We do them in Black for 14.99

I was recently sent an article which stated that “Novel strategies are needed to increase the uptake of voluntary medical male circumcision (VMMC) in sub-Saharan Africa and enhance the effectiveness of male circumcision as an HIV prevention strategy.”

The operation is provided free of charge. But this ‘intervention’ randomized participants into three groups, the first receiving about $2.50 in food vouchers, the second receiving about $8.75 and the third about $15, conditional on getting circumcised within two months. There was also a control group of men who received no compensation.

You may wonder why an operation said to be so highly beneficial requires a financial incentive; your wonder may (or may not) be assuaged by the assurance that some men face certain “economic barriers to VMMC and behavioral factors such as present-biased decision making”.

‘Present-biased’ suggesting that people will not spend money now on something that promises a future benefit only. However, perhaps these men don’t see any benefit; perhaps they use condoms, have only one, HIV negative, sexual partner, don’t have sex at all, live in a place where HIV prevalence is extremely low (there are many in Africa, far more than places where prevalence is high), etc. It’s also unclear what proportion of HIV is transmitted through heterosexual sex, which is the only mode of transmission circumcision enthusiasts even claim to reduce.

So those providing the operation propose ‘compensating’ each man for some of the costs involved in having the operation, possibly including the opportunity costs of missing work for a few days. You could argue that there will be no net financial benefit, and that this is nothing like bribing people to conform to a practice that some western donors from rich countries see as beneficial, but that the majority of people, even in rich countries, consider useless, perhaps even harmful.

The claimed future ‘benefit’ comes to this: one person out of every one hundred or more men who are circumcised (we don’t know the number because mass male circumcision trials have been biased towards showing the effectiveness of the operation) may be ‘protected’ from infection with HIV; ‘protected’ if it really is the circumcision that protects the man; no causal protective mechanism has ever been convincingly demonstrated.

The upshot of the trial will not surprise anyone. Hardly any of those in the control group went on to avail of their free circumcision. Slightly more of the men receiving $2.50 did so. The same goes for those receiving $8.50 and those receiving $15. But the overall impact was “a modest increase in the prevalence of circumcision after 2 months”.

The several hundred thousand Kenyans claimed to have already agreed to be circumcised under these mass male circumcision programs (many of whom would have been circumcised anyway in accordance with tribal practice), and the millions claimed to have been circumcised under similar programs in other African countries, may be disappointed that they will not receive anything at all to reflect “a portion of transportation costs and lost wages associated with getting circumcised”.

Depending on whose figures you use, circumcisions in African countries are claimed to cost as little as $60. Other figures suggest that the cost is at least twice that, and NGOs profiting from these programs would have an interest in claiming costs as high as possible. All the figures are puny compared to what the operation would cost in a rich country. But with an estimated 22 million men said to be currently eligible in Africa, and several tens of millions more boys not counted in the original estimate, just how much money is available?

Much of the literature about mass male circumcision is about notional economic benefits and quite superficial issues, such as assumed cleanliness and hygiene (for which there is no evidence), aesthetic aspects, improved sexual experience, and the like. Very little is about ethics, politics or, god forbid, human rights.

The ‘benefits’ of circumcision are easy enough to exaggerate and any disbenefits can be discounted because the ‘beneficiaries’ are male Africans, whose ‘unsafe’ sexual behavior is said to be responsible for the bulk of HIV transmissions.

To those promoting mass male circumcision, the useless piece of flesh on the end of a penis is a man, an African man, at that. Whereas the foreskin represents a vast funding opportunity and permits unbridled expression of a pathological belief in the multiple virtues of genital mutilation. The right to bodily integrity has, apparently, been suspended.

Uganda’s HIV Prevention and Control Act May Fall Foul of Itself

The Ugandan HIV and AIDS Prevention and Control Act, 2014, has been rightly criticized for potentially criminalizing certain kinds of HIV transmission and for compelling pregnant women (and their partners) to be tested for HIV.

It is felt that the law will result in people avoiding testing in order that they cannot be accused of attempted or intentional transmission of the virus. However, pregnant women who are not tested are unlikely to receive prevention of mother to transmission treatment or treatment for their own infection.

But there are other flaws in the act, which appears to have been put together in a hurry and without any proof reading. For a start, it seems to be assumed that HIV is almost always transmitted through sexual intercourse, aside from transmission from mother to child.

In Uganda, this is ridiculous. Children with HIV negative mothers were found to be HIV positive in three separate published studies, in the 80s, the 90s and the 2000s. More recently, several men taking part in the Rakai circumcision trial were infected even though they did not have sexual intercourse, and several more were infected despite always using condoms. (There are links to all the studies on the Don't Get Stuck With HIV site.)

The act makes no explicit mention of non-sexual transmission through cosmetic and/or traditional skin-piercing practices, though tattooing and a handful of other practices are mentioned. But there is no mention of circumcision (or genital mutilation), male or female, whether carried out in medical or traditional settings.

The above incidents raise questions about the act's definition of 'informed consent', which requires that people be given "adequate information including risks and benefits of and alternatives to the proposed intervention". Were mothers informed about all of  the risks that their infants faced? Were they even made aware of risks to themselves, through unsafe healthcare?

Were the men in the Rakai trial informed about unsafe healthcare risks? Trials should not endanger the health of those taking part, and participants should be adequately informed about the risks. But where people appear to have been infected with HIV as a result of taking part in the trials, this possibility has not even been investigated.

The act does not include transmission as a result of infection control procedures not being followed (or not being implemented). Nor does it include careless transmission, as a result of not following (or implementing) procedures, not training personnel adequately, not providing health facilities with the equipment and supplies needed, etc. The Ugandan state itself has an obligation to prevent and control HIV transmission, according to the act.

Curiously, the act states that there will be no conviction if transmission is through sexual intercourse but protective measures were used (also if the victim knew the accused was infected and accepted the risk). Protective measures probably include condoms, but do they also include antiretroviral treatment? Vast claims are made about reductions in HIV transmission when the infected party is on treatment. Yet people have been convicted of intentional transmission in countries other than Uganda; being in antiretroviral treatment didn't always protect them from conviction.

Part one of section 45 reads: "All statements or information regarding the cure, prevention and control of HIV infection shall be subjected to scientific verification"; part three reads: "A person who makes, causes to be made or publishes any misleading statements or information regarding cure, prevention or control of HIV contrary to this section commits an offence and shall be liable on conviction...".

So it’s not just pregnant mothers and other parties who may fall foul of the HIV Prevention Act. Those who wrote the act may have contravened it themselves in a number of ways. Even those running drug and other health related trials, health practitioners and traditional and cosmetic practitioners may also risk contravening the act.

South Africa: Don't Panic About Ebola, We Have Extremely Effective Surveillance Systems

Some may beg to differ with the health minister. While TB is very different from ebola, South Africans will (I hope) recall hearing about an epidemic of multidrug-resistant (MDR) and extensively drug resistant (XDR) TB being transmitted in health facilities in South Africa and surrounding countries, perhaps since the early 2000s. Scaremongering about infectious disease outbreaks doesn't do anyone any good, but nor does underestimating the ease with which diseases can spread, within a country and internationally.

A three decade HIV pandemic has shown us that surveillance systems on their own are not enough. The XDR/MDR epidemic is very closely connected with the HIV epidemic in South Africa and has been attributed to poor infection control. Countries that wish to control disease spread need strong health systems. However, the reaction to HIV has not been a sustained strengthening of health systems as a whole, but rather a vertical, cherry-picking approach. The result is that most countries in sub-Saharan Africa now have crumbling health systems, massive shortages in skilled health personnel, inadequate equipment and unreliable vital supplies.

Conditions are so dangerous that UNAIDS advises UN personnel not to use health facilities in developing countries, although the institution seems to believe that the same facilities are fine for Africans. Guinea, Liberia and Sierra Leone have relatively low HIV prevalence, whereas the number of HIV positive people in Nigeria could be the second highest in the world; South Africa is home to the highest population of HIV positive people. This has only weakened health systems further.

Nor is there any need to single out South Africa, Nigeria or the three countries that have the worst ebola outbreaks so far. There are Service Provision Assessments and other reports for many African countries showing that basic supplies such as gloves, soap and water, drugs, even injecting and other equipment, are frequently lacking. There are also scores of articles alluding to dangerous conditions, some published many years ago.

The South African health minister, and health ministers in all African countries, would be better off using outbreaks of ebola, MDR and XDR TB, hepatitis and HIV as arguments for investing in health systems that can provide safe health services for everyone, rather than for the rich alone, or for those suffering from headline grabbing diseases. Nosocomial TB in South Africa is thought to have started more than ten years ago, and affects many health facilities, in several countries. Therefore, there have been numerous outbreaks over that period, not just a few isolated instances.

Many of the people who have died of ebola are health professionals and others who are probably more aware of the risks they face than their patients are. Claiming that health systems are fine and that they are able to cope is a betrayal of the work their health professionals are doing. Minister Dr Aaron Motsoaledi should tell the WHO and other international institutions something that is an open secret about healthcare safety in African countries - it is in very urgent need of attention.

Nigeria, Unsafe Healthcare and Bloodborne Virus Epidemics

An article in a Nigerian newspaper highlights the very serious hepatitis epidemic there, with an estimated 20 million people, about 12% of the population, infected with either hepatitis B (HBV) or C (HCV). Although one of the ways HBV can be transmitted, and the way HCV is usually transmitted, is through blood, it is less common to find explanations of why or how people come into contact with someone else's blood, or how to avoid this.

The Don't Get Stuck With HIV site gives details of numerous ways you can come into contact with someone else's blood through healthcare, cosmetic and traditional practices. Healthcare practices include antenatal care, birth control injections and implants, transfusions, child delivery, dental care, donating blood, injections for curative and preventive reasons, catheters, male circumcision and others.

Cosmetic practices include manicures and pedicures, shaving, tattooing, body piercing, use of Botox and other products, performance enhancing drugs and perhaps colonic irrigation. Traditional practices include male and female genital cutting (FGM and MGM), traditional medicine, scarification and various other skin-piercing practices.

The Don't Get Stuck with HIV site also lists some of the steps you can take to protect yourself from exposure to HIV, HBV, HCV or other bloodborne pathogens, even ebola. The site also links to articles and sources of data about unsafe healthcare, unexplained HIV infections and other indications that risks for bloodborne transmission of various viruses are not always so widely recognized.

As a result, people often don't know there is a risk and they don't know how to protect themselves. This is as true of HIV in high prevalence countries with inadequate health services, HBV and HCV in countries where those viruses are common, and even ebola or other haemorrhagic viruses, when such an outbreak occurs. Indeed, ebola epidemics have only occurred in countries where healthcare is known to be unsafe, such as Democratic Republic of Congo, Sudan, Uganda, Guinea, Sierra Leone, Liberia and most recently Nigeria.

Two lengthy reports on healthcare safety in Nigeria have been published in the last few years. The second was a survey using the WHO's 'Tool C', also used for the survey from Philippines mentioned in a recent blog. Bearing in mind the warnings we are currently hearing about ebola, and the warnings we should have been hearing about HIV and hepatitis:

"Of the health facilities observed, only 23 (28.8 percent) had soap and running water for cleansing hands, and no facility had alcohol-based hand rub available.

Overall, fewer than half of all injections observed were prepared on a clean surface...

They found that injection providers only washed their hands in 13 percent of cases; none used an alcohol-based hand rub...

Fewer than half of the providers were seen to use water or a clean wet swab to clean the skin before vaccination, therapeutic, and family planning injections...

For vaccination, in 79.7 percent of cases, auto-disable syringes were used.

However, for dental procedures, there were two observations where providers used sterilizable syringes, and of these two, one of them also used a sterilizable needle...

18.7 percent had a needle left in the diaphragm of a multi-dose vial.

When glass ampoules were used during vaccination, the providers used a clean barrier in 1 of the 11 vaccination injections observed. Providers used a clean barrier in the only such dental injection observed, 3 of 11 family planning injections, and 4 of 43 therapeutic injections observed (9.3 percent).

Providers generally used standard disposable needles and syringes (70 percent) for phlebotomy procedures, and lancets for procedures requiring lancing (78.6 percent). Providers were rarely seen to use safety devices such as auto-disable and retractable syringes...

62.6 percent of procedures were prepared on a clean, dedicated table or tray where contamination of the equipment with blood, body fluids, or dirty swabs was unlikely (in 42 out of 67 hospitals and 20 out of 32 lower-level facilities).

[for blood draws and intravenous procedures] Overall, providers washed their hands with soap and running water in only 2 of the 99 observations.

Data collectors observed that patients shared a bed or stretcher with another patient in 17.6 percent of IV infusions. This was also the case for 4.5 percent of IV injection patients.

Data collectors observed that in 69.3 percent of cases, the provider used a clean gauze pad and gently applied pressure to the puncture site to stop bleeding after the procedure.

Only 10.5 percent of providers cleaned their hands with soap and water or an alcohol-based hand rub following the observed procedures. In the 35 cases in which there was blood or body fluid contamination in the work area, the area was cleaned with disinfectant in 20 percent of observations (see Table 14).

During interviews, five percent of providers (11 out of 217) reported that they used sterilizable needles in injections, phlebotomies, IV injections, or infusions. Of the 5 out of 187 supervisors who reported use of sterilizable syringes and needles, three said that fuel was always available to run the sterilizer, while the remaining two reported that fuel had been unavailable for less than one month at some point.

Half of the 80 health facilities had infectious waste (non-sharps) outside of an appropriate container."

This list includes only some of the risks to patients. There is also a section on risks to the provider, risks to other health staff, such as waste handlers, and risks to the community. Nigeria is unlikely to have the worst health facility conditions in Africa and there are many areas of healthcare safety requiring urgent attention.

When news reports about ebola constantly emphasize things like eating bushmeat and 'traditional' practices at funerals, think of the kind of conditions that can be found in Nigerian hospitals even when healthcare personnel are aware that an inspection is taking place. When reports about hepatitis concentrate on intravenous drug use and other illicit practices, and when reports about HIV seem to be almost entirely about sexual behavior, conditions in health and cosmetic facilities and contexts where traditional practices take place must also be relevant.

Seek and you shall Find: Evidence in Support of HIV Drug Sustainability

A recent piece of research claims to find that mass male circumcision programs do not result in 'risk compensation', the idea that some HIV interventions can result in an increase in 'risky' behavior, such as sex without condoms. Happily for those aggressively promoting mass male circumcision, they say they found no evidence of risk behavior. Whether they found evidence that it doesn't occur, rather than failing to find evidence that it does occur, is another matter.

Similar research into the use of pre-exposure prophylaxis (PrEP), the use of HIV drugs before some kind of exposure to HIV, such as through sexual intercourse with a HIV positive person, also found no evidence of 'risk compensation', although this research was carried out in the US; PrEP is more of a rich person's intervention at the moment.

And a meta-analysis of "every study that has looked at the sexual behaviour of people after starting HIV treatment" has found no evidence of 'risk compensation'. Most of the studies took place in African countries. These results must have found a welcoming audience at the HIV industry's annual back-slapping event that has just finished in Melbourne.

But these findings may suggest something very significant that the researchers have not mentioned: perhaps HIV positive people are nowhere near as promiscuous, careless and uncaring as they are depicted as being by the HIV industry thus far.

It is not known what proportion of HIV transmission is a result of sexual intercourse and what proportion is a result of other modes of transmission, such as exposure to contaminated medical instruments, unsafe cosmetic or traditional practices.

The assumption that most transmission is a result of sex is a prejudice, rather than an empirical finding. The assumption that transmission through various non-sexual routes is low is a result of not looking for evidence that would demonstrate such transmission and ignoring any evidence that comes to light, which it usually does inadvertently.

Those promoting mass male circumcision and other revenue streams do seem to be inordinately blessed when it comes to finding 'evidence' that the intervention is safe, acceptable, effective and worthy of the hundreds of millions that has been spent, and the billions that has been earmarked for moving from adult and child circumcision to include infant circumcision, the latter being a far more sustainable proposition.

Now that so much money can be made from various mass HIV drug administration strategies, such as pre-exposure prophylaxis, early treatment, treatment as prevention, treating HIV positive pregnant women for life (as opposed to a shorter course of treatment), etc, it seems unlikely that any of the big funders will wish to put much money into finding out how people in high prevalence countries are infected in the first place, and aiming to prevent such infections from occurring.

Of course, like infant circumcision, allowing a substantial number of people to continue to be infected with HIV is far more sustainable than aiming for the industry's claimed goal of virtually eliminating HIV by 2030. A steady stream of new infections from the worst epidemics should keep the industry afloat for at least a few more decades, and perhaps even ensure their survival for the rest of the century.

Kenya's HIV Prevention Revolution: Beating Swords into...Condoms

Kenya's recently published 'HIV Prevention Revolution Road Map - Count Down to 2030' presents various HIV data for each of the 47 counties, based on their new constitution. National prevalence is estimated at 6%, 1.6 million people (compared to 5% in the latest Aids Indicator Survey). But instead of getting rough data for each of the 8 provinces, it is now possible to see just how heterogeneous the country's epidemic is.

Prevalence ranges from a very low .2% in Wajir to a massive 25.7% in Homa Bay, 128.5 times higher. The estimated number of people living with HIV in Wajir is 500, compared to 140,600 in Homa Bay, 281 times higher. Of course, people can work that out for themselves. But try working out how the situation in these counties can be so different if you also believe that HIV is almost always transmitted through sex.

Because that is the conclusion of the experts who put together this research. The contribution made by Homa Bay alone is said to be roughly the same as the contribution of sex workers plus their clients in the country. Over 60% of new infections are said to be a result of the sexual behavior of the populations of 9 counties, making up less than a quarter of the population. In contrast, the 10 lowest incidence counties are said to contribute 1% of all infections, through their sexual behavior, of course.

It is now claimed that 93.7% of all new cases of HIV are sexually transmitted. Only 20% of the hundreds of millions of dollars being pumped into the epidemic is to be spent on prevention, and most of that will be spent on condoms, finger wagging and a lot of other rubbish that has failed to have any influence on the epidemic so far. And yet it is expected to reduce transmission to about 1000 cases by 2030.

One of the most disturbing aspects of the report is a photograph that sums up the attitude of UNAIDS and other big players in the HIV industry (a lot of drugs are being sold through reports like this) towards Kenyans and other Africans. It depicts a crowned 'King of Condoms', with a paper crown on his head, demonstrating to the country's first lady how to put a condom on a wooden dildo, while others look on.

Or perhaps others don't see that as an instance of crass infantilization? Perhaps they don't find anything questionable about the idea that HIV is transmitted almost entirely through sexual behavior in African countries? But the assumption is based on an entirely flawed 'Modes of Transmission' spreadsheet, rather than on research. Thirty years into the epidemic, with next to nothing to show for the billions that have been spent on prevention, shouldn't we start collecting empirical data to guide future efforts?

Why 'Reducing HIV Transmission' Must Never be an Excuse for Genital Mutilation

The English Guardian has put together figures for female genital mutilation (FGM) and the top ten are Somalia, Guinea, Djibouti, Egypt, Sierra Leone, Mali, Sudan, Eritrea, Gambia and Burkina Faso. But the top ten for HIV that I have been looking at recently are Swaziland, Botswana, Lesotho, South Africa, Zimbabwe, Zambia, Namibia, Mozambique, Malawi and Uganda. The table below shows just how dramatic the non-correlation is.

The English Guardian is calling for an end to FGM, of course. But a far less dramatic non-correlation has been used to justify three randomized controlled trials of mass male circumcision in African countries. The results of these trials are have been used to justify a continuation of mass male circumcision, involving tens, even hundreds of millions of men, boys and infants and several billions of dollars. While HIV prevalence is lower among uncircumcised men than circumcised men in some countries, it is lower among uncircumcised men in others, while in several more countries circumcision status makes no difference. The correlation coefficient is roughly zero.

Results of further research into mass male circumcision is being presented to 16,000 attendees at the Melbourne HIV conference this week, research carried out on people who are not aware that they are guinea pigs for the current obsession with the operation. Because, as the figures show, we have no idea why circumcision sometimes appears to 'protect' against HIV and why it sometimes appears not to. Nor do we have any idea what proportion of HIV is transmitted through sexual contact and what proportion is transmitted through non-sexual routes, such as unsafe healthcare, cosmetic and traditional practices.

Similarly, we have no idea why HIV prevalence is so high in some African countries but so low in others. The fact that HIV prevalence is very low in countries that practice FGM is not seen as justification for carrying out trials of the operation on millions of people and presenting the results at an international HIV conference (such trials would probably be carried in secret). In fact, it is assumed that FGM status is seen as irrelevant to HIV transmission, and that, even if it is somehow relevant, carrying out trials into the operation as a HIV intervention would be entirely unethical.

International health and development institutions, the UN, the mainstream media, political and religious leaders all around the world, and many others, condemn FGM and would not consider it as a means of reducing HIV transmission. They would not even condone carrying out field trials into any kind of FGM, not even the less damaging kinds, not even the kind that leaves no permanent damage, because it is not ethically justifiable to carry out such an operation for no medical reason, on infants, children, or even unconsenting adults. Quite right, too.

But the research carried out by the people slapping each other on the back in Melbourne, presumably at some considerable cost, were financed by the likes of the Gates Foundation (which also funds the English Guardian's Development section, where the FGM article appears), FHI 360, Engender-Health and University of Illinois at Chicago. Several (if not all) of these institutions have their origins in a 'population control' theory of development, the belief that the population of developing countries is too high, and lowering birth rates will increase development and reduce poverty; less polite people would call this 'eugenics'.

I wonder if these parties have some information about, or beliefs about, mass male circumcision having some negative influence on fertility. Because, if they were to believe the same thing about FGM, would they also promote it with the same energy and persistence (and funding, and institutional backing)? What about other means of reducing fertility, such as Depo Provera, which has been associated with higher rates of HIV transmission? Gates and other 'population control' organizations certainly do promote that.

So promoting your favorite 'public health' intervention as a means of reducing HIV when the evidence is slim is bad enough. But this intervention involves something that is ethically unjustifiable unless it is carried out for medical reasons. So these various parties went a step further: they carried out, and continue to carry out, 'trials' of this operation on millions of people. The excuse is that it 'reduces HIV transmission'. But using that kind of evidence, so does FGM.

Genital mutilation without consent is not ethically justifiable; the fact that HIV prevalence is lower in countries where genital mutilation is common does not justify mass male circumcision programs, where millions of people are unwitting guinea pigs to this neo-eugenicist experiment. Those promoting mass male circumcision programs, funding them or working on them are involved in a crime of inestimable proportions, and must be stopped.