Deal With Your Anger Wisely, Obama

Obama is 'angry' over the spread of HIV/Aids. It appears he's angry with African governments for not doing anything about the epidemic and perhaps with Africans for doing the spreading. That seems to be the direction his thinking takes. He says "treating patients while others are catching the virus is untenable."

"We are never going to have enough money to simply treat people who are constantly getting infected," he said. "We've got to have a mechanism to stop the transmission rate."

I couldn't agree more. That's why I believe some of the main actors in the HIV industry should find out why HIV transmission is so high in some African countries and in some sectors in some African countries, yet it is low in other countries and other sectors. These actors include UNAIDS, the WHO, the UN as a whole, the US Center for Disease Control, universities such as Johns Hopkins and various other extremely well funded institutions. I assume Obama has some influence with them. (That he has influence in Africa is not in question but how that influence works or how legitimate it is are less clear.)

And while we're on the subject of money, my guess is that the amount of money made out of HIV dwarfs the amount spent on it, it's a good investment. Institutions like the ones mentioned, various commercial interests and other big NGOs have done very well out of funding over the years. So let's not pretend that money is leaking out of the US and the country gets nothing in return. And the absolute amount of HIV money coming from the US may be high, as Obama claims, but as a percentage of GDP, the US is nowhere near the highest contributor.

The “retrogressive culture that makes females satisfy the pleasure of men” that Obama says is responsible for the “upswing in new HIV/Aids infections in Africa” is, presumably, the same culture that gave rise to a Black American politician who won the last US presidential elections. Has he anything to say about the retrogressive culture that allows billions of dollars to be spent enriching rich people and institutions while Africans die?

"In Africa, empowering women is going to be critical to reducing the transmission rate because so often women, not having any control over sexual practices and their own body, end up having extremely high transmission rates”.

Women all over the world have little control over sexual practices and their own body but nowhere in the world are HIV rates as high as they are in some Southern African countries. The entire cash-rich industry has failed to explain what is behind the source of their wealth and power: HIV epidemics in certain African countries.

It's great to hear that the "US has a huge interest in public health systems in Africa" because health systems have been ignored for several decades, with all the attention being concentrated on a handful of diseases considered newsworthy enough to attract funding. Let’s get on with it.

It's hard to believe that such statements as the ones found in this article could really emanate from one of the most powerful politicians in the world. Doesn't he have anyone to do his publicity or to provide him with up to date information? It is not true that in Uganda "infection rate was about 30 per cent in the late 1980s". Prevalence in certain sectors of the population may have reached that level but there was never a time when 30% of sexually active people in Uganda were HIV positive. HIV prevalence did reach such levels some time later, but not in Uganda.

There was no "politically-led three-themed campaign - for Abstinence, Being faithful and Condom use or ABC model - [that] helped drive down the rate to an average six per cent." ABC didn't exist till the late 1990s and it was not dreamed up in Uganda. The abstinence only campaigns imposed by his predecessor on Africa in the early 2000s have had little or no effect in Uganda, just as they had little or no effect in the US. They may have been confusing but most behavior change programs failed, so any damage they could have done may have been similarly limited.

If Obama wants to "explore workable preventive programmes" he needs to challenge the behavioral paradigm, the view that most HIV is transmitted sexually in African countries. He needs to question the view that Africans have unbelievable amounts of ('unsafe')sex with incredible numbers of partners.

If he wants to "build greater public health infrastructure", he needs to be informed about basic distinctions between vertical approaches to health, which target individual diseases and horizontal approaches, which concentrate more on primary healthcare. And he shouldn't be distracted by nice distinctions like 'diagonal' approaches, which claim to be some kind of 'third way'.

And if he wants to "institutionalise country-specific interventions", he needs to campaign for the abolition of UNAIDS and perhaps other big players in the HIV industry. Their programs to date have painted whole continents with the same brush, failing to identify all the ways that HIV is being transmitted and ignoring some of the most vulnerable groups. Buzzwords like 'global health' seem to lead, inexorably, to this sort of broad brush policy.

Massive rates of HIV transmission in African countries can not be explained by resort to myths about the great sexual appetite Africans have. And no research has yet demonstrated that Africans have more appetite for sex than people who live in other continents.

Rapid rates of HIV transmission can partly be explained by very low standards of healthcare, where the majority of injections given in healthcare settings are not necessary and are unsafe, very likely to transmit HIV, hepatitis and various other infections. The extent to which unsafe healthcare could explain high rates of HIV transmission in African countries is unclear, because the HIV industry, in all its splendor, wealth, power and wisdom, has never seen fit to investigate.

Please Mr Obama, before you consider punishing anyone, try to establish what wrong has been perpetrated and who has perpetrated it. The important thing is to reduce HIV transmission, not to apportion blame, despite what the Christian Right may tell you. But unless we are clear about how HIV is being transmitted, and you seem very unclear, we will never reduce transmission enough to eradicate the disease.

Will a New HIV Boss at WHO Make a Difference?

The World Health Organization (WHO) has a new head of HIV called Gottfried Hirnschall and he gave an interview recently to IRIN. Apparently he feels that, as a prevention message, abstinence is unrealistic. That's good, but not good enough. Abstinence didn't just fail because it's unrealistic. There's no reason why the option of choosing not to have sex under certain circumstances shouldn't be part of a comprehensive sex education program. It's just better if it's not called 'abstinence' and if it isn't the only trick in the box.

There are probably many reasons why HIV prevention programs have failed in African countries but the one reason that WHO, UNAIDS, CDC and all the main HIV institutions refuse to countenance is that not all HIV is transmitted sexually. They go as far as admitting that a small amount is transmitted non-sexualy, but not enough for them to bother spending money or time on. And sure enough, Hirnschall mentions male circumcision and 'treatment as prevention'.

But what does treatment as prevention involve? Because HIV positive people who are responding to antiretroviral treatment (ART) eventually have a low viral load, they are very unlikely to transmit HIV to their partner. If it were possible to test every sexually active member of a population regularly, say once a year, anyone found HIV positive could be put on treatment.

There are just two small flaws. One is that persuading the majority of sexually active people to be tested even once, even to save their lives, has proved elusive. The second is that the majority of people who are currently in need of treatment are not yet receiving it. Much of the funding for HIV treatment that was so fothcoming in recent years has been cut or flatlined. Just as the WHO released new guidelines that would put more people on ART, there isn't even enough money to keep some people already on treatment in drugs.

People on ART need to take the drugs every day for the rest of their lives. If they miss their dose too many times, resistance builds up and they need to move to a different drug regime, a far more expensive one. It is very difficult to get credible figures on what percentage of people in African countries are adhering to ART. But numbers of people dying from Aids is suspiciously high in some countries. It would be one thing if those providing people with the drugs could afford the second or third line drugs for those who develop resistance. But some countries are in the position of not even being able to afford first line drugs.

Hirnschall is asked about the shortage of money and he mentions 'task shifting', things like training nurses to do what doctors have been doing up till now. For people who don't mind being seen by a doctor or who really don't need to see a doctor, that's fine. Most people in developing countries don't get to see doctors anyway, they are too scarce. But even nurses are scarce and they are pretty stretched already. Perhaps more nurses will be trained and these ones will not be poached by rich countries.

So much for treatment, though it's not very much. But will those advocating putting more people on treatment get around to preventing new infections? Ok, they like to say that treatment is also prevention, but from a practical point of view, this will not work. People are becoming infected faster than others can be put on treatment and if money for treatment becomes scarce, where will prevention be then?

First of all, not all HIV is transmitted sexually. It needs to be established how much is coming from non-sexual routes, such as unsafe healthcare and other things. And this needs to be dealt with because it sure as hell won't stop by handing out condoms, circumcising men and telling people how to run their sex lives. Hirnschall thinks that a HIV vaccine would be ideal. But what would be ideal would be to establish where most HIV infections are really coming from so that, even if there were a vaccine, we wouldn't need to waste so much money on it.

Second of all, if Hirnschall is worried about where all the money is going to come from if donors are thinking of pulling out he should get on to the issue of generic drugs. He talks about negotiating with big pharma. What's the point of negotiating with them? They want the highest price they can get, they know people in developing countries can't pay it but they think donors can. They will never reduce their prices to a reasonable level. The only way to ensure that drugs are made available at an affordable price is to open up the market to generic producers.

Of course, big pharma don't want that, they don't want to compete, they want to hide behind the protectionism of intellectual property 'rights'. There are companies well able to produce enough generics to supply everyone who needs ART, to scale up treatment and to continue treating people who go on to need second and third line drugs, as many people eventually will. This has to happen some time. It should have happened a long time ago. Will Hirnschall just drag his heels the way all the others are doing?

Is the WHO's new head of HIV just going to give us more of the same? Or is he going to question the behavioral paradigm that says that most HIV is transmitted sexually? And is he going to stop 'negotiating' with the blood suckers in big pharma and open up the drugs market to competition? If his aims are to reduce HIV transmission and eventually eradicate it, and to treat as many HIV positive people as possible, he will have to take both these steps.

You've Been Bad: No Sex for a Month

One of the noticeable characteristics of many HIV researchers is that they seem to have a liking for telling people how to run their sex lives, who to have and not to have sex with, when to have sex, where to have sex and what sorts of sex to have. Crucially, they feel the need to tell people in developing countries these things. They certainly don't tell people in rich countries, unless they are men who have sex with men (MSM) or commercial sex workers.

This is because, typically, HIV researchers toe the line on HIV transmission: that in high prevalence countries, it is almost all transmitted through heterosexual sex but in low prevalence countries, it is mainly transmitted by MSM, intravenous drug users and perhaps commercial sex workers. These researchers seem to see themselves as arbiters of good sexual behaviour and they can even threaten to come along and circumcise anyone who misbehaves, as long as they are not already circumcised, of course. If they are circumcised they are considered to be better behaved than the uncircumcised, anyhow.

So two of these intrepid researchers have come up with a plan to have an official 'no sex month'. The thinking behind this is that HIV positive people are most infectious when they have just been infected. At this stage, they will probably not know they have been infected and even if they test, they will probably not receive a positive result. Anyone going through this stage of HIV infection during a no sex month will avoid transmitting the virus, at least for a while. Once they have gone through to the next stage, they will be far less infectious and, hopefully, they will be tested before they reach the third stage, during which they will be highly infectious again.

There are people to whom this proposal will not appeal, specific groups that these researchers will probably want to include. Commercial sex workers will be unlikely to forgo a month of earnings, for example. (And intravenous drug users could be relatively unaffected by the cunning plan.) But the researchers point to the Muslim month of Ramadan, where Muslims abstain from sex during daylight hours. I wonder if they have done any research into whether this has had any impact on HIV transmission, aside from their assumption that because HIV is often lower among Muslims, Ramadan could the the key. And is daytime sex more likely to result in HIV transmission than nighttime sex? Or perhaps daytime sex is seen as more in need of censure.

Well, because we are talking mainly about African countries, it will probably be seen as perfectly reasonable to 'test their hypothesis' on the people. After all, they clearly have too much sex, of the wrong kind and possibly even during the day. Why these researchers see their proposal as a one off is not clear. But they are wrong in saying that it 'does not create additional stigma'.

The behavioural paradigm, which says that HIV is mainly transmitted heterosexually in developing countries, is what causes the main stigma that attaches to HIV. It is because people in developing countries are being told that they have too much sex, and sex of the wrong kind, that HIV is stigmatized, that people are made to feel that they are bad people, who must be censured and punished, if necessary.

More importantly, the behavioural paradigm is completely unfounded. HIV is not mainly transmitted by heterosexual sex in developing countries. The extent to which HIV is transmitted non-sexually is not clear precisely because researchers like the two in question refuse to consider non-sexual transmission as being important enough to research.

If, as a result of this 'experiment', HIV rates are found to have dropped, this will not necessarily mean that sexual transmission will have been cut. Non-sexual transmission, for example, through unsafe medical practices, could also go down during the no sex month. Sex workers and MSM, if they do give up sex, will have less need to visit sexually transmitted infection clinics to receive jabs and contraceptive injections (very popular among sex workers). These are likely routes to HIV infection through unsafe injections. Will the research take such circumstances into consideration?

Perhaps the researchers would like to carry out another experiment on this obliging and convenient population of human beings: perhaps they would like to have a medical safety month. During this month, it would be ensured, not just that every health care worker takes the utmost care during every procedure, but that there are enough health care workers everywhere and all of them have enough equipment so that they don't need to reuse anything or do anything that could put their patients at risk. During this month, Everyone in the country would have access to safe health care, no one would have to resort to some quack wielding a much reused needle and no one in the health care industry would have to take any risks because of lack of resources.

Apart from seeing how this affects HIV transmission, it would be interesting to see what sort of demand there was for treatment and what levels of diseases and other health conditions would be revealed. But if no sex months provide a 'potential strategy', then so do medical safety months. Indeed, medical safety months would have benefits that go far beyond HIV transmission. Perhaps we could have clean water and sanitation months, where people are provided with enough water and sanitation facilities to reduce some of the biggest killers in the developing world. The possibilities are endless, we could have infrastructure months, electricity and lighting months, connectivity months and many other types of month.

The researchers assure us that a no sex month would produce "easily verifiable data with regards to adherence, evidenced in the number of births occurring nine months after the campaign". And I'm sure all the other types of month would also supply vast quantities of data, such as maternal health figures, infant mortality figures, child mortality health figures, nutrition figures, disease mortality figures, more data than you could shake a circumciser's scalpel at. In fact, I don't think you would need to threaten people at all, I really think they would go for these dedicated months without any incentive. They may even demand that such benefits be granted to them all the time, not just for a month.

Even the researchers themselves warm to their theme and suggest that such months could be adapted for different populations "depending on what is driving the epidemic". So, among miners in South Africa they suggest a 'no commercial sex' month. But how about a no mining month? Then they could have a significant impact on the TB epidemic, which is driven by the mining industry and is said to spread hand in hand with HIV.

The researchers conclude that "In hyper-endemic countries policy-makers, populations and politicians are open to new ideas to address the epidemic". But are these researchers open to new ideas? Are UNAIDS and CDC open to new ideas? The biggest new idea, which is only new in the sense that it has been ignored by those who are best placed to apprehend it, is that HIV is not only transmitted sexually, that the behavioural paradigm is wrong. No new discovery needs to be made: these people and institutions simply need to tell the truth. A 'no lies' month from UNAIDS would do more to reduce HIV transmission than all their HIV 'prevention' programs, past, present or future.

HIV Industry Admits They Got it Wrong? Sort of!

The US has launched a new grant to help developing countries to strengthen their health systems. The term 'health system strengthening' has become quite fashionable recently. But it's usually used by defenders of the likes of PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global fund, who argue that their funds do not target HIV at the expense of other diseases or of health systems strengthening. Remarkably, the article about this new fund, the Global Health Initiative, flatly contradicts these claims and even reads like an admission that mistakes have been made. Such admissions are rare, but vital if serious diseases such as HIV are to be controlled.

In another article, it is noted that the amount of money spent on HIV in Tanzania has risen by over 2000% between 2001 and 2007, from 17 to 381 billion Tanzanian shillings (11.5M to 259M USD). And the author is encouraged that in the same period, prevalence has dropped by 1%, from 6.7% to 5.7%. Is that encouraging? Hard to say, but apparently "Some of the biggest challenges in the fight against HIV/Aids are embezzlement and mismanagement of funds." One wonders where prevalence would stand if the money hadn't been embezzled and mismanaged. In some sectors of the Tanzanian population prevalence has been increasing.

The article ends with the conclusion that HIV was not adequately addressed because the focus was on the health sector, whereas this disease in particular is not simply a health problem. But you could argue that diarrhoeal diseases and intestinal parasites are a matter of water and sanitation, respiratory diseases are a matter of environment and housing and malaria is a combination of all of these factors and perhaps some others. None of them are 'simply' health problems.

Yet, it is true to say that you can't just reduce HIV transmission by sending everyone to a clinic and giving them counselling and drugs if they are infected and lecturing everyone who is not infected about safe sex and perhaps giving them condoms. This has been tried and has failed. Amazing amounts of money have been thrown at HIV and the result has been a continuation of very high levels of transmission and a distinct lack of understanding of why some countries and parts of countries have such profound HIV epidemics and why some do not.

So, like other diseases, HIV epidemics are not just a matter of dealing with a particular pathogen, you must also consider the host and the environment. Looking at it (and other diseases) from this point of view, there are a lot of ways of spending 381 billion Tanzanian shillings aside from on health aspects alone. Many people are said to be more susceptible to HIV infection because they don't have a choice about when, how often or with whom they have sex. Others are susceptible because they have various health conditions that make them so, for example, malnutrition, intestinal parasites, sexually transmitted infections, TB, malaria, etc.

As well as dealing with host factors, then, money could be spent on environmental factors, water and sanitation, infrastructure, gender relations, equality, poverty and many other things. But anyhow, the claim is that the money was spent on the health sector, not on health systems (supply chain management, health worker retention, information management, etc). And it seems fairly clear that money has not been spent on health systems, pace the argument for the Global Health Initiative and contra the unconvincing arguments of Global Fund and PEPFAR proponents.

But here's a thing, you could argue that those tenets of epidemiology leave out something very important, perhaps most important when the epidemic is HIV: nosocomial infections. This is where the disease is spread by medical procedures. The pathogen is clearly being introduced into a host, but artificially so and the environment is a rarefied but highly risky one. Do nosocomial infections, to some extent, elude epidemiologists altogether (or just those who work for UNAIDS, WHO or CDC and a few other institutions that have a lot of influence in the HIV industry)?

Following the pronouncements of those august institutions, you would think that nosocomial infections hardly infect anyone in developing countries, with the rare exception of some of their own employees who happen to be working in those countries and have to use the same medical facilities as the natives. Don't worry, that has probably never happened, though that doesn't stop them from warning their employees.

Ignoring other diseases, health in general, water and sanitation, nutrition, environmental conditions and structural conditions in the fight against HIV has been unbelievably stupid. Equally stupid is the failure to ensure that there were adequate health structures in place to implement various HIV prevention and treatment initiatives, however misguided some of these may have been. In fact, in countries like Kenya, health structures were being dismantled from the 1980s onwards at the instigation of institutions like the World Bank (yes, the one that came up with the Global Fund!).

In admitting that health systems have been ignored, the HIV aristocracy may be getting just a little closer to admitting that their view of HIV transmission in developing countries is in bad need of reconsideration. They still tell us that HIV is almost entirely transmitted through heterosexual intercourse in developing countries. But it would seem very hard to maintain this view when the Global Health Initiative is admitting that health systems have been ignored and this has done a lot of damage and has wasted much of the money that has been poured into HIV so far.

Huge amounts of money have been and still are being spent on trying to get people into medical facilities, to be tested and/or treated for HIV and many other diseases. Pregnant mothers are encouraged to go to clinics and to bring their babies and infants to be vaccinated. Men are being encouraged to go to clinics to be tested and/or treated for HIV and sexually transmitted diseases and even non-communicable diseases. But if health advocates want people to go to health facilities, they would need to make sure those health facilities are safe enough that people do not become infected with something as life-threatening as HIV. People need to be made aware of the risks they face in health facilities and those health facilities had better be improved quickly and thoroughly. I don’t think the admission that grotesque mistakes have been made was intended but it has certainly let the genie out of the bottle, well, one of them.

Facts, Facts, Facts, Just Not That One

In an article entitled ‘Aids and Evidence: Interrogating Some Ugandan Myths’, Tim Allen concludes something that others have also concluded about HIV, in relation to Uganda, in particular: ‘Much less is known about the epidemic than is asserted’. We don’t know why prevalence and even incidence in Uganda dropped from very high rates in the 1980s to far lower rates in the 2000s. There is a lot of speculation about why this happened, but it remains speculation. It is possible that much of the apparent improvement in Uganda’s epidemic was a result of the disease taking its natural course. And it is fairly clear that many of the things that are said to have contributed to the epidemic’s decline either didn’t occur or didn’t have much effect.

It was established quite early on that HIV could be transmitted through blood and other bodily fluids, not just through sexual contact. This meant that people could be infected through medical procedures such as injections and blood transfusions, intravenous drug users could be infected, HIV positive mothers could pass on the infection to their babies, either in the womb, during delivery or through breastfeeding and people might even be infected by their hairdresser or manicurist, if they didn't take proper precautions. Early on in the epidemic, these considerations probably influenced the measures that countries such as Uganda took to reduce the spread of HIV. But later, as HIV became more dominated by political and religious leaders, it was treated as if it was almost entirely sexually transmitted. According to the official view, this is only true of developing countries, though.

For me, the thing that doesn’t ring true in the many allusions to Uganda’s great success in fighting HIV is that they all assume the truth of the behavioural paradigm. They all assume that because HIV is mainly sexually transmitted, what a country needs to do is tell people everything about ‘safe sex’, give them some condoms and everything will be ok. When Uganda first started putting in place measures to reduce the spread of HIV, they probably didn’t subscribe to what became the enduring fiction that drives HIV policy, national and international. But later, when donors, politicians, religious prognosticators and commercial interests become involved, Uganda said whatever was required to get the money flowing and to keep it flowing.

Because the most prominent people in the industry so much want everyone to believe that HIV is primarily sexually transmitted, they even want to believe it themselves, they have rewritten everything that happened before the fiction was created. They so much want this fiction to be true that they refuse to countenance the possibility that a certain amount of HIV, perhaps a very large amount, comes from non-sexual processes. Even though there are measures that can be taken to prevent non-sexual HIV transmission, these measures are generally not taken in developing countries. Even though we know that it is not possible to significantly influence people’s sexual behaviour just by telling them what they should and shouldn’t do, that’s what most HIV prevention programmes consist of.

Given that those who control the HIV industry and its considerable wealth base all their decisions on a fiction, it’s not surprising that others, who don’t have access to the same levels of data, expertise and other resources, weave their own fictions. A man calling himself ‘Dr’ Ayiko, seems to accept the fiction based on the behavioural paradigm. He therefore also accepts the story about Uganda reducing HIV prevalence by exhorting people to abstain from sex, be faithful to one partner and use condoms. But he feels that this approach no longer works and that one of the main reasons for the continued spread of HIV is ‘intentional’ transmission.

I assume he means the intentional spread of HIV through sexual means. He refers to the bill currently being discussed in the Ugandan parliament that would make it a capital offence to intentionally spread HIV and I think the bill is aimed at sexual transmission, though I’m not sure and I doubt if many Ugandans, including the ‘Dr’ in question, are sure either. Anyhow, Dr Ayiko says that ‘in virtually all the 112 districts [of Uganda], there are people who boast of having successfully lured 20 plus people into unprotected sex knowing they are HIV positive’.

The deluded man goes on to make the ‘modest’ assumption that there are eight such people in each district and that if each of them infects 20 people who all go on to infect two more people, there will be many tens of thousands of people infected (although his calculations go a bit awry here). Even if Dr Ayiko is right in assuming that there are many people who behave this way and that they have many partners who also have many partners, HIV is not transmitted quite so fast. If it was, HIV prevalence would be a lot higher, in every country in the world, not just in Uganda. The partners of HIV positive people can remain HIV negative for many years, even if they are having regular, unprotected sex. HIV just doesn’t spread that quickly through heterosexual sex.

What the doctor needs to do is calculate how many times each of the 8 people per district would have had to have sex with the 20 others and how many times they would have to have sex in order to infect two others each, given the probability of heterosexual HIV transmission per sex act. That’s not a simple calculation and I won’t even attempt it here. But even if the probability is relatively high, each HIV positive person would have to have sex with each HIV negative person several hundred times for HIV to spread at the speed Dr Ayiko suggests. Deliberately spreading HIV is despicable, especially where there may be force or coercion involved. But deliberate spread of HIV through heterosexual intercourse would be a very slow process indeed. However heinous, it is not a major factor in Uganda’s HIV epidemic.

I would suggest to Dr Ayiko and others who support the Ugandan bill that purposely ignoring what could be the main modes of HIV transmission, non-sexual modes, is despicable. Not only is it despicable but some non-sexual modes of transmission, such as certain unsafe medical practices, are very efficient, far more efficient than sexual transmission. Worse still, the same people who have all the data and the epidemiological expertise that Dr Ayiko lacks are the ones who continue to ignore these modes of HIV transmission. UNAIDS, WHO, CDC and the rest of the HIV industry know that they are wrong about non-sexual HIV transmission in developing countries but they don’t admit it, for some reason.

Tim Allen notes the current dependency on large scale rollout of antiretroviral treatment (ART) as a possible remedy for HIV epidemics, despite the fact that we know so little about how these epidemics increase and decline. He warns that such dependence could give rise to widespread resistance, which could result in Uganda’s epidemic taking a serious turn for the worse. And it does seem sensible to find out how the epidemic progressed in the first place before climbing on the latest bandwagon, ART. In a country where it is not even clear how much medical treatment contributed to the epidemic, it seems rash to advocate purely for more medical treatment. There’s something of the black box about the HIV industry.

Promoting HIV Transmission

A recent survey in Chad has shown that a third of sex workers think that mosquito bites or sharing a meal can spread Aids. National HIV prevalence in Chad is 3.3%, only half the prevalence in countries like Kenya, Uganda and Tanzania. But among sex workers in Chad, HIV prevalence is 20%. In Mombasa, it is estimated to be about 31%. Yet in Mombasa, and throughout Kenya, the vast majority of people, male and female, know the right answer to the questions they are regularly asked about Aids and how to protect themselves.

Many years of data on HIV prevalence, HIV knowledge and HIV behaviour show that these three are not very closely connected. People may know all the HIV industry want them to know about HIV but their behaviour is relatively uninfluenced by their knowledge. More to the point, their sexual behaviour is not very closely connected with HIV prevalence. Those who do all the things the HIV industry would like them to do often have higher HIV prevalence than those whose levels of unsafe behaviour would be deemed very high by the industry.

Indeed, sex workers in Kenya have been targeted for a long time. But the shockingly high prevalence found among sex workers in the 1980s, which peaked at 81% in 1986, fell continuously thereafter, falling below 50% in 1997 and remaining below this level. The amazing thing is that behaviour change didn't occur till a long time later. HIV and other sexually transmitted infections (STI) fell even though people didn't change their behaviour significantly. It simply became less likely that people in this group, said to be at high risk of becoming infected, would become infected with HIV or other STIs.

I write 'said to be at high risk' because it is only in some countries that sex workers are at much higher risk of being infected with HIV than other groups. In other countries, sex workers are only really at risk of becoming infected with HIV if they are also intravenous drug users (IDU), which only some sex workers in African cities are. But this kind of data seems to suggest that HIV appears to be a sexually transmitted infection in African countries whereas it is mainly transmitted among men who have sex with men and IDUs in rich countries.

This is not to suggest that HIV is not sexually transmitted, just to remind people that it is not entirely sexually transmitted. But there is a surprising lack of clarity about how much HIV is transmitted sexually and how much non-sexually, especially in African countries with high HIV prevalence. It is clear that HIV can be and is transmitted by unsafe medical and cosmetic practices but it is not clear what percentage of HIV transmission is caused by such practices. The only thing that is clear is that the HIV industry doesn't want to admit that non-sexual HIV transmission is something to worry about in African countries.

Note, they are not saying that no one should worry. Those in the industry worry about their own employees and the risks they face when they visit developing countries. They warn their own employees not to visit clinics unless they are approved, because the industry has its own well funded clinics. They just don't worry about the fact that people who have to live in these countries have no option but to use whatever clinics are available. The even deny that there is a significant risk from medical treatment in these countries while, at the same time, warning their own employees about this risk!

So what is the HIV industry going to teach people, especially sex workers, in Chad? If they approach the problem in the same way that they did in Kenya, prevalence is unlikely to drop. It reached a peak of about 10% in Kenya in the late 1990s and even higher in Uganda some time earlier. But over a decade of 'HIV prevention' later, both countries have prevalence of over 6%. That's nothing to boast about. Will people in Chad be told the truth, rather than a little bit of the truth?

The truth is that people there are at risk of being infected with HIV by medical and cosmetic procedures. How high a risk is not really clear, it depends on how good the hospitals are and how many people have easy access to them. If there are few hospitals and few people go to them, they are probably less likely to be infected with HIV, though they could be more likely to suffer from and die from numerous other preventable and curable conditions. But people need to be warned that sexual behaviour is not the only risk.

I was in Nairobi a few days ago and I talked to several sex workers and, in common with many other people I have talked to in East Africa, they have heard a lot about sexual transmission of HIV. They have heard a little about the risk from intravenous drug use and only brief and infrequent remarks about risks from contaminated blood, such as during blood transfusions. But they are not told that they and their children could be at risk when they go to a clinic or to the hairdresser. Sex workers, especially, go to clinics a lot. They usually go to clinics that specifically target sex workers, where the risk of being infected with an STI would be higher than in clinics not targeting sex workers.

If people in Chad and other African countries are only told how to protect themselves from sexually transmitted HIV, they will not be very well protected. They also need to be told about non-sexual risks, unsafe medical and cosmetic practices. If they don't know about these risks they will not what measures to take to reduce the risks they and their families face. It would also be unsurprising if they continue to believe that they are at risk from mosquito bites and from sharing food.

As long as the HIV industry continues to insist that HIV is primarily transmitted by sexual behaviour in African countries and that other risks are not significant, a lot of preventable HIV infection will continue to occur. If medical facilities are risky for UN employees then they are also risky for Africans. It's hard to believe that the UN can have one story for Africans and another for their employees, but that seems to be the case at the moment.

Institutional Sexism and HIV Transmission

There was a time when HIV was thought to affect men far more than women. That may be partly because it was first recognized in rich countries, where people infected were usually male and had sex with men. But it was soon accepted by the health care profession that both men and women could be infected, sexually and non-sexually. In developing countries, the number of women infected soon outnumbered the men. In Kenya, the ratio of HIV positive females went from 1:2.7 in 1986 to 2:1 in 2006 and it's probably about the same now, in 2010.

That makes HIV much more of a woman's disease than many others, even sexually transmitted diseases. The orthodoxy of UNAIDS, the WHO, CDC and others is that women are more susceptible, for various reasons, than men. But these institutions have been trying for years to say what it is that makes women more likely to be infected with HIV in developing countries than women in rich countries. They have come up with a lot of theories about African sexual behaviour, many of which are not borne out by the evidence. These 'theories' are mere prejudices in the absence of evidence, but they have been used to influence most of the HIV prevention activities carried out in high prevalence countries.

It's no wonder that most of these high prevalence countries have only seen small drops in HIV transmission. If there is no evidence for very high rates of unsafe sexual behaviour in high prevalence countries, and plenty of evidence for higher rates of unsafe sexual behaviour in low prevalence countries, the behavioural paradigm, the belief that most HIV transmission is due to high levels of unsafe heterosexual behaviour, is clearly faulty.

The behavioural paradigm was not so evident in the 1980s or even in the early 1990s. It arrived later, probably on the back of large amounts of donor funding from countries who chose, for political or religious reasons of some kind, to see HIV transmission as a moral issue. They chose to see high HIV prevalence as a sign that people in some countries were the victims of immoral behaviour and they switched their attention from non-sexual transmission modes to sexual modes.

The issue of institutional racism on the part of these institutions, UNAIDS, the WHO, CDC and others, has been raised on this blog before. The belief that Africans have higher levels of unsafe sex than non-Africans, when all the evidence says this is not so, lays the charge of institutional racism on their doorsteps. Never mind their posturing about wanting to reduce stigma or improve the lot of women.

But these institutions are also guilty of institutional sexism. Far from reducing stigma, the orthodoxy that says that HIV is mainly transmitted by heterosexual sex in developing countries stigmatizes women more than it stigmatizes men. How are HIV positive women supposed to see themselves in the light of this kind of orthodoxy? What options do they have to defend themselves from the implication that they are promiscuous? And how do they explain their positive HIV status to their husbands when they find that they are infected when their husband is not?

The orthodox view, the racist and sexist orthodox view, says that the majority of people infected, including the 53% of married HIV positive women, were infected by having unsafe sex of some kind. Some HIV positive women with HIV positive husbands are not even infected by their husbands because they are infected with a different genetic strain of the virus. All these women and men are tarred with the same brush, stigmatized by the very institutions that use public money, ostensibly, to reduce stigma, to reduce HIV transmission, to find out why HIV is being transmitted at such high rates in some countries and not in others.

We can offer HIV positive people in developing countries some hope of not being stigmatized. But only if we accept that the behavioural paradigm is wrong, that we don't yet know why people are being infected in such huge numbers. We can offer then a thorough investigation of the non-sexual modes of transmission, because this is clearly relevant. We just don't know the significance of non-sexual transmission yet and that is because we, or at least UNAIDS, the WHO and CDC, have steadfastly refused to investigate properly why HIV transmission is still so high in some countries. We behave like people who don't know anything about HIV transmission. But, in reality, we know the behavioural paradigm is a piece of racist and sexist nonsense.

Are we going to continue to allow people to become infected with a chronic and life threatening illness, even though we know that our policies are based on prejudice rather than on scientific knowledge? How do we face off the charges of institutional racism and sexism that we are so clearly guilty of? Or do we need to go through a process of truth and reconciliation, where the movers and shakers of the HIV industry are allowed to admit their abject failure and promise to eradicate racism and sexism from their institutions? This is not a time for professional, political or religious pride: until we admit we were wrong, we will continue to allow people to suffer and die.

Big Media: Double Standards or Negligence?

I searched in vain for any mention of the risks of non-sexually transmitted HIV before the World Cup. But all the big news sources, CNN, BBC, Al Jazeera, along with lots of newspapers and news sites, covered sexual transmission of HIV, exclusively. They warned people about unprotected sex and using condoms, etc, but none of them warned people that in South Africa, medical and cosmetic treatment can carry huge risks from unsterilized equipment and unsafe procedures.

This is particularly odd because I would put money on it that these same organizations warn their own employees about non-sexual dangers. I could be wrong, perhaps they don't warn their own employees. But many big organizations do, such as the UN, WHO and CDC. Even an MSF Kenya employee I talked to recently said she and her colleagues wouldn't use local medical or dental facilities (though, inexplicably, she didn't seem to think medical transmission posed much of a risk to people who lived in the country). So big media are either guilty of the double standard of warning their own employees of a risk that everyone in African countries face without warning African people; or they are guilty of negligence in not warning their employees about this serious risk.

Of course, they may have been advised by UNAIDS or the like that medical treatment does not pose much of a risk. What they mean by this is that they are currently admitting that in excess of 5% of HIV is transmitted by medical treatment. These thousands of people infected are so insignificant that UNAIDS deems it better to keep talking about sexual transmission and completely ignoring medical transmission because otherwise, people might not have confidence in their medical service providers. So, is there a risk or is there not?

If the risk is so small, only a few tens or perhaps hundreds of thousands of new cases every year, why not warn people about it? Because if the risk is small, they shouldn't be unduly worried about their medical service providers. But then, if the risk is small, why do UN agencies warn their own employees away from using medical services in African countries that are not approved by the UN? And while in excess of 5% of cases may not seem so significant to UNAIDS, that's 8 or 9 times higher than the contribution of medical treatment to HIV prevalence claimed for Kenya, which the same UNAIDS put at about 0.6%.

What is so wrong with saying that people face risk from both sexually transmitted and non-sexually transmitted HIV? Is it so hard to admit that when millions of needles and other sharp objects are stuck into people every day, some diseases may be accidentally transmitted? Because, if UNAIDS had the balls (or do I mean teeth?) to admit this obvious possibility, people living in African countries would be in a position to do something to protect themselves, perhaps even to lobby their governments to change things so that they don't face these dangers.

I think UNAIDS are right, if people found out that they or their children face an appreciable risk of being infected with HIV, they would think twice before having routine medical treatment. But what would UNAIDS prefer? That tens of thousands of preventable HIV infections continue to occur because they think that number is insignificant compared to people suspecting that their medical service providers are not very safe?

Either the danger of medical transmission is insignificant, and then it shouldn't be beyond the capability of UNAIDS and their chums to manage the fallout from telling the truth: that there is some danger. Or medical transmission is anything but insignificant, in which case UNAIDS and all other relevant agencies should lose no more time in warning people of the risks and in mitigating those risks so that people can return to their medical service providers with greater confidence.

I don't accept that it is better to keep people in the dark and allow some of them to become infected with HIV when this is completely avoidable. I don't accept that it is better not to tell people how to protect themselves or to try to cover up the danger on the grounds that people not using medical services is a bigger evil. African people are being treated like idiots, who don't know how to evaluate risks and to take measures to avoid them.

It looks as if people visiting the World Cup are being treated the same way, being told to avoid sex or to use a condom. Some of the more self righteous in the HIV industry like to say that the only way to be 100% sure of not contracting HIV is to abstain from sex. But this is not true. Abstaining from sex has not protected the thousands who have been infected non-sexually and the thousands more who will continue to be infected because UNAIDS, in their great collective wisdom, don't wish to inform people that there are also non-sexual risks that abstaining from sex and wearing a condom won't protect you from.

What is so difficult about telling the whole story, that HIV can be transmitted sexually and non-sexually? And if UNAIDS can't be trusted to do so, why is it so difficult for news agencies to do so? Do they really all care that little about HIV continuing to spread, unnecessarily? Or are they just so obsessed with sexual behaviour that only sexual risks are considered worth reporting?

Condoms Won't Protect Fans Against Non-Sexual HIV Risk

Since writing about HIV and the World Cup in the last few days, I have looked for news outlets and the like for coverage of non-sexual HIV risks that people visiting or living in South Africa face. I found nothing. A couple of sites mention needle sharing as a potential risk but the tone of the warning suggests that it is aimed at intravenous drug users. There is no mention of the risks of visiting a dentist, a doctor, a nurse, a surgeon, a tattoo artist, a hairdresser or any other non-sexual risks. Can journalists and others trying to squeeze all that they can out of the World Cup not find space for a brief mention of these issues?

The remarkable thing about medical transmission of HIV in African countries is not that it doesn't happen. It's that no investigations have been carried out when medical transmission has clearly occurred or where it may have occurred. Infants, children and even adults who have had no sexual exposure are HIV positive, yet there have been no calls by international health institutions, African governments or HIV donors for investigations. In most African countries, the number of women infected far exceeds the number of men infected. And though women's groups fall over themselves to get their issues heard, they don't seem to be outraged that women seem to comprise the largest number of victims of medically transmitted HIV.

Compare this to a story in Australia. There are fears that thousands of patients at a clinic may have been infected with HIV, hepatitis and other diseases after hygiene standards were found to be seriously deficient. The clinic has been closed while the investigations take place. I don't know of any similar investigation in an African country and I've rarely heard of a hospital or clinic closing merely because patients health and lives may be at risk.

Endoscope and biopsy equipment were found to have been insufficiently sterilized after nine patients became sick. There was also a contaminated anaesthetic involved. These are problems that African hospitals face all the time. They often don't have the equipment to sterilize everything properly, nor even enough trained staff to carry out the work. African hospitals also have the problem of old equipment, shortages of equipment and the need to reuse things that are designed to be disposable. Health workers are not going to do without gloves just because there is a shortage. How many options do they have?

In Australian hospitals, people are far less likely to be infected with HIV, hepatitis or other serious illness. But in African countries, where only the sickest go to hospital and many serious diseases are endemic, the risks are very high. But patients becoming ill after receiving medical treatment in African hospitals is so common that this is unlikely to trigger any kind of investigation, as happened in the Australian instance. And if people die, there are unlikely to be any questions asked. Many people die every day of all sorts of things. Health workers have little enough time to deal with sick people, let alone dead people.

In the UK, children who may have been jabbed with discarded hypodermic needles in a paddling pool are being monitored for HIV and other conditions. The have to wait three months to be sure they have not been infected with HIV, but at least they and their parents were alert to the fact that they may have been contaminated. I have passed through a couple of health facilities in East Africa and seen needles and other sharps in the grass where people walk in rubber sandals and where children play. I wonder if African children running around in bare feet would even notice a pinprick or scratch from a needle.

But I know that the parents of most children here would have no idea that needles and other hospital wastes carry a risk of infection with HIV and other diseases. Some people can tell you that sharing needles and the like carries a risk but most have not been fully warned about the risks associated with medical and cosmetic facilities. Indeed, the official line is that there is only a tiny risk from medical and cosmetic transmission of HIV. Those responsible for the official line, UNAIDS, WHO, CDC and the rest, must be well aware that non-sexual risks are far higher than they admit. But for some reason, they don't want Africans to know that these risks exist and, consequently, how to protect themselves.

And so, as the Western world worries about Westerners going to the World Cup being infected with HIV through some kind of sexual encounter, it's quite amazing that there are no warnings about non-sexual risks. Football supporters don't just like drinking and having sex after matches, they also like fighting, especially when their team loses. And drunk people can be prone to all sorts of accidents. People will end up in accident and emergency wards, dental surgeries and the like. People also may like to get that special football tattoo in South Africa, where it may be cheaper, but also more dangerous.

No doubt, there will be the usual slew of stories after the event about how various efforts and initiatives failed and how things should have been done differently. Journalists will never close the stable door if they can make a story about the bolted horse. So if the media, websites, officials and other sources of information will say nothing about non-sexually transmitted HIV, instead concentrating exclusively on sexual transmission, there will also be stories about how people are let down by health services and how unhygienic tattooists, hairdressers and ear piercers are. But only when it is too late for the victims.

If the Western press is really so worried about the health of Westerners, they should highlight the risks of non-sexually transmitted HIV and other health risks that people receiving medical and cosmetic treatment in South Africa face. They clearly are not worried about the risks that South Africans face and will continue to face after the World Cup has ceased to be front page news. But there is hope that South Africans themselves will one day question the official line, that they have so much sex that this explains why the country has more HIV positive people than any other. South Africans themselves may question the state of the health services that are available to them and ask why they have not been warned about non-sexual HIV risks or how to protect themselves. This is a very good time for them to raise these questions, before the Western press goes back to seeing Africa as a far away place populated by foreigners who have a lot of risky sex.

Why is HIV Policy in Africa Written By Racists?

Kenya appears to have yet another 'campaign' to reduce HIV transmission. This one purports to target HIV positive people, whom, some 'senior government officials' claim, have been ignored so far. This is an odd claim, considering the largest part of the vast sums of money being spent on HIV for many hears now has gone into treatment for HIV positive people. HIV prevention has received a very small amount of money and much of that has been frittered away on 'behaviour change programmes' widely acknowledged to be useless in Western countries.

Of course, HIV positive people must be part of the equation when trying to reduce HIV transmission. But so must HIV negative people. Concentrating on one group and ignoring the other has been counterproductive. One of the reasons that big funders are questioning the continuation of ever increasing funding for HIV drugs is that this approach hasn't yet had much effect on HIV prevalence. As HIV drugs are rolled out, more and more people continue to become infected. If there was an end in sight, perhaps in the form of significant reductions in transmission in high prevalence countries, funders might be persuaded to hang in for a bit longer.

The article is, in fact, very misleading:

"We have focused so much on empowering HIV-negative people to avoid infection. We now need to focus on people who are already infected and empower them to prevent new infections, re-infection, and maintain their own and their partners' good health," said Dr Nicholas Muraguri, head of the National AIDS and Sexually Transmitted Infections Control Programme.

I haven't seen much evidence of empowerment of HIV negative people, though I've seen many references to it. Whether the focus of most of the money and attention for the last several years on drugs and treatment has also included any empowerment for HIV positive people is another matter. It probably hasn't because pharmaceutical companies don't make money out of 'empowerment', they make money out of drug sales.

I have searched high and low for the guidelines in question without finding a copy but the article goes on:

One of the main aims of the guidelines is to ensure that all HIV-positive Kenyans are aware of their status; government statistics show that 84 percent of HIV-positive people do not know they are infected.

I hope this figure is out of date because it is the same as it was back in the 2008 Aids Indicator Survey, the data for which was collected in 2007. Since then, articles have claimed that several million more Kenyans have been tested, one even claiming that about 1.5 million were tested in a six week period near the end of last year.

The more people tested the better, but will any effort ever be made to figure out how people became infected? The assumption is still, despite plenty of evidence to the contrary, that most transmission in Kenya and other high prevalence African countries is due to unsafe sex.

Despite finding medical facilities to be too dangerous for UN employees, UNAIDS claims that medical transmission of HIV in Kenya is around 0.6%. There are children who are HIV positive whose mothers are not and nearly half the married women who are HIV positive are married to men who are HIV negative. Are we supposed to believe that all these women are becoming sexually infected with HIV through some relatively small number of men, to whom they are not married? Well, if you pander to the stereotype of the oversexed African, you may be happy with this explanation. But if you're an economist, no matter how bigoted, you may wonder how a large number women can have anything to gain by having sex with a small number of men to whom they are not married.

Dr Muraguri goes on to say "We want to de-stigmatise the HIV test so that HIV testing becomes a 'kawaida' [usual] thing". What better way could there be to stigmatise HIV than to assume that it is mainly sexually transmitted? Even the possibility that some HIV is transmitted non-sexually is not considered in most of the literature, perhaps from unsafe medical procedures, perhaps from unsafe cosmetic procedures or some other likely candidates. In what way, I wonder, is Dr Muraguri suggesting that this de-stigmatises anything? I see the sexual behavioural paradigm as the very source of HIV related stigma.

The article continues:

"At one point, every adult with sexually transmitted HIV was the HIV-negative partner in a discordant relationship," Muraguri said. "Over 44 percent of married HIV infected partners have an HIV-negative partner - if they are aware of their status, they can take steps to protect their partners from infection.

Yes, over 44% of married HIV positive people have a HIV-negative partner, and haven't people like the doctor ever wondered why this is? And if they were infected by some route other than sexually, their partners could also be infected non-sexually. Isn't it strange that HIV transmission in concordant relationships is so slow? Doesn't it suggest that sexual transmission of HIV alone may not be enough to explain the very high prevalence of HIV in Kenya and other African countries?

People who are aware of their status can protect their partners or protect themselves, but only if they know what the risks are. People can not protect themselves from medical, cosmetic or other non-sexual transmission by wearing a condom or even by abstaining from sex, especially if they don’t even know about these risks.

Anyone worried about reduced funding for HIV, as many claim to be at the moment, should be wondering why the various campaigns that were mere variations on Abstain, Be faithful and use a Condom (ABC), or even worse, abstinence only, have been so unsuccessful. As well as being intuitively unappealing, perhaps they were just barking up the wrong tree. Africans don't have more sex or more unsafe sex than non-Africans, so why should HIV prevalence be higher in many African countries than in many non-African countries?

In case there is any doubt remaining that the campaign excludes all but sexually transmitted HIV:

Prevention with Positives includes encouraging partner disclosure, scaling up prevention of mother-to-child transmission, increased condom use, large-scale male circumcision, and ensuring adherence to antiretroviral (ARV) drugs, which have been shown to significantly reduce the risk of mother-to-child as well as sexual HIV transmission.

This is all good advice, especially for sexually transmitted HIV. But for non-sexually transmitted HIV it offers nothing. People must know how they are becoming infected in order to protect themselves. The racist view that Africans are all having unsafe sex at such high rates that non-sexual transmission is almost irrelevant will not help to cut HIV transmission. But this latest Kenyan programme is being funded by some arch racists, it appears. The American President's Emergency Plan for Aids Relief, the Elizabeth Glaser Paediatric AIDS Foundation, and the US Centres for Disease Control are mentioned but apparently there are others.

Yet another stigamatising attitude is expressed by Nelson Otuoma, chairperson of the Network Empowerment of People Living with AIDS in Kenya (NEPHAK). This seems surprising, but he claims that the 18,000 or so members of NEPHAK have a "have a common message - they must not be generous with the virus, giving it away; they want to be mean with it, keeping it to themselves." There may have been rare (but very media friendly) exceptions of people deliberately or carelessly transmitting HIV but most people don't want their friends, partners, family or anyone else to become infected. Do people seriously believe otherwise?

Even nurses and other healthcare workers have been denied the knowledge that many people in Kenya probably became infected with HIV through a non-sexual route. Many people will list non-sexual ways of transmitting the disease, but it is clear that the assumption is that HIV is usually transmitted sexually. There is no reason for healthcare workers to assume that people face other risks because, regardless of how much money has been spent on improving healthcare (and I've seen little evidence of much of that in Kenya), they are bombarded with courses, publicity and literature on sexual transmission.

If I get to see the guidelines I'll link to them here. But I am very disappointed to hear that, yet again, non-sexual transmission of HIV has been ignored and the old stigma has been given more fuel, as if it needed any more. I have spoken to many people (laypeople and professionals) in Kenya, Uganda and Tanzania and most of them are willing to admit that things in health facilities are slack and must be giving rise to a lot of risks, whether for HIV or any other blood-borne diseases.

In addition to being able to access treatment when they are HIV positive, HIV negative Kenyans and other Africans need to be able to ensure that they stay negative. This means being made aware of the risks they face, not just sexual risks but risks they face when receiving medical treatment, cosmetic treatment, traditional medicine and other practices and the like. If they are not made aware of these risks, no matter how embarrassing it is to those in UNAIDS, CDC and other institutions that steadfastly deny that such risks exist, people will continue to become infected.

Unsafe medical practices are known to be common in some African countries, which means that everyone who receives medical treatment is at risk of becoming infected with HIV and other diseases. Continuing to maintain that sexual behavior is responsible for most HIV transmission among Africans, while warning non-Africans about these risks, is not the way to reduce HIV transmission. The belief that Africans have a lot of unsafe sex, and that’s why HIV prevalence is high in some African countries, is a prejudice: it arises despite evidence to the contrary, not because of evidence for the belief. But these two claims are what HIV policy in Africa tends to be based on.

Face the Problem of Medically Transmitted HIV, Don’t Cover it Up

In December of last year, three researchers published a paper in the peer-reviewed journal, the International Journal of STD and Aids (IJSA), concerning HIV infected children with HIV negative mothers in Kenya and Swaziland (entitled 'Horizontally-acquired HIV infection in Kenyan and Swazi children'). The researchers concluded that blood exposures are the most likely routes of transmission in these cases. The researchers also called for greater surveillance and investigation of such phenomena and public education about the risks people face, along with steps they can take to reduce these risks.

The Swazi Observer, the Swazi Times and the English Telegraph all covered the research in question, with the two Swazi papers appearing to refer to the Telegraph article, rather than the original research article. [It should be noted that the Telegraph's figure of 5 million new cases of HIV being created annually by healthcare practices is an error as it's higher than the total number of new infections, which was about 2.5 million in 2007.] These newspaper articles were alarmist and tended to go way beyond anything written in the IJSA article. But they were probably no more or less irresponsible than normal newspaper coverage of medical and other issues.

A member of the public working for or studying with the London School of Hygiene and Tropical Medicine (LSHTM) then wrote to the Swazi papers complaining that this kind of sensationalist reporting is a danger to the health of Swazi people. On balance, the newspaper articles were sensationalist and distorted the findings of a careful and professional study.

But this correspondent goes on to criticize the IJSA article itself. These criticisms may need to be dealt with by the authors and by other professionals involved. However, the correspondent’s criticisms are either irrelevant or they relate to limitations that are made quite clear in the paper. It is true that the authors of the paper don’t ‘prove’ that the children were infected by medical procedures; no investigation was done in Swazi health facilities; and the data on routes of transmission were for Kenyan children, not Swazi children. These matters are all made clear in the methodology and throughout the paper.

The correspondent puts great effort into grasping at straws to defend the health services that are not necessarily being attacked by the IJSA article. And in this way, she seems to imply that there is no need to investigate the very possibility that people face risks when they attend medical facilities (and hairdressers, traditional healers, cosmetic service facilities, etc). Even the WHO and the UN would admit that there are serious risks of blood borne transmission of HIV in African medical facilities. They just don’t bother to do anything about it in African countries. They content themselves with endlessly repeating the discredited mantra that HIV is mostly spread through unprotected sex.

The correspondent goes on to clarify her worry: that people needlessly fear going to clinics for medical procedures that may save their lives, including HIV testing, and that these newspaper articles could confirm people’s fears. The IJSA authors come up with questions about the safety of health procedures in African countries, something even the WHO doubts, estimating that up to 50% of injections could be unsafe, and this correspondent thinks the public are worrying needlessly!

Perhaps this correspondent is afraid that people will think they are being lied to. And to assuage their worries, she advocates lying to them. Or, at least, she advocates keeping the truth from them. Is this the LSHTM take on medical ethics? The correspondent goes on to indulge in a bit of sensationalism herself, about newspaper articles killing people and their babies because members of the public are afraid to seek medical treatment. Her attack on the newspapers ends without further reference to a careful piece of research which shows that many questions need to be raised about medical services in Swaziland (and other countries). It is because these incidents have remained uninvestigated that the public need to be made aware. It is because they have remained unaired that people will fear medical facilities: their fears have already been realised.

The date of the newspaper articles is significant, the 2nd of December, the day after the HIV industry gets together to slap each other on the back for the great work they have done and the successes they have had in reducing HIV transmission over the past year. No doubt, it stung those in the industry to get a wake up call the day after International World Aids Day, especially those working in Swaziland, which has one of the highest prevalence figures in the world. But a sensationalist rant about sensationalist reporting should not be used to deflect attention to what may turn out to be one of the biggest drivers of HIV transmission: non-sexual transmission, either through medical procedures, cosmetic procedures or various other modes.

Anyone studying or working in public health should be concerned if there is evidence that lax procedures may be allowing people to become infected with HIV or other blood borne diseases. Anyone truly concerned with the safety of patients and members of the public would advocate that potential medical transmissions be investigated. And they would not let themselves be distracted by entirely separate issues, such as irresponsible newspaper reporting. To date, the many peer-reviewed articles highlighting possible instances of medical HIV transmission in African countries have been ignored. No investigations have been carried out. But those who are most aware of these matters (WHO, UN, CDC) continue to claim that HIV is primarily transmitted though heterosexual intercourse. If people object to what the newspapers are saying or to what the researchers in the IJSA are saying, they should carry out a thorough investigation.

If the LSHTM student or employee is so concerned about newspapers behaving irresponsibly, she could take to task the ones who always tow the official line on HIV, that it is primarily transmitted by heterosexual sex in African countries. As a result of this official view of HIV, people who find they are HIV positive are stigmatized. HIV is so closely related to illicit or unsafe sexual behaviour in people’s minds that they don’t even know that they could be at risk when they visit the dentist, the doctor or the manicurist. And if they don’t know they are at risk, they will not make any effort to protect themselves. It’s all the other newspaper articles that read like UNAIDS press releases that we should object to, not the few questioning the status quo.

If we don’t want the ‘sensationalist’ press to warn the public of the dangers they and their children may face when they visit medical facilities, we need some credible party to let people know. People need and have a right to know in order to protect themselves. But by refusing to investigate any possible instances of medically transmitted HIV, the WHO, the UN and the CDC show that they are not credible parties. It would not be a desirable outcome for people to avoid medical treatment, but nor would it be a desirable outcome for people to continue getting treatment that may be transmitting HIV. This is a dilemma that those working with HIV need to face, not cover up.

We in the UN Have Been Lying About HIV and Now...

Myself and a friend are taking a trip around Lake Victoria to visit some of the places where HIV prevalence is exceptionally high. Countries around the lake, Kenya, Tanzania and Uganda, all have similar HIV prevalence of between 6 and 8%. But in many places on or close to the lake shores, prevalence is (or was) often well over 20%. Bukoba in Tanzania, Suba and Homa Bay in Kenya are examples, as is Rakai in Uganda.

Our first stop was in Shirati, Tanzania, where there is a Mennonite run hospital. We were made very welcome there and visited several people who have worked for a long time with HIV and health in general. Most people were happy to talk about their experiences and concerns and we were introduced to people who work in various positions in areas around Shirati.

However, even people who work closely with HIV, as well as lay people, seem to regard HIV as being mainly sexually transmitted. This is not surprising because most public education campaigns and most money are concentrated on sexual transmission. People have been listening, to a greater or lesser extent, to all sorts of advice about using condoms, having fewer partners, testing for HIV and other sexually transmitted infections and various other measures thought to reduce transmission of HIV.

But these HIV prevention interventions have had very limited success, despite exaggerated claims by some of the people behind the emphasis on sexual transmission. Perhaps, as a lot of data shows, people in these three countries already take precautions to avoid HIV, but without success. Research has shown that sexual behaviour in African countries differs greatly from place to place, just as it does in non-African countries. In fact, there is no evidence that sexual behaviour thought to be unsafe is that much higher in African countries where HIV prevalence is high. On the contrary, often, areas that have high HIV prevalence also have low levels of unsafe sexual behaviour.

So, if levels of sexual behaviour do not explain differences in prevalence within and between various African countries and non-African countries, it is possible that HIV is also being transmitted in various non-sexual ways. Two prominent examples of this are transmission through unsafe medical procedures and through cosmetic procedures. In the former group, there could be reuse of disposable equipment or failure to sterilize equipment. In the latter, again, use of equipment that is not properly sterilized.

People we talked to showed high levels of awareness of possible exposure to HIV through sexual behaviour and this is corroborated by various research that has taken place over many years. For a long time, people have been able to list all sorts of things about sexual transmission of HIV but this has had little or no effect on HIV prevalence rates in those countries. But few mention non-sexual transmission and even when they do, they don't appear to know of ways to avoid non-sexual transmission.

Some of the people we talked to confirmed that they and their children had their hair cut by a machine that breaks the skin, especially where there are sores or new scars. But they were unaware that it is necessary to sterilize the equipment properly to avoid transmitting infection to the next person who uses the same equipment. They said that hairdressers sterilize equipment using methylated spirits or water. But they didn't know that this is not enough to ensure that all possible infection has been eliminated. They also thought that HIV infection only lives on instruments for a very short period, which is a common belief, though wrong. [There are abstracts to a couple of articles on this subject on PubMed.com, here and here.]

There is remarkably little interest in non-sexual transmission of HIV among the mainstream, UNAIDS, WHO, CDC, UN and others. There seems to be a reluctance to take on board the considerable amounts of research that suggests that a significant amount of HIV transmission occurs through non-sexual means, whether in cosmetic or medical contexts. This is surprising because non-sexual transmission has been recognised by these bodies since the mid 1980s, when HIV had only recently been identified as the virus that causes Aids.

For example, regarding medical conditions in developing countries, the UN has this advice for its employees:

"Use of improperly sterilized syringes and other medical equipment in health-care settings can also result in HIV transmission. We in the UN system are unlikely to become infected this way 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. 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."

This suggests that the UN is perfectly well aware that unsafe medical practices are widespread enough to be a threat to their employees. But they and other institutions don't seem to extend the same advice to people who live in those countries and would be likely to visit available facilities more frequently. Maybe the UN is even in conflict with UNAIDS in some instances because the latter claim that medical transmission of HIV in Kenya is around 0.6% of all transmission, meaning that they think health facilities in Kenya are very safe.

The UN goes on to say:

"In several regions, unsafe blood collection and transfusion practices and the use of contaminated syringes account for a notable share of new infections. Because we are UN employees, we and our families are able to receive medical services in safe healthcare settings, where only sterile syringes and medical equipment are used, eliminating any risk to you of HIV transmission as a result of health care."

Am I being oversensitive here in detecting a total disregard for the health and safety of people who happen to live in 'several regions', while paying a lot of attention to people who generally don't have to avail of the services that the general populace have to put up with? Perhaps the UN would like to reveal what this 'notable share of new infections' is and inform UNAIDS, WHO, CDC and others. In particular, perhaps they would like to inform people who live in any of the countries they are worried about. After all, 'we' are not all privileged with being UN employees.

The UN certainly knows how to avoid medical transmission when it comes to its own employees:

"None of us should ever share with another person a needle, syringe or equipment used for injection. If we receive medical care from the UN system medical services or from a UN-affiliated health-care provider, we can be confident that every effort has been made to ensure that injecting devices used to administer a shot are sterile and will not expose us to HIV. If we need to give ourselves a shot outside a UN health-care setting, we should only use disposable needles and syringes and we should use them only once. Because safe injection practices are not followed in all healthcare settings and it may not always be possible to purchase sterile injection devices, the WHO medical kit that is made available to all UN agencies includes disposable syringes and needles."

This means that we have all the information and know-how necessary to reduce non-sexual HIV transmission. Now that we know all this, it's time we went out to tell all the people the truth. We have been telling them lies for a long time now. We have spent years telling people that HIV transmission in Africa is mainly sexual and arguing that this is because Africans have so much more unsafe sex than non-Africans. We can no longer shore up this argument, nor should we. We have the means to cut HIV transmission significantly straight away, we don't need to wait for expensive vaccines or other programmes that will take years to be effective, if they ever are effective. We just need to admit that we have been lying and make amends before more people become infected and die.