue [Tanzanian] students in higher learning institutions from contracting HIV/Aids" because "most students engage in risky behaviours", according to an article in The Tanzanian Guardian. 'Risk', of course, refers to sexual risk here, as it tends to do in the mainstream media. Presumably, Tanzanian students don't go to hospitals, sexually transmitted infection clinics, hairdressers, manicurists, tattoo artists or anywhere blood-borne infections might be a risk.

Africans are almost always infected through heterosexual sex, according to UNAIDS. This is quite unique as transmission through penile-vaginal sex is the exception in Western countries, where men having sex with men and intravenous drug users who share injecting equipment face the highest risks. Indeed, Africans are also unique in that UN employees, international NGO employees and foreign tourists face non-sexual risks when travelling and working in African countries, but Africans, apparently, don't.

The article gushes on about 'multiple concurrent partnerships' (MCP), which 'most students' engage in. This means they have several partners that overlap with each other, rather than several partners one after the other. The author, one 'Correspondent', clearly hasn't followed the issue of MCPs, which Larry Sawers, Eileen Stillwaggon and others have shown does not result in increased rates of HIV transmission. MCP is not "a major driver of [the] HIV epidemic", as Correspondent would have us believe.

The correspondent goes on with the usual cliched stuff, but according to Tanzania's Malaria and AIDS Indicator Survey 2007-08 (THEMIS), HIV prevalence in 15-24 year olds is 5.5% among females with no education and 3.1% among those with an incomplete primary education. And while it is 3.8% among those with complete primary education, it drops to 1.4% among those with secondary education or higher. For males, the highest prevalence is among those with no education or those with incomplete primary education, both at 1.5%. For those with a complete primary education, prevalence is .8%, and only .7% for those with secondary education or higher.

Some of the revered 'risks' for HIV also seem a lot less threatening according to THEMIS. Prevalence among females with a partner 10 or more years older is 5.1% but it only drops to 4.9% for those whose partner was less than 10 years older, the same age or younger. HIV prevalence is higher for females who didn't have higher risk sexual intercourse in the previous 12 months than those who did. It's even higher among those who didn't have sex at all in the same period. Bear in mind, these are young people, 15-24 year olds, most of whom have not been sexually active for long. But surely it's the fact that HIV prevalence is .7% in female virgins and 1.1% in male virgins that's in need of explanation?

According to one of the author's respondents, sex is often for 'subsistence'; but he also says that "the desire for luxury material possessions was one of the key driving factors compelling girls to go for more than one sexual partner". It's hard to know how much of this sort of thing is lifted straight from poorly researched newspaper articles. But given that HIV prevalence for young people in Tanzania stands at 3.6% for females and 1.1% for males overall, prevalence for those with higher levels of education are lower than for those in all other groups.

Far from showing that "Most university students [are] at high risk of HIV infection", the title of the article, one could be led to believe that high levels of 'risky' sex do not lead to high HIV prevalence. Taking into account the figures from THEMIS, one might even suspect that when non-sexually transmitted, and perhaps non-heterosexually transmitted HIV are subtracted, we have been teaching young people the wrong things, and asking them the wrong questions when trying to pad out a rather limp article about student life.

Don't get me wrong, unprotected sex with someone about whom you know little is a mistake; sexually transmitted infections and unplanned pregnancies should be avoided. Abuse of alcohol and other drugs can also have serious consequences and students should be counselled against such behavior. It's also deplorable that anyone should have so little money that they could put their own health and life at risk. But let's tell young people about non-sexual risks for HIV and other blood-borne diseases as well, the risks they may face in health facilities and perhaps cosmetic facilities.

It would be far more instructive to know why HIV prevalence is so much lower among those with secondary education or higher, especially if 'unsafe' sex is as widespread as this and other journalists would have us believe. 1.4% prevalence among young females and .7% among males is totally unacceptable. But wagging our fingers to the bone about sex will not reduce transmission if young people, unknowingly, face easily avoidable non-sexual risks.


[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]

Population Control: Propaganda is Not Information

Ida Odinga, writing for Kenya's The Star newspaper gets it right: an estimated 7,700 women dying each year from pregnancy related complications means the "need to address safe motherhood [is] a human rights imperative". But Kenya's Public Health Permanent Secretary, Mark Bor (also cited in Kenya's Star) attributes "the numerous statistics in maternal mortality and unsafe abortion to unwanted and unplanned pregnancies". Many mothers suffer serious illness, injury and death because of a lack of accessible and safe healthcare. All women attending healthcare facilities in Kenya are at risk, not just pregnant women, let alone those who don't plan their pregnancy. As for unsafe abortion, this is quite separate from conditions in health services because abortion is illegal in Kenya.

Odinga identifies high maternal mortality as "the single greatest indicator of health systems that fail to meet the basic needs of the society's poorest and most vulnerable: women." She also notes that maternal deaths have increased from 414 deaths per 100,000 live births in 2003 to 488 in 2008/9. In addition to the negative consequences for families, communities, the economy, the environment, peace and stability, failure to reduce maternal morbidity and mortality will also keep child and infant morbidity and mortality high. Newborn deaths are currently estimated at 140 per day.

For Bor, population control is the solution to the problem. For Odinga, birth control is only part of the solution Also required are skilled health practitioners, emergency obstetric care and the like; in fact, development of health requires development of education, infrastructure, security and good governance. Bor seems to think that all those things, and more, will follow population control and he sets a goal to increase use of family planning. Even the estimated 70% figure for urban dwellers living in slums Bor puts down to lack of population control, certainly not to a failure of the government to develop cities and reduce the number of people living in unacceptable conditions.

Both Odinga and Bor are probably referring to the same figures, but they seem to start with entirely different paradigms. Odinga appears to feel that adequate levels of development will include better conditions for mothers as one of its consequences. Bor clearly hopes that population control will include adequate levels of development as one of its consequences, that improvements in health, education, infrastructure and the rest will somehow magically follow from greater use of modern contraceptive methods. The experience of countries that are now developing, and of those that are developed, suggests that Odinga is right and that Bor is wrong (although he is not at odds with much of the development community, which shares his paradigm).

Bor is reacting to figures from the "Measurement, Learning and Evaluation (MLE) Project and the Kenya Urban Reproductive Health Initiative (Tupange)". Yet this shows that there is little difference between use of modern contraceptive methods among the poorest and richest quintiles in three of the five areas surveyed; rates are higher among poorer quintiles in the other two areas. Differences in fertility, on the other hand, are quite marked between rich and poor, being a lot higher in poorer quintiles. This could suggest that fertility is related to many factors, rather than just to attitudes towards and use of family planning.

Although the survey finds that about 10-15% of women would like access to contraceptives to space births and about 10% would like to have fewer births, the authors conclude that this represents an 'unmet need' of over 20%. However, giving a response to a survey about contraception does not necessarily translate into greater use of whatever methods the funders of this survey are trying to push. Everyone who has worked in marketing knows that.

Frighteningly, almost half of those using modern birth control methods are using injectable hormonal contraceptives, which are suspected of increasing HIV transmission from women to men and from men to women. Those collecting the data, Bor and others stress the need for education and information, but those without education are not in a good position to evaluate some of the information they may be receiving, especially where that information is, effectively, sales pitch; by pharmaceutical companies selling their wares; by NGOs selling their services; and by politicians and philanthropic institutions selling their ideologies.

Despite decades of pushing birth control on people in developing countries, with promises of development, wealth, success, etc, people are not convinced about much of the 'information' they have been receiving. The vast majority of males and females adhere to beliefs that are considered to be myths by the promoters of birth control. Hardly any say they don't use birth control because of lack of knowledge or because or lack of access or high costs. The main reason for not using contraceptives is a desire to have children.

The research also supports Odinga's contention that the problem relates to health systems, perhaps even health as a whole, through some of its other findings. Providers of all kinds of contraceptive in all areas surveyed had stock-outs in the last year, 40-50% of facilities or higher. Quality assurance has a low priority; many facilities are lacking in basics such as piped water, dedicated phones, storage areas and even appropriate private facilities. 41% or fewer recipients of family planning services felt they were treated 'very well' by their provider. It sounds like those who think family planning is going to solve most problems are not even getting that aspect of health provision right.

While maternal health is an extremely important indication of the health of a nation, low levels of maternal health and high rates of morbidity and mortality will not be addressed by the mere provision of contraception. Family planning is an important right, but it is just a part of overall health, it is not health itself. Many Western institutions and even governments feel that lack of development is due to large family sizes. However, history has shown us that large family sizes are partly due to low standards of health, education, infrastructure, etc. Provision of family planning in developing countries needs to be separated from a population control agenda, which all too often degenerates into various forms of extremism.


[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]

Some Ignorance Kills, Some Sells Newspapers

It's easy enough to associate HIV with 'ignorance' and poverty, which may be why journalists have such a strong tendency to do so, as in this article on HIV in Swaziland. Communicable diseases often infect people in poorer and less well educated communities in greater numbers, though high HIV prevalence is not common to all poor countries with low levels of education. But HIV has often gone in the opposite direction, with higher prevalence among wealthier and better educated quintiles.

Swaziland is not just the country with the highest HIV prevalence in the world, it is also a country where the virus appears to infect people regardless of their wealth and education level, which is another counterexample to the 'ignorance and poverty' reflex. But the subtitle should also raise questions that the author leaves unasked: "Despite improving healthcare and information campaigns, country still has world's highest infection rate". Could there be something about the healthcare and education people receive in some countries that lies behind high transmission rates?

We are told that neighbouring countries have seen HIV prevalence fall, but not Swaziland, because of "cultural norms around sexuality being exacerbated by a financial crisis". But such a vague comment could be applied to any country, with or without high HIV prevalence. Show me the country without any 'cultural norms around sexuality', or even one that is not suffering the effects of the financial crisis. There are lots of countries where sexual behavior remains relatively uninfluenced by public health programs and other attempts to change things.

If "research has found that, despite government information campaigns, understanding of HIV/Aids is poor", it's about time the information campaigns themselves were given some thought. There is a lot of finger-wagging about using condoms, yet condom use is often associated with higher HIV prevalence. Other finger-wagging exercises are about numbers of sexual partners and 'high-risk' sexual partners; while HIV prevalence does appear to be higher among people with more partners, the numbers of people with more sexual partners is far smaller than numbers with one partner, or even zero partners.

For all the sexual risks researchers have thought of for HIV, the majority of new infections occur among people who probably face extremely low levels of sexual risk. Yet, HIV and sex education tends to concentrate almost entirely on sexual risk, to the exclusion of non-sexual risk. The article also notes that attempts to persuade men to be circumcised have not been very successful in Swaziland. And some of those who were circumcised ended up thinking they didn't need to use condoms any more, which is hardly a surprise, given the breathless evangelism that seems to accompany circumcision campaigns.

Oddly enough, newborns are being circumcised in higher numbers; perhaps they take less persuasion. But various randomised clinical trials claiming that circumcision reduces HIV transmission have not shown that circumcision of newborns also reduces transmission. People are receiving what is called information, but how often is it disseminated in the form of disinformation?

Apparently 78% of people in need of antiretroviral drugs are currently receiving them, which is a very high figure if it's true. In the long run this should significantly reduce sexual transmission of HIV; whether it will also reduce non-sexual transmission is not clear yet as too little research has been carried out. We need to wait for the HIV industry to admit that non-sexual transmission occurs enough for it to be in need of research, and that could take a long time. But instead of the old slogan 'don't die of ignorance', people could be advised not to live in ignorance of how they became infected. Because knowing how people became infected can result in a lot of transmissions avoided.

We are told that some of the gains in the fight against HIV in Swaziland have been jeopardized by the financial crisis because some maternal health services were interrupted. In fact, this could reduce the risk of transmission in health facilities, if conditions in health facilities are not safe. Of course, reduced access to health facilities has other negative health consequences. But several African countries with low access to health facilities have far lower HIV prevalence than Swaziland, for example, Kenya, Uganda and Tanzania. And countries with almost no access to health facilities have even lower HIV prevalence than those three; examples are the Democratic Republic of Congo, Ethiopia and Somalia. In many countries, it is those who attend health facilities who are most likely to be HIV positive.

Far from being an argument for reduced health services, this is an argument for ensuring that health services are safe. It is also an argument for investigating the relative contribution of non-sexual, as well as sexual transmission in high and medium HIV prevalence countries. It is also an argument for a bit of analysis when spending money on HIV. It's all very well to be able to provide drugs for everyone who needs them but treatment goes beyond the provision of drugs; health goes beyond the absence of disease; and disease goes beyond HIV; there are many diseases, some of which cause a lot more suffering and death than HIV.

The entire article swallows the assumptions about African HIV epidemics being almost entirely due to sex, without even having to dwell much on sex. There's even the claim that a Swazi MP "had encountered impoverished patients mixing cow dung with water to fill their stomachs in order to be able to take ARVs", a rather dubious story that nevertheless was echoed by the vast echo chamber that is Big Media. Does widespread poverty and starvation really need this kind of nonsense in order to be read?

Improved information campaigns are useless if much of the information is untrue, or if only part of the story is given. This can result in people disbelieving what they are told, whether it's true or not, and remaining ignorant of matters that may save their lives. It's not surprising many are reluctant to test for HIV if they know they will be told it was a result of their sexual behavior. Yet, there's a very good chance that many people were not infected sexually.

It's a lot easier to avoid non-sexual infection than sexual infection, but people need to know it exists and how to avoid it. Countries like Swaziland need better healthcare, but it must be safe healthcare. Information campaigns need to include advice about non-sexual risks as well as sexual risks.

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]

City Dwellers Are From Mars, Rural Dwellers Are From Venus, Or Something Like That

Despite the monstrous quantities of 'unsafe' sex that Africans are claimed to engage in by UNAIDS and other HIV institutions, HIV is not at all distributed evenly. Prevalence ranges from less than 1% in some African countries, a lot less than in some US cities, to more than 25% of the adult population in others (and even 50% in some demographic groups). Even within high prevalence countries HIV is not distributed evenly. In many African countries the virus tends to be far more common in cities, close to main roads, close to health facilities, among wealthier and better educated people, etc. It is also generally far more common among women than among men.

Other research has found HIV prevalence to be higher in areas where diseases such as schistosomiasis (bilharzia) and malaria are higher. However, as these both tend to be higher among less wealthy people with lower levels of education and in rural, as opposed to urban areas, there is more than a suggestion that HIV transmission may have widely varying risk factors. Yet UNAIDS and friends tend not to dwell on most forms of non-sexual risk in Africa.

As David Gisselquist writes in the Don't Get Stuck With HIV website: "Unlike Western countries, where almost all HIV transmission occurs outside families, a lot of HIV transmission in Africa happens within families – mother-to-child and spouse-to-spouse transmission together account for an estimated 45% of new infections." Not only is a lot of HIV not transmitted sexually, but a lot is not transmitted through 'unsafe' sex. Many of these couples where at least one partner is infected have no sexual risks. Hundreds of thousands of new infections every year occur through these two routes.

In Africa, then, the main groups are those at risk of mother to child transmission and married couples, especially couples where one partner has been infected. It's as likely to be the female as the male partner, but how does the index partner become infected, the first in the couple? Sex, says UNAIDS, but sex with whom, how much sex and what kind of sex? Heterosexual sex is not an efficient means of transmitting HIV. Gisselquist is suggesting that the focus of international HIV reduction efforts in African countries should address these and other risk groups, where sexual risk is very likely to be low but HIV prevalence is high; this could cut as many as 700,000 transmissions annually.

A serious set of risk factors could arise from unsafe healthcare and perhaps even unsafe cosmetic services. It's not just that conditions in healthcare and cosmetic facilities in African countries are primitive but also that many people are not aware that such risks exist; if they are not aware of the risks, they will not know that they need to avoid them, nor how to avoid them. But if they are aware, they will also realize that a person's HIV status is not a reliable indication of their sexual behavior. This should reassure some who have been brainwashed to associate HIV with 'immoral' behavior; many women, especially, have been beaten by their partners, ostracized by their communities and even killed because of the incorrect association of HIV with sexual behavior.

The HIV industry does talk a lot about the importance of HIV testing. But they also put people off testing where being positive has such terrible consequences. If people were to know that there were other, non-sexual risks, the stigma associated with testing and with having (or being thought to have) HIV should reduce. People who know their status don't tend to take risks, neither sexual nor non-sexual; but they must also be advised of the non-sexual risks. Those who are infected non-sexually can be involved in sexual transmission just as easily as those who are infected sexually. But in the current climate of sex-obsessed HIV policies, they are unlikely to know about non-sexual risk.

Prevention of mother to child HIV transmission is vital if the mother is already infected. But more effort needs to be made to ensure that mothers are not infected in the first place. A lot of pregnant mothers who are HIV positive have HIV negative partners. How did the mothers become infected? Often they seroconverted well into their pregnancy, or even some time after delivery. As the chances that all women in this position engaged in 'unsafe' sex are low (except in the minds of those who think most Africans engage in 'unsafe' sex most of the time), their non-sexual risks also need to be examined. Why wait till the mother is infected with HIV before intervening to protect her child if the mother could be protected first, obviating the need to protect her child?

In Western countries it's not so likely that HIV will infect several members in the same family, being mainly transmitted through male to male anal sex and sharing needles during intravenous drug use. But, as well as clustering in various demographics and in those close to cities, roads and health facilities, HIV in African countries frequently infects more than one person in the same family. Sometimes, infants and very young children are found to be infected when their mother is not. Others who have no identifiable sexual risks are found to be infected... UNAIDS says 80-90% of transmissions are through heterosexual sex, but this claim is not supported by evidence.

There's little point in looking for a sexual risk, or worse, assuming a sexual risk, when many HIV positive people may not have been infected sexually. And there is no need to impute 'unsafe' sexual behavior to people solely on the grounds that they are HIV positive, which can result in persecution and stigma, even injury and death. Even if non-sexual risks play a relatively small role in serious HIV epidemics, we need to know the relative contribution of both sexual and non-sexual risks if we hope to eradicate transmission altogether. At the rate we are going, we could be missing an awful lot of opportunities to reduce HIV transmission and to eventually eradicate the virus.

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]

HIV Policy: Can Science Be Apolitical?

Several times I have been taken to task for, among other things, using the term 'HIV industry', as if there is some homogeneous group of people beetling away in the field of HIV who all think pretty much the same way. But my use of the term is a way of expressing the view that many people benefit from HIV as if it is, to them, a kind of commodity. Interestingly, a paper called 'Limits to evidence based health policymaking: Policy hurdles to structural HIV prevention in Tanzania' (link to full article), by Moritz Hunsmann, cites some people who make money out of HIV and also use the term 'AIDS industry'. (I chose 'HIV' rather than 'AIDS' because where prevention is successful, even where treatment and care of HIV positive people are successful, AIDS is less common; otherwise my blog would be called 'AIDS in Kenya'.)

Because of a massive inflow of international funding, "HIV is big business", "thousands of people make a living from HIV/AIDS in Tanzania", "many people in Tanzania would prefer HIV being there for a while!", according to various respondents. There is a demand for money to do things that the big NGOs are experienced in doing, such as abstinence workshops, rather than, say, reducing co-factor diseases in HIV transmission, like malaria, schistosomiasis and TB. What HIV money is actually spent on is not a matter of evidence, it's a matter of interest. Worse, the policies are heavily influenced by those same interested parties.

In contrast to the lowly role of evidence in the choice of priorities, quick political returns are vitally important. Broader 'structural interventions', which may address the "legal, political and socio-economic contexts in which people make behavioural decisions", are not only too long term, but outcomes that don't relate fairly directly to HIV are considered to be 'externalities'. Behavioral interventions are considered to deliver quick returns, even though many would admit that they have delivered very little; it is the sheer amount of money that has been spent on them that is presented as the measure of their brilliance.

Ironically, if an intervention were to eradicate schistosomiasis, malaria and other diseases which have been shown to be significant co-factors in HIV transmission, the very fact that these diseases affect hundreds of millions of people would make it look like the money had been wasted. That hundreds of millions of lives would be improved and millions more saved would be 'externalities'. For far smaller amounts of money, a lot more could be achieved by addressing co-factors, and HIV transmission would also be reduced at the same time. But the 'vertical' approach to HIV (and other diseases) means that a parallel health system has been cobbled together which, while failing to reduce HIV very much in the last 10 years, has had little or no impact whatsoever on other diseases.

The amounts of money involved in Tanzania' HIV epidemic are mind-blowing: "97 percent of HIV-related expenses are donor-financed and external support for AIDS control represents over ten percent of public expenditure and one third of all international aid", "available resources for HIV/AIDS increased fifteen-fold between 1994 and 2007, reaching USD 520 million annually - roughly the equivalent of the country’s health budget for all non-HIV concerns combined", etc. Much of the money over the last 10 years comes from the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for HIV (TB and malaria).

A common excuse given for not changing the way HIV is currently addressed, as mainly a matter of individual sexual behavior, is that "We don’t want to complicate our messages"; the excuses go on: “[P]eople would feel safe and may not protect themselves anymore” if they thought it wasn't purely a matter of sexual behavior. Yet these are also reasons for not implementing mass male circumcision programs or pre-exposure prophylaxis (PrEP). But as the author says: "Changing a whole continent’s sexual behaviour ... is generally considered a feasible endeavour." A whole continent's assumed sexual behavior, that is. High levels of unsafe sexual behavior were attributed to high HIV prevalence countries because heterosexual HIV transmission is not efficient. But attributed levels needn't be so high if the biological co-factors Hunsmann and others are drawing attention to are added to the equation.

Interventions that go beyond sexual transmission of HIV, including structural interventions, are not more costly or less cost efficient, as some would claim. Nor are they in any way less relevant to HIV. There is no lack of evidence for their effectiveness, unlike the behavior change interventions on which so much has already been spent, the effectiveness of which was unknown before the were implemented and is all too well known now. Rather than risking underselling Hunsmann by paraphrasing his conclusion: "Excluding the political nature of prevention policymaking from the analysis exposes AIDS players and scholars to repeated frustration and hampers the formulation of scientifically sound and politically informed strategies for positive change."

Much though I appreciate Hunsmann's approach and his careful analysis, I wonder if he is being polite towards scientists or if I am misunderstanding him. Many scientists also appear to be part of the HIV industry and to use or not use evidence, depending on the circumstances. I wouldn't suggest that policy makers are too scientific, far from it, but I suspect many scientists of being highly political, perhaps far more political than rational at times. Surely many of them are also involved in policy-making? Surely many of them have control of substantial budgets? Perhaps the struggle between science and politics is sometimes within, rather than between, various players.

Africa: Contraception Is So Good It Should Be Compulsory?

It's a very misleading title: 'Contraception for the 215 Million Women Who Want It'. It turns out that 215 million is the number of women "who want – but do not have – access to or information about modern contraception". The article goes on to suggest that the implications of this lack includes "complications from pregnancy and childbirth", these being "the leading cause of death among women in their reproductive years in developing countries".

However, if women in Western countries were suffering from complications during pregnancy and childbirth, would it be concluded that many of them shouldn't have had a child, or shouldn't have had so many children? Many of the 350,000 maternal deaths per year could be prevented by safe and accessible healthcare. So why is contraception so often held up as the most appropriate solution?

In fact, some contraceptive methods probably involve substantial risks to women, especially in developing countries. Injectable Depo Provera hormonal contraceptive, hardly used outside of high HIV prevalence African countries, has been implicated in increasing transmission of HIV from women to men and from men to women. Some other forms of birth control involve invasive procedures, which also carry the risk of transmission of HIV and other blood borne diseases.

So the issue is confused: Western NGOs have always been keen on birth control for developing countries, for purely eugenic reasons and because of fears of a 'population explosion' and the inability of the world to produce enough food for everyone; so they tend to cite figures that suggest that birth control is the answer to various problems relating to development, sometimes even all problems relating to development.

The article calculates that if everyone who is said to need information on contraception has fewer (or no?) children, maternal mortality will be cut by one third, infant mortality by 10-20% and the need for abortions by 70%. Even the need for maternal and newborn health services is acknowledged, but not the need for safety. In some countries (such as Ethiopia), it is the very people who receive maternal health services who are more likely to be infected with HIV. Universal access to safe healthcare does, indeed, save lives. But is the author of this article advocating healthcare for all (safe or otherwise), or just healthcare that involves uptake of contraceptive services at levels that the Bill and Melinda Gates Foundation would approve of?

Because it is the Gates Foundation that is behind the article, although it is written by Kathy Calvin of the United Nations Foundation, funded by Ted Turner, another philanthrocapitalist who shares Gates' worries about world hunger, overpopulation, food shortages and the like. So what are the limits of 'healthcare' and even philanthropy for such people? After all, Gates is also behind other dubious programs, such as mass male circumcision, unethical research, almost total reliance on drugs and other technological solutions, genetically modified organisms, geoengineering, etc.

There's always the claim that contraception, especially certain methods, 'empower' women. But which ones do? Ones that may increase risk of infection with HIV, like Depo Provera? Ones that involve other healthcare risks? Or is it just the ones that make a lot of money for pharmaceutical companies and others who have a vested interest? Many NGOs have been set up to work primarily with birth control and receive a huge percentage of aid money every year. The article mentions 'voluntary' contraception, but I wonder how voluntary a lot of programs are.

Of course, associating such programs with women's empowerment, maternal and child health, environmental sustainability and protection of resources makes it difficult for anyone to question the fervor for advocating for something on behalf of people who may not have had much say in the matter and may themselves feel quite differently about it. I don't doubt that the UN and Gates Foundations have "the power to save the lives of women today, and create a better world for tomorrow", but I am not convinced that is their aim. I'm not convinced that either operate in a transparent and democratic manner; and by 'democratic', I don't mean 'administrated by Westerrners'.

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]

HIV Drugs Necessary But Nowhere Near Sufficient for Treatment or Prevention

Under new US guidelines for HIV antiretroviral treatment, it is now recommended that all HIV positive people receive the drugs, regardless of what stage of disease progression they have reached. Draft UK guidelines, on the other hand, recommend treatment where CD4 cell count, a measure of immune function, falls below 350, though treatment may be started earlier under certain circumstances.

But, as an article on the UK guidelines points out, patients should "be told that the evidence of a lower risk of transmission on treatment mainly relates to vaginal sex, not anal sex, and that use of condoms will continue to protect against sexually transmitted infections as well as lowering any residual risk of HIV transmission." This is important because in UK and US contexts, most HIV transmission occurs among men who have sex with men and intravenous drug users.

Reminiscent of mass male circumcision campaigns and the insistence that injectable Depo Provera hormonal contraceptive is safe in African countries, we are told that condoms also need to be used even when on antiretrovirals. In other words, under ideal conditions greater access to antiretroviral drugs should reduce HIV transmission; but a lot of transmission, perhaps most, occurs where ideal conditions do not prevail.

But the caution seems justified by the finding that HIV transmission continues to occur among men who have sex with men who are receiving treatment. One of the reasons may be that a substantial number of men with an undetectable viral load in their blood have a detectable viral load in their semen. As for the effect of widespread antiretroviral use on behavior, this is not so clear. Will one of the results be 'disinhibition', the adoption of unsafe behaviors because HIV is no longer seen as such a threat?

Things are quite different in African countries, many of which have far higher HIV prevalence figures than found anywhere else. It's not just that epidemics are far more severe but the virus is not confined to identifiable risk factors. Men who have sex with men, intravenous drug users and probably even sex workers contribute a relatively small fraction to overall country epidemics. In stark contrast with non-African countries, most transmission appears to occur among people who face very low sexual risk.

It is possible that 25% or more HIV positive people in African countries know their status; some countries claim 30 or 40% do, though such claims are hard to verify. But it seems unlikely that enough money will ever be forthcoming to treat even those who know they are positive, let alone all HIV positive people. Estimates of how much it would cost seem to concentrate on figures that are not so difficult to guess at, such as costs of commodities like drugs. But the overall cost of treatment, which includes a lot more than just drugs, is so difficult to guess at, most don't bother trying.

A few years ago, someone came up with a suggestion that everyone at any risk at all of being infected with HIV should be tested, perhaps every year or more, and everyone found to be infected should be given antiretroviral drugs. But even the logistical difficulties involved in testing so many people once may prove insurmountable; they are certainly inscrutible. Even the much vaunted mass male circumcision program has been shown to be a lot more expensive when you include the overall costs, which likely double the $60 figure that is often bandied about.

Indeed, drug supply chains are not an easy matter for any country, but especially for a country like Tanzania, where health services have been decimated by structural adjustment policies and torn apart by various vertical health programs, especially HIV related programs. A recent article finds that many millions of dollars worth of drugs have been lost because they expired before being used. Some may have been 'donated' shortly before expiration or even after; others may not be of any use in Tanzania. But it's a huge loss for this health service, albeit one that is virtually inaccessible to many Tanzanians.

The new guidelines on antiretroviral drug use may be, in part, a reaction to research data. But it's hard not to wonder if it is also a reaction to substantial lobbying by pharmaceutical manufacturers and others who profit from ever increasing use of these very expensive drugs. The US guidelines, in particular, will be very good news for Big Pharma. It's hard to know how good the news will be for those with HIV or those who are at risk of being infected. I have been sent a link to a list of those who write these guidelines and their financial disclosures. That's very Big Pharma indeed!

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]

SAVE: Safer practices, Access to Treatment, Voluntary counselling and Testing, Empowerment

When I see a title like 'Kenya: War Against HIV/Aids Stepped Up', I expect it to be more of the same, sex, stigma, blame, etc. But this article suggests a genuinely more inclusive HIV strategy and specifically rejects the sex-only, immorality theory of HIV epidemics in Africa. ABC (Abstain, Be faithful, use Condoms), the article points out, has failed to reduce HIV transmission enough to eradicate the virus; it has also done a lot to spread stigma and blame. It is mostly directed at heterosexual sex and ignores other kinds of transmission. It also divided those who chose to oppose condoms and even being faithful to one partner, insisting that abstaining from sex was the only way to prevent transmission.

It seems there are those who would like to stress "the need for urgent comprehensive prevention strategies that tackles all the facets of the epidemic". Of course, those promoting ABC, or even abstinence only, claimed they were tackling all facets. It is proposed that ABC be replaced with another acronym, SAVE, which stands for Safer practices, Access to treatment, Voluntary counselling and testing and Empowerment. All four facets of this strategy could include non-sexually transmitted HIV, such as through unsafe healthcare or cosmetic services. Apparently even religious groups find it less polarizing than ABC.

Those promoting SAVE correctly point out that ABC placed little or no emphasis on testing, care and treatment for infected people. These also play a significant role in reducing HIV transmission, as well. But, despite blaming ABC for leaving out women, effectively disempowering them, or failing to empower them, circumcision is one of the interventions that is advocated for. This intervention does little to reduce transmission from women to men and it probably increases transmission from men to women. It is likely to have an overwhelmingly disempowering effect, as men pretend and women believe that circumcision is connected with lower HIV rates, perhaps with complete protection against HIV.

However, the article goes on to mention things such as "use of sterile injection equipment and ensuring that all blood transfusions are tested for HIV", also "standard hygiene precautions such as gloves and clean needles for all patients". These are issues that WHO, UNAIDS, PEPFAR, the Global Fund and various other big players in the HIV industry have long refused to address, or even discuss. Now that funding is thin on the ground, it would be better for countries like Kenya to decide on their own approaches to HIV, given how badly the big funders have done. The last thing the country needs is to adopt a new strategy but to have all the priorities set by external funders; that's what happened to ABC, which started as a weak idea and became a lot weaker, in the form of abstinence only.

Access to treatment is in serious need of work so that a far hiigher percentage of HIV positive people are able to reduce illness, live longer and even avoid the risk of infecting their partner, either through sexual or non-sexual contact. And it seems as if the prevention of mother to child transmission (PMTCT) program is not doing well at present. If SAVE can get this on track, it would have a huge impact on transmission rates. PMTCT can work very well, reducing transmission to just a few percent. However, it is reported that only 4% of pregnant women started antiretroviral therapy within six months of diagnosis in Kenya. That sort of coverage will make little impression on overall transmission rates and it is disappointing that this opportunity has, so far, been almost entirely missed.

It is also disappointing that women themselves have not received as much attention as their children (although a lot of that turned out to be mere lip service). If more attention was paid to women before, during and after pregnancy, if they had access to safe healthcare, HIV transmission to women might be a lot lower. This would be an even better way of reducing transmission to children, if the mother wasn't infected in the first place. Many countries have notably high rates of HIV infection among mothers who have received professional healthcare. Let's hope SAVE achieves all of its aims, which appear to include safe healthcare.

A spokesperson for the SAVE strategy points out that treatment and care are not just a matter of giving people drugs, which is often the best that many can expect in Kenya; some don't even get the drugs. But there are other disease that are in as much need of prevention and treatment as HIV; it can not be dealt with in isolation. And health is more than just the elimination of diseases; people need good levels of nutrition and access to clean water and sanitary conditions.

Professor Alloys Orago of the National Aids Control Council sounds a bit lukewarm about SAVE and points out that ABC "has had gaps" but can not "be discarded all together". SAVE doesn't appear to want to discard ABC, but to build on it. Orago says "ABC effectiveness has not been felt because many organisations working around HIV/Aids agenda failed to implement it fully and their approach tried to portray HIV fight as a moral question and not looking at it holistically", which could easily be interpreted as meaning that it wasn't up to the job; though I don't think that's the intention.

We don't need more ABC because it was derailed by those who had their own agenda. SAVE could suffer the same fate if those with the big money are attracted to it. The only hope would seem to be if those in Kenya who believe things could be different refuse to give in to those with various axes to grind (and the money to ensure they do the grinding). It's good to hear that some big international NGOs are supporting the initiative, as long as they are free to spend their funding as they see fit. Hopefully we'll hear more about this initiative.

[For more about non-sexual HIV transmission and how to avoid it, see the Don't Get Stuck With HIV site.]